A FLASH IN THE PAN
This age bracket has the most favorable benefit-risk ratio for menopausal hormone therapy (MHT).
Age 50-59 (will also accept “within 10 years of menopause”).
Which symptoms are most associated with VMS?
A) Hot flashes and night sweats
B) Vaginal dryness and burning
C) Palpitations and hair loss
D) Urinary incontinence
A) Hot flashes and night sweats
Which symptom is most characteristic of GSM?
A) Hot flashes
B) Night sweats
C) Vaginal dryness
D) Palpitations
C) Vaginal dryness
It’s normal to see breakthrough bleeding up to ____ months after starting continuous MHT and within ____months of a change in dose or preparation in those already established on MHT.
6 months and 3 months respectively
In the Women’s Health Initiative (WHI) study, these 2 medications were used at the following doses in subjects with an intact uterus.
Conjugated equine estrogens (CEE) 0.625 mg once daily + medroxyprogesterone acetate (MPA) 2.5 mg once daily.
If a hysterectomy has been performed, which systemic MHT regimen is appropriate?
A) Estrogen-only therapy
B) Estrogen + progesterone
C) Tibolone only
D) Non-hormonal NK3 antagonist
**DOUBLE JEOPARDY**
A) Estrogen-only therapy
What is considered as a reasonable option for moderate-to-severe GSM if non-hormonal moisturizers fail?
A) Oral estrogen
B) vaginal DHEA
C) Local progesterone
D) Tibolone
**DOUBLE JEOPARDY**
B) vaginal DHEA
Which statement(s) regarding stopping MHT is true:
A) Women should stop MHT once they reach 65 yrs of age
B) Slowly tapering off MHT provides better symptom control in the long-term
C) Stopping MHT may cause a recurrence in VSM and GSM symptoms and further bone loss with an increased risk of fractures
D) Both B and C
C) Stopping MHT may cause a recurrence in VSM and GSM symptoms and further bone loss with an increased risk of fractures
Name 2 estrogens and 1 progestogen that are body-identical.
**DOUBLE JEOPARDY**
For estrogens:
17β-estradiol (or just estradiol)
estrone
For progestogens: micronized progesterone (mP)
Which formulation is preferred for women at increased risk of VTE, migraines, or metabolic concerns?
A) Oral conjugated estrogens
B) Transdermal estradiol
C) Tibolone
D) Medroxyprogesterone acetate
B) Transdermal estradiol
Progesterone is required for this vaginal estrogen product?
A) Vagifem®
B) Estring ®
C) Estragyn ®
D) Osphena®
C) Estragyn ®
Which statement(s) regarding duration of MHT is false:
A) Incidence of breast cancer may increase with longer use of MHT, especially with continuous combined estrogen-progestogen
B) GSM tends to improve with age
C) Benefit/risk ratio should be reviewed every 6 months
D) Both B and C
D) Both B and C
GSM tends to improve with age and Benefit/risk ratio should be reviewed every 6 months are false statements
These are 2 of the populations who should receive transdermal instead of oral estrogens.
Any 2 of the following:
Increased VTE risk including BMI>30
Intermediate CVD risk (5-10% 10-yr risk)
History of migraine
Hypertriglyceridemia
Active gallbladder disease
Known thrombophilia such as Factor V Leiden
Micronized progesterone has which risk/benefit profile compared to medroxyprogesterone acetate (MPA)?
A) ↑VTE, ↑CVD, ↑Breast cancer risk, but ↓drowsiness
B) ↓VTE, ↓CVD, ↓Breast cancer risk, but ↑drowsiness
C) Same risk as MPA
D) No effect on breast cancer risk
B) ↓VTE, ↓CVD, ↓Breast cancer risk, but ↑drowsiness
The following GSM therapies are body-identical to human hormones, estrone (Estragyn®), estradiol (Vagifem®, Imvexxy®, Estring®) and prasterone (Intrarosa®)?
A) True
B) False
A) True
Which statement(s) regarding side effects of MHT is false:
A) Breakthrough bleeding is the most common adverse event with MHT
B) TSECs are associated with more breakthrough bleeding and breast tenderness than estrogen-progestogen therapy (EPT) regimens
C) Side effects are usually dose related and improve with time
D) Ospemifene (Osphena®) may increase hot flashes and sweating
**DOUBLE JEOPARDY**
B) TSECs are associated with more breakthrough bleeding and breast tenderness than estrogen-progestogen therapy (EPT) regimens
These were 3 key limitations of the WHI study and how it was interpreted.
Any 3 of the following:
Primary objective was to evaluate MHT for primary prevention of CVD, not evaluate efficacy for vasomotor symptoms (VMS) or genitourinary syndrome of menopause (GSM).
The study primarily included older women (mean age 63), many of whom were already at higher risk for cardiovascular disease (too late for primary prevention).
The study used Prempro (conjugated equine estrogen and medroxyprogesterone). It is not body-identical, unlike newer commercial formulations; different formulations may have different risk profiles.
The dose was considered high for older menopausal women (expert opinion).
Included women who had mostly (73% in the combined group) never used HRT before and were already at risk of CVD (and since the women were average age 63; they had 10-29 years of E deficiency before starting HRT, so plenty of time to develop subclinical arteriosclerosis before starting HRT).
News articles focused on relative risk, not absolute risk. Relative risk numbers appear larger and more alarming, but absolute risk numbers tell the real story.
Didn’t look at vaginal estrogens but these were “collateral damage” as people stopped using MHT in general.
High dropout rate (53.8% for E alone, 42% for E+P).
Confounding factors: decrease in event rate in placebo group.
Reported risks were based on 95% CI that were unadjusted for multiple measurements; adjusted 95% CI showed breast cancer and CHD risk increases were not statistically significant
45% unblinding rate
According to menopause guidelines, which patients should avoid systemic MHT and use non-hormonal therapies as first-line?
A) Age <60 OR < 10 years since LMP, with hyperlipidemia
B) Recent hysterectomy, with metabolic syndrome
C) Age ≥60 OR >10 years since LMP, especially with high CVD or breast cancer risk
D) Women with only VMS symptoms and diabetes
C) Age ≥60 OR >10 years since LMP, especially with high CVD or breast cancer risk
In women with a history of breast cancer, what is the key clinical consideration when offering low-dose vaginal estrogen therapy?
A) It is contraindicated
B) Safe if taken with systemic progesterone
C) May be considered if non-hormonal options fail, but requires oncology input if on aromatase inhibitors
D) Only oral ospemifene should be used
C) May be considered if non-hormonal options fail, but requires oncology input if on aromatase inhibitors
For a person on continuous EPT experiencing breakthrough bleeding within the acceptable timeframe, what are 3 possible options to manage the breakthrough bleeding.
Any three of the following: