question

Perimenopause

answer

is the period immediately prior to menopause and the first year of menopause. It is characterized by menstrual cycle irregularity due to the increased frequency of anovulatory cycles

question

Menopause

answer

Menopause is the permanent cessation of menses -usually defined as 12 consecutive months of amenorrhea. Menopause is the loss of ovarian function and subsequent hormonal deficiency.

question

Symptoms of perimenopause and menopause

answer

-Vasomotor symptoms -Sleep disturbances -Mood changes-anxiety, depression, mood swings -Problems concentrating and memory -Atrophic vaginitis/genitourinary symptoms -Osteoporosis

question

Vasomotor symptoms

answer

hot flushes and night sweats-- primarily characterized by the perception of intense heat (hot flash) and subsequent cooling by cutaneous vasodilation (skin flushing), perspiration, and chills. Also, may include headache, dizziness, palpitations, and sleep disturbances. Approximately 75-85% of women are affected with vasomotor symptoms.

question

Symptoms are associated with circadian rhythm and are worse in ______________ and _________.

answer

early morning and evening

question

Symptoms can range from

answer

being a minor nuisance to being severe and disruptive to daily living.

question

Vasomotor symptoms occur due to

answer

a transient lowering of the hypothalamic temperature regulatory set point.

question

Typically, vasomotor symptoms occur ___ -___ years of menopause. Only 25% of women have vasomotor symptoms for more than __ years.

answer

1-2 years 5 years

question

Atrophic vaginitis/genitourinary

answer

Urogenital atrophy is caused by estrogen loss because the urogenital tissues (vagina, vulva, urethra, and bladder) contain a large number of estrogen receptors. Atrophy results in thinning of tissue and loss of elasticity.

question

Genital symptoms include

answer

dryness, burning, dyspareunia, loss of vaginal secretions, and vulvar pruritus.

question

Over time, lack of vaginal lubrication may lead to _____________ and _______________.

answer

sexual dysfunction and emotional

question

Urinary symptoms

answer

include urethral discomfort, frequency, dysuria, stress incontinence, and increased urinary tract infections.

question

Urogenital atrophy occurs in at least ___ % of postmenopausal women.

answer

50

question

Osteoporosis is associated with _____________and ____________.

answer

low bone mass increased fracture risk.

question

Risk factors for osteoporosis include_____________ and _____________________.

answer

being female postmenopausal Approximately 40% of postmenopausal women have osteopenia and 7% have osteoporosis.

question

Signs of perimenopause

answer

dysfunctional uterine bleeding

question

Signs of menopause

answer

signs of urogenital atrophy

question

FSH level that is indicative of perimenopause

answer

FSH on day 2 or 3 of the menstrual cycle is >10-12 milliinternational units/mL

question

FSH level that is indicative of menopause

answer

FSH > 40 milliinternational units/mL

question

Hormone therapy (HT)

answer

refers to estrogen with or without progestins.

question

Clinical evidence of efficacy of hormone therapy shows

answer

a reduction in fracture, but an increase in breast cancer, CHD (during the first year), stroke, and DVT/PE. The benefit versus risk assessment has been altered in light of this newer evidence.

question

In the absence of contraindications, hormone therapy is indicated (approved indications) for women with

answer

vasomotor symptoms (hot flushes and night sweats) and urogenital atrophy and prevention of osteoporosis

question

The most effective drug intervention for vasomotor symptoms

answer

Systemic hormone therapy

question

_____________ products should be considered for symptoms of urogenital atrophy.

answer

Intravaginal

question

Transdermal patch (Menostar®) or the nonestrogen products (raloxifene and bisphosphonates) should be considered for

answer

osteoporosis prevention

question

Hormone replacement therapy is contraindicated in women with

answer

endometrial cancer, breast cancer, undiagnosed vaginal bleeding, coronary heart disease, thromboembolism, stroke or transient ischemic attack and active liver disease.

