HRT
The standard recommendation for duration of menopausal hormone therapy use is ___ years.
What is 5 years?
(For patients who are not at increased risk for breast cancer or cardiovascular disease, the benefits of MHT outweigh the risks until approximately age 60)
A 68-year-old woman presents for a GYN exam. She has been on menopausal hormone therapy for years to treat persistent vasomotor symptoms. She wants to know the risks of continuing the medication. In discussion hormone therapy, you counsel her that in addition to vasomotor symptom reduction, the use of combined oral estrogen-progesterone therapy is associated with a decreased risk of:
A) Breast malignancy
B) Colorectal malignancy
C) Coronary heart disease
D) Fractures
What is D) fractures?
The first choice SSRI/SNRI for the treatment of hot flushes in menopause is __.
What is paroxetine?
(FYI: paroxetine should be avoided in patients taking tamoxifen, as it blocks the conversion of tamoxifen to active metabolites)
52 y.o. with history of ER+ IDC of L breast presents with symptoms consistent with genitourinary syndrome of menopause. What is first-line treatment for her symptoms?
What are vaginal lubricants/moisturizers (i.e., Replens)?
Vaginal lubricants and moisturizers are 1st-line options for those with estrogen-sensitive cancers.
The mean age of menopause is __.
What is 51?
Contraindications to hormone therapy include ___.
(Extra points per contraindication)
What is:
History of breast cancer
CHD
Previous VTE or stroke
Acute liver disease
Unexplained vaginal bleeding
High risk endometrial cancer
Transient ischemic attack
A 50-year-old woman, G2P2, reports daily moderate-to-severe hot flushes. She has been without menses for 1 year. She also notes breast tenderness for several months. Her BMI is 21 and her exam is normal. The results of her mammography reveal BI-RADS 1 with dense breasts noted. She is interested in starting medication. The best next step for the treatment of this patient's vasomotor symptoms is:
A) Bazedoxifene and conjugated equine estrogen
B) Conjugated equine estrogen and medroxyprogesterone acetate (MPA)
C) Venlafaxine
D) Gabapentin
What is Bazedoxifene and conjugated equine estrogen?
(Bazedoxifene was developed for the prevention and treatment of postmenopausal osteoporosis and was found to have agonist and antagonist activity in estrogen responsive tissues. This treatment therapy has positive effects on bone density and antagonistic effects on estrogen receptors in the endometrium and breast.)
In patients whose hot flushes occur mostly at night, this is the preferred medication.
What is gabapentin?
(The sedating effect of gabapentin and its effects to reduce vasomotor instability work together)
A 67 y.o. G4P3013 with rheumatoid arthritis (on prednisone 5mg daily) presents to R3 panel for a well woman exam. In addition to mammogram and colonoscopy, which screening test should she be offered?
What is DEXA scan?
(According to ACOG, DEXA screening should be offered to 65+, younger than 65 with fracture risk, or FRAX 10-year risk of major osteoporotic fx of 9.3%+. This patient >65 years old and on chronic steroids is at increased risk and warrants screening.)
The most commonly reported menopausal symptom is ___.
Bonus: this symptom peaks at what time period?
What are vasomotor symptoms (hot flushes)?
What is peaks approximately 1 year after the final menstrual period?
For patients who cannot tolerate a cyclic or continuous oral progesterone regimen, alternatives include ___.
(3 answers)
What is:
1. Vaginal micronized progesterone
2. Levonorgestrel-releating IUDs
3. Conjugated estrogen/bazedoxifene (SERM)
A 34-year-old woman, gravida 2 para 2, presents with worsening hot flushes, sleep disruption, and vaginal dryness after undergoing a TVH and BSO 2 months ago to treat severe dysmenorrhea resulting from endometriosis. On exam her BP is 138/82. Pelvic exam shows mild atrophy and an intact vaginal apex with no lesions or tenderness. The best next step in management of this patient's symptoms is to initiate systemic therapy with:
A. Clonidine
B. Estrogen
C. Gabapentin
D. Paroxetine
E. Micronized progesterone
What is estrogen?
In nonhormonal treatment for symptoms of menopause, if one SSRI/SNRI is tried but does not work, the next step should be __.
What is try a second SSRI/SNRI?
