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Menopause symptoms and treatments

Terms in this set (46)

Menopause
12 consecutive months without menses that are not associated with a physiologic (lactation) or pathological cause
Perimoenopause
the period immediately prior to menopause when the clinical and biologic features of menopause begin and the first year after menopause
Postmenopuase
a women is considered to be postmenopausal after one year of amenorrhea
Endocrine changes
drop of estrogen
Increase in FSH
main estrogen becomes peripherial
as a result, heavier women have menopause later due to more body fat and peripheral estrogen
Diagnosis of Menopause
-12 consecutive month of no menses without physiologic or pathologic cause
-Progestin challenge (MPA 10mg daily or norethindrone 2.5-5 mg daily): Bleeding, not menopausal
-after 6 months of ammenorrhea - could measure FSH and estradiol level
-if patient takes OC: over 50 should measure FSH, and if menopausal, should start HRT
Symptoms of menopause
-disturbances of menstrual pattern
-vasomotor symptoms: hot flahes/night sweats
-vaginal dryness
-sleep disturbances
-weight gain
-younger and heavier women, smoker, and sedative lifestyle has more severe vasomotor symptoms
Dysfunctional uterine bleeding treatment
-OC: Natazia or 50 mcg OC tablet QID for 5-7 days and then one tablet for 21 days and then 7 days off, repeat
-intermittent progestin (MPA) until no bleeding occurs
Hot flashes
-first flash, a sudden warmth
-then flush, a visible redness
total last around 2-3 min, but can persist for 30 min
-increase by smoking
non pharm: management of Hot flashes/flushes
-laying of clothing
-splashing cool water on face and wrists
-keeping home/office cool
-avoiding "trigger"
-exercise
-paced respiration
herbal
phytoestrogens: soy product and flaxseed, mix result at the best
Herbs:
Black Cohosh: mix result
Red clover: contain phytoestrogen, no difference
Dong Quai: no effect
estrogen and hormone therapy for hot flushes
moderate to severe: estrogen/Hormone therapy; occurs 3-4 weeks, wait 2-4 weeks to see max benefit; use 0.625 mg/day or lower dose or 0.3 -0.625 mg of conjugated equine estrogen. higher dose may be require. lower dose may work slower
-standard and low dose FDA approved, not ultra low dose
Progestins: hot flushes
use progestine if estrogen is contraindicated
-oral MPA (10-20 mg/day)
-depo-MPA (50-150 mg/month)
-megestrol acetate (40 mg/day-initial dose; 20 mg qd or qod for maintenace); should see effect within 2 weeks, max after 4 weeks
-SE: irregular bleeding, headache, vaginal dryness and weight gain
-FDA approved
combination estrogen and SERM
-conjugated estrogen + bazedoxifen
-vasomotor and prevent osteoporosis in postmenopausal women with a uterus
-SE: muscle spasms, nausea, diarrhea, upset stomach, abdominal pain, throat pain, dizziness and neck pain
-VTE risk
-FDA approved
antidepressants on hot flashes
-paroxetine is FDA approved
-SSRI and SNRI are used
-use to treat mild-moderate hot flashes
-can be used to in combo with HT
-do not use paroxetine with tamoxifen, switch to velafaxine or desvenlafaxine
Clondine used on hot flashes
-0.1-0.2 mg /day
- less effective than estrogen or MPA
-benefit only for women with breast cancer history taking tamoxifen/SERM
Gabapentin used on hot flashes
-300 mg initial, titrate to 900 (2400 mg) mg/day
-similar effect as SSRI/SNRI
-effective in managing hot flashes in women with breast cancer
Cognitive effect caused by menopause
-HRT should not be used to protect the cognitive functioning of older women
Atrophic Vaginitis
symptom due to decrease in estrogen level
-mostly experienced by postmenopausal women
-also reduce lactic acid production and increase in pH
-smoking increase symptoms
SE: vaginal irritation, dryness, burning, itching, leukorrhea, and dyspareunia
Estrogen therapy on atrophic vaginitis
-oral or topical
-use low dose
-if topical estrogen therapy is used intermittently then progestin therapy is not needed
-initial treatment: daily (hs) for 7-21 days, then 1-3 times weekly for maintenance
-if there is a CI for oral estrogen, topical should not be used
personal lubricant products for atropic vaginitis
-lubricant: K-Y jelly or replens
-applied daily in 1-2 teaspoonful amount than are titrate
-provide short-term improvement
-dyspareunia may also require used during sexual activity
ospemifene
-estrogen agonist/antagonist-indication for moderate-severe dyspareunia due to menopause
-60 mg qd with food
-increase cardivascular events (VTE)
-interacts with oral azole antifungal (toxicty)
-rifampin (decrease effect)
-pregnancy X
Osteoporosis
HT is an option for prevention (treatment) of osteoporosis when alternate therapies are not appropriate or cause adverse effects
-Taking HT before age 60 and then stopping is unlikely to provide any bone benefit when most needed
-Long-term HT prevents bone loss and fractures-however, other therapies offer this benefit with fewer risks
-HT is an appropriate first-line therapy for prevention/treatment of osteoporosis in women under 60 years of age, particularly those women with premature menopuase
-HT should not be used solely for the purpose of preventing bone fractures in women over the age of 60 yo
Cardioprotective effects of estrogen
-lower total and LDL-C
-increases HDL-C
-inhibits LDL oxidation and penetration of vessels walls
-decreases lipoprotein a level
-reverses postmenopausal increases in fibronoge
negative cardiovascular effects of estrogen
-increase plasma triglycerides
-activates coagulation
effects of progestins
-increase LDL and decrease HDL, diminish or lost of beneficial effect of estrogen (MPA)
-use of transdermal estrogen decreases LDL-C and do not increase triglycerides, no effect on HDL.