question

Relative contraindications to HRT

answer

uterine leiomyoma, migraine headaches, and seizure disorders

question

____________ should be avoided in women with hypertriglyceridemia, liver disease, and gallbladder disease.

answer

Oral estrogen Transdermal administration is safer.

question

Primary reasons for stopping hormone therapy are side effects such as

answer

bleeding, breast tenderness, bloating, and "premenstrual-like symptoms".

question

Interventions to decrease side effects of HRT

answer

Reducing the dose or changing the regimen or the route of administration can minimize these effects

question

If a woman is menopausal with only urogenital symptoms the treatment recommended is

answer

Vaginal estrogen preparation with low systemic exposure

question

If a woman is menopausal with vasomotor symptoms +/- urogenital symptoms without contraindications the treatment recommendation is

answer

Consider estrogen/progestogen or estrogen alone (in women with hysterectomy). Use lowest effective dose and for the shortest duration -Reassess yearly

question

If a woman is menopausal with vasomotor symptoms +/- urogenital symptoms with contraindications the treatment recommendation is

answer

Consider venlafaxine, paroxetine, megestrol acetate, clonidine, gabapentin -Reassess yearly

question

Treatment recommendation for a woman that is not menopausal and asymptomatic but at risk for osteoporosis

answer

Calcium, vitamin D and exercise with a bisphosphonate or raloxifene. Estrogen + progestogen or estrogen alone (in women with hysterectomy) should be given only if the benefits clearly outweigh the risks -Reassess yearly

question

Treatment recommendation for a woman that is not menopausal but has osteoporosis

answer

Calcium and vitamin D with a bisphophonate, teriparatide (for women at high risk of fracture), or possibly calcitonin -Reassess yearly

question

Drug treatment of first choice

answer

Hormone therapy is the most effective treatment option for alleviating vasomotor and vaginal symptoms.

question

In women with an intact uterus, hormone therapy consists of

answer

an estrogen plus a progestogen.

question

In women who have undergone hysterectomy, estrogen therapy is given

answer

unopposed by a progestogen.

question

Most women require HT for < __ years so the risks of HT appear ________.

answer

5 small -If treatment can be tapered and stopped within 5 years there is no evidence of increased risk of breast cancer seen.

question

_____________ has been shown to be as effective as estrogen therapy in alleviating significant vasomotor symptoms

answer

No therapy

question

Estrogens diminish _____ _________ in most women, and all types and routes of administration of estrogen are equally effective.

answer

hot flushes

question

Alternatives to estrogen for treatment of hot flushes include

answer

paroxetine, venlafaxine, fluoxetine (commonly used antidepressants), medroxyprogesterone acetate, megestrol acetate, clonidine (antihypertensive), and gabapentin (an anticonvulsant; also used for treatment neuropathies)

question

Atrophy of the vaginal mucosa results in ______________ and ______________.

answer

vaginal dryness and dyspareunia.

question

Lower urinary tract symptoms include

answer

urethritis, recurrent urinary tract infection, urinary urgency, and frequency.

question

Women with significant vaginal dryness require _____________ estrogen therapy for symptom relief.

answer

local or systemic

question

For local estrogen therapy treatment, consider treatment with

answer

intravaginal estrogen cream, tablet, or ring.

question

____________ is better than __________ estrogen for relieving these symptoms

answer

Vaginal estrogen systemic estrogen -and avoids high levels of circulating estrogen.

question

If women are using low dose micronized 17β-estradiol then concomitant progestogen therapy is usually (necessary/not necessary)?

answer

not necessary.

question

If women are using conjugated equine estrogens (CEE) vaginal creams and other products that can promote endometrial proliferation in women with an intact uterus then they require

answer

intermittent progestogen challenges (for 10 days every 12 weeks).

question

Vaginal atrophy requires

answer

long-term estrogen treatment.

question

Urinary incontinence (is/is not) improved by estrogen therapy.

answer

is not

question

Prevention of osteoporosis is _____-term.

