Menopause (Xavioer)

What is peri-menopause?

The time from which menopause becomes irregular to the Final Menstrual Period

What is menopause?

The cessation of menstrual bleeding for a continuous 12-month period

Smoking, genetics, and body size can affect the ___ of menopause.

age of onset

True or false: Estradiol concentrations increase with aging due to oocyte atresia.

False. Aging leads to atresia (diminished oocytes), which causes decreased estradiol concentrations.

True or False: Aging results in a significant decrease in FSH and LH concentrations.

False. Aging causes a significant increase in FSH and LH concentrations.

What is the effect of the lack of a corpus luteum during menopause?

It leads to a lack of progesterone activity

Testosterone production drops to about ___ of that seen in women in their 20s.

Half

What are vasomotor symptoms of menopause?

Hot flushes and night sweats

Vasomotor symptoms typically last an average of ___ years, with the highest occurrence within ___ years post-menopause.

7; 2

What are some examples of GSM?

• Urogenital atrophy

• Vaginal dryness

• Dyspareunia

• Recurrent UTIs

• Urge/stress incontinence

True or False: The STRAW staging system can be used for diagnosing menopause in women with an IUD or hormonal contraceptive use.

False. STRAW staging is not useful if the patient has no uterus, uses hormonal contraceptives, has an IUD, or has had prior procedures affecting menstrual function

What is the most effective option for managing VMS and GSM in menopause?

Menopausal Hormone Therapy (MHT)

The risk of ___, ___