(A different SSRI/SNRI should be tried before moving to another class of drug. If the SSRI/SNRI class of drugs is ineffective, a trial of gabapentin is reasonable).
63 y.o. postmenopausal female presents to GYN clinic with vulvar irritation, dyspareunia, and dysuria. Her urine culture and vaginitis swabs are negative. How do you counsel her on to take the appropriate medication for her condition?
What is nightly for 2 weeks followed by twice a week?
The percentage of patients who will experience recurrence of menopausal symptoms after HRT is discontinued.
What is 50%?
The initiation of hormone therapy is a safe option for healthy, symptomatic patients who are within ___ years of menopause or younger than the age of ___ years and who do not have contraindications to hormone therapy.
What is 10 years?
What is 60 years?
A 55-year-old woman has just completed 6 cycles of chemotherapy after a unilateral mastectomy for stage II breast cancer. She reports having hot flushes 3 times a day and severe vaginal dryness and irritation that makes intercourse painful. She has tried water-based lubricants and vaginal moisturizers with no relief. The intervention most likely to reduce her vaginal symptoms is ___.
What is vaginal estrogen therapy?
Which of the following SSRI/SNRI is not recommended for treatment of hot flushes?
A) Venlafaxine
B) Paroxetine
C) Citalopram
D) Sertraline
What is sertraline?
(Sertraline and fluoxetine have been shown to be as effective as a placebo in trials)
A 47 y.o. presents to R2 panel with AUB. She reports skipping 1-2 cycles of periods at a time followed by periods with prolonged spotting. This has been ongoing for 6 months. What is the next best step in her management?
A) Obtain a detailed clinical history
B) Obtain FSH level
C) Endometrial biopsy
What is A) obtain a detailed clinical history?
A history to assess for sx of menopause including possible sleep/mood disturbances/hot flushes, a menstrual history of the last 6-12 cycles, etc is the first step given this patient is at typical age for onset of menopausal transition. While FSH level may be helpful, it may not be elevated during menopausal transition and is *not* required for a diagnosis of perimenopause. Endometrial biopsy may also be considered in a patient presenting with heavy bleeding, but is not the next best step in management for this patient.
What neuronal network is implicated in the development of hot flushes?
What is the KNDy neurons (Kisspeptin, Neurokinin, Dynorphin)?
In patients with a uterus taking standard doses of estrogen therapy, how often is progestin therapy required?
What is at least monthly?
For the patient below, choose the most appropriate nonhormonal initial medication to manage menopausal hot flushes:
A) Venlafaxine
B) Paroxetine
C) Gabapentin
D) Clonidine
E) Sertraline
A 48-year-old woman reports bothersome and worsening hot flushes. She finds that she is quicker to snap at her children and generally more irritable. She wants a method that will not cause weight gain or affect her libido.
What is paroxetine?
(Of the nonhormonal alternatives, only paroxetine is approved by the FDA for the treatment of menopausal hot flushes)
A drug working in the thermoregulatory center in the hypothalamus to decrease hot flushes targets the __ receptor.
What is the Neurokinin 3 receptor?
(The thermoregulatory center in the hypothalamus is innervated by kisspeptin/neurokinin B/dynorphin or KNDy neurons that are stimulated by neurokinin B and inhibited by estrogen. Since estrogen declines in menopause, it is thought that neurokinin B signaling increases and this results in unregulated KNDy neuron activation and vasomotor symptoms. Antagonism of the neurokinin 3 receptor has been studied as an alternative to hormone therapy for management of hot flushes).
55 y.o. female without PMH/PSH presents to clinic with 2 months of trouble sleeping. On further question, she also reports vaginal dryness, hot flushes, and menopause at age 51. You decide to start her on a cyclic regimen of HRT. You prescribe daily PO estradiol __ mg/day and PO micronized progestin ___ mg/day for 14d of the month.
What is 1 mg/day and 200 mg/day?
These are standard doses for PO estradiol and PO progestin, respectively.
During the first 10 years after menopause, __% of a woman's lifetime bone loss is lost.
What is 50%?
Women lose about 50% of their trabecular bone and 30% of their cortical bone during the course of their lifetime, about half of which is lost during the first 10 years after menopause! About 40% of postmenopausal women will experience fractures.