answer

long

question

For prevention of osteoporosis, the advantages of hormone therapy must be weighed against the risks, including ___________and increased incidence of _________________ and ___________cancer and consideration should be given to approved nonestrogen alternatives.

answer

thrombosis cardiovascular disease breast

question

Prevention remains an indication for estrogen products but

answer

the FDA withdrew the indication for osteoporosis treatment.

question

________________ are as effective as hormone therapy for preventing osteoporosis.

answer

Bisphosphonates

question

_______________ is no longer considered first-line therapy for prevention of osteoporosis because of the risks associated with its long-term use.

answer

Long term HT

question

HT should not be continued or initiated for prevention of ______________ ______________.

answer

cardiovascular disease -Major US trials provided evidence of no protection from cardiovascular disease and some evidence of harm

question

Combination estrogen and progestin has been shown to increase ___________________ in the first year of therapy and resulted in no difference in CHD events in remaining years.

answer

coronary heart disease

question

________________ may be tried prior to initiating drug therapy.

answer

Lifestyle modifications

question

Herbal therapies that have estrogenic mechanisms should be used with

answer

caution in patients who would have contraindications for estrogens.

question

Menopausal lifestyle modifications: wearing layered clothing

answer

(to remove and add layers as needed)

question

Menopausal lifestyle modifications: Avoiding triggers

answer

(such as warm environments, caffeine, hot beverages, stress, alcohol, spicy foods)

question

Menopausal lifestyle modifications:Exercise

answer

Exercising for as little as 1-2 hours/week has shown benefit. The mechanism for this is an increase in production of β-endorphin which is the primary neurotransmitter responsible for thermoregulation.

question

If __________ symptoms are present, symptoms will often be alleviated by lifestyle modifications.

answer

only mild

question

Black cohosh mechanism

answer

weak estrogenic activity and possible serotonergic effects

question

Black cohosh AEs

answer

gastrointestinal discomfort and rash, concern of similar risks to estrogen, potential for liver damage

question

Black cohosh dose

answer

39-127 mg daily PO

question

Black cohosh efficacy

answer

Inconsistent results have been observed in clinical trials.

question

Soy protein mechanism of action

answer

Plant compound with estrogen-like biologic activity and relatively weak estrogen receptor binding properties.

question

________________ has the most estrogenic activity.

answer

Isoflavones (soy protein)

question

Soy protein AEs

answer

gastrointestinal symptoms, concern of similar risks to estrogen

question

Soy protein dose

answer

34-93 mg daily PO

question

Soy protein efficacy

answer

Inconsistent results have been observed in clinical trials.

question

Premarin route

answer

oral, intravaginal cream

question

Estrace route

answer

oral, intravaginal cream

question

Vivelle Dot route

answer

transdermal patch

question

Menostar route

answer

transdermal patch

question

Estring route

answer

Intravaginal

question

Vagifem route

answer

Intravaginal

question

Divigel route

answer

Dermal

question

Evamist route

answer

Dermal

question

The most effective formulation of estrogen therapy

answer

In general, there is no evidence that one formulation is any better than another.

question

The ________ and _________ should be selected taking into consideration the patients' preference to ensure acceptability and enhance compliance.

answer

product and delivery method

question

______________ HT avoids first-pass metabolism because it bypasses the gastrointestinal tract. Thus, eliminates the risk of gallbladder disease and may be beneficial for patients with elevated triglycerides.

answer

Topical HT (including transdermal and dermal)

question

Low doses (i.e. 0.3 mg CEE) have been shown to be effective in controlling _____________ and ________________.

answer

postmenopausal symptoms and reducing bone loss.

question

Low doses may be safer than standard doses. However, the safety of low-dose estrogen and intravaginal estrogen has not been

answer

evaluated in long-term studies. Low doses are now recommended due to the long-term risks of standard doses. Dosing should start low and titrate slow.

question

If intolerable adverse effects occur, consider ____________ or ______________.

answer

adjusting dose down try alternative formulation (compound or route).

question

If symptoms are not controlled, then consider

answer

increasing dose upward.