-the greater the androgenic potency the greater the adverse lipid effects
-MPA in 10 mg still decrease HDL-C
-micronized progesterone appears have a preferential effect on lipids compared to the synthetic progestins, no adverse effect on HDL
HT and CHD bottom line
-Age and time of use of HT in relation to menopause may alter the CVD effects of HT
- In women < 60 years of age who are recently menopausal and without CVD, the use of HT reduces cardiovascular morbidity and mortality
-HT should not be used for prevention of CHD.
-women with CHD and/or who have experienced CVD events should avoid use of HT
-women with premature menopause should use HT until at least menopause age or age 60 years to prevent atherosclerosis and CHD
-the addition of a progestin to estrogen therapy may reduce the CVD benefit of estrogen. If HRT is used, micronized progesterone may be a preferred agent compared to the synthetic progestins
HT and VTE
-women at high risk of VTE should avoid HT
-Women at high risk: cancer; clotting disorder; history of VTE
-transdermal therapy may cause risk for VTE
HT and endometrial cancer
-increase risk if ERT is used by women with a uterus
-the increase persist for years after estrogen therapy is discontinued
-continous combined HT is preferred; sequential therapy increase risk
HT and ovarian cancer
very small increase of risk due to HT
Breast cancer and HT
most common invasive cancer
-HT appears to increase risk among current users and in women who have used HT for 5 years or longer. the increase risk disappear after HT is stopped for 5 years
- the increase is significant in lean women
-more significant in estorgen + progestin
Bottom line of HT and breast cancer
-Increase risk of HT is small but high in HRT.
-use less than 5 years has less increase than long term
-more in lean than overweight
-estrogen and progestin higher than other type of HT
-dose related, higher dose higher risk (more than 1.25)
-time from menopause to the start of HT may be an important factor in affecting risk of breast cancer
-after discontinuation of HT for 5 years the risk returns to that of never user of HT
-use of HT delay diagnosis of breast cancer, leading to later treatment and worse outcome
Colorectal cancer and HT
estrogen use reduces the incidence of colorectal cancer and also reduces the mortality associated with this cancer
HT uses
-not to prevent CHD OR osteoporosis
-only used for women who experience early menopause before the age of 40-45 years, used until normal age of menopause
-should be used for short term, with lowest effective dose
-use vaginal therapy for vaginal symptoms to reduce risk and increase efficacy
-except for low dose vaginal therapy, women with a uterus should be accompained by progestin therapy
-use of androgen for bilateral oophorectomy
Benefit of HT
-management of vasomotor symptoms
-management of urogenital atrophy
-reduced risk of CHD
-reduced risk/management of Osteoporosis
-potential reduction in risk of Colon cancer
-potential reduction in risk for Alzheimer's disease
risks of HT
-breast cancer
-endometrial cancer
-thromboembolism
-cardiovascular event
CI of postmenopausal hormones
-estrogen-related cancer (uterine, breast)
-undiagnosed abnormal vaginal bleeding
-active liver disease or chronic severe liver dysfunction
-active thrombophlebitis or thromboembolic disorder
-prior complication from estrogen
High risk group for HT
-risk for thromboembolic diseae
-history of gallstones
-condition aggravated by fluid retention (CHF, seizure disorder, athma)
-active endometriosis + uterine leiomyomata
-previous (treated) breast cancer
-tobacco smokers (less effecitve)
doses of estrogen
-less than 0.3 - 0.65 CEE
people that needs higher dose
-women with surgical menopause
-tobacco smoker
-user of medications which stimulate liver enzymes
-women who continue to lose bone mass on standard doses of estrogen
-still experience menopausal effect
-may be increase to 0.9-1.25 mg cee daily, higher are rare
benefit of transdermal
-patients cannot tolerate peak serum level of oral or symptoms at lowest level
-tobacco smoker
-history of thromboemolism,migraine HA, isolated hypertriglyceridemia or gall stone
-cystic breast change
-problem with remembering to take the med
-use less than 50 mcg
progestin therapy
-micronized progesterone
--does not increase VTE or breast cancer
--no adverse effect on HDL-C
-200 mg daily
--may cause drowsiness
-MPA
--most common
--low androgenic effect
--good choice for women with history of breast tenderness or fibrocystic disease
-19-nor-testosterone
--most androgenic
--use of heavey menstrual bleeding or dysmenorrhea
--better tolerated
use of progestin
-women who not had a hysterectomy
-main use to provide endometrial protection
-not required: low dose/ intermittent vaginal therapy or ultralow dose transdermal estrogen used for osteoporosis
-dose not eliminate risk, by protect against the increase risk due to estrogen
ERT regimen
-uninterrupted
HRT
-continuous (most common)
-cyclic (5 hormone-free days)
-sequential (intermittently or daily)
SE
estrogen: nausea, breast tenderness, vasomotor symptoms, heavy withdrawal bleeding, headache
progestin: bloating, mood alterations
insufficient androgen: decreased libido
most common is vaginal bleeding
after d/c ht
-moderate-severe patients are more likely to experience similar symptoms after d/c
-smoking also increased the likehood of vasomotor symptoms after d/c HT
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