question

Women who have not undergone hysterectomy should be treated

answer

concurrently with a progestogen in addition to the estrogen.

question

Four combination estrogen and progestogen regimens currently in use are

answer

1. continuous cyclic (sequential), 2. continuous combined, 3. continuous long-cycle (or cyclic withdrawal), and 4. intermittent combined (or continuous pulsed) hormone therapy.

question

Sequential hormone therapy results in ___________ vaginal withdrawal bleeding but is very ______ or _______ in older women.

answer

scheduled light or absent

question

New hormone therapy regimens that reduce monthly bleeding (________________) or prevent monthly bleeding (___________________ ) have been developed

answer

continuous long-cycle continuous combined and intermittent combined

question

Sequential hormone therapy

answer

Estrogen given daily Progestin given 12-14 of 28 day cycle

question

Sequential hormone therapy comments

answer

Withdrawal bleeding occurs 1 to 2 days after last MPA dose

question

Continuous combined hormone therapy

answer

Estrogen and progestogen given together daily

question

Continuous combined hormone therapy comments

answer

Causes unpredictable spotting or bleeding -usually resolves in 6-12 months.

question

Continuous long-cycle hormone therapy

answer

Estrogen given daily; progestogen given 6 times/year for 12-14 days

question

Continuous long-cycle hormone therapy comments

answer

Results in bleeding 6 times/year

question

Intermittent combined or continuous pulsed or pulsed progestogen hormone therapy

answer

Estrogen given for 3 days followed by 3 days of estrogen plus progestogen repeated continuously

question

Intermittent combined or continuous pulsed or pulsed progestogen hormone therapy comments

answer

Lower incidence of uterine bleeding; lower progestogen dose produces lower side effects

question

Risks of sequential hormone therapy

answer

The risks of hormone therapy include ovarian cancer, endometrial cancer, breast cancer, venous thromboembolism, gallbladder disease, increase in blood pressure, stroke, and possibly cardiovascular disease in older women

question

Adverse effects of sequential hormone therapy: estrogen

answer

nausea, bloating, headaches, breast tenderness, edema.

question

Adverse effects of sequential hormone therapy: progestin

answer

increased appetite, weight gain, fatigue, hypomenorrhea, acne, oily scalp, hair loss, hirsutism, depression, irritability, headaches.

question

Adverse effects of sequential hormone therapy: transdermal

answer

Application site reactions in 5-10% of women. Transdermal therapy has been shown to be less likely to cause nausea and headache versus oral therapy.

question

Benefits of androgen HRT

answer

improved libido and bone mass in perimenopausal and postmenopausal women with androgen deficiency.

question

Symptoms of androgen deficiency are more pronounced in women with ___________ _____________, and use of androgen is generally accepted in this population.

answer

surgical menopause --Androgen use is becoming more acceptable in women with natural menopause.

question

_____________ therapy combined with an androgen significantly improves sexual activity, satisfaction, and pleasure (more than with ________ alone.)

answer

Estrogen estrogen

question

Androgen HRT efficacy

answer

Androgen therapy has been shown to be effective and safe if given in doses to achieve concentrations within the normal physiologic range. Data is not available on fracture or breast cancer risks.

question

The most appropriate candidates for consideration of estrogen plus androgen therapy include:

answer

women who have had their ovaries removed and those with sexual dysfunction especially loss of libido.

question

Androgen HRT should always be co-adminstered with _____________ in postmenopausal women

answer

estrogen

question

Oral methyltestosterone

answer

i. Most studied androgen in postmenopausal women ii. Dosing: 1.25-2.5 mg PO QD iii. Combination products with estrogen: Estratest®, Syntest® Other dosage forms include intramuscular, subcutaneous, and transdermal.

question

Androgen HRT AEs

answer

virilization, fluid retention, adverse lipid effects

question

Androgen HRT contraindications

answer

moderate to severe acne, clinical hirsutism, androgenic alopecia, and androgen-dependent neoplasia

Hormone Replacement Therapy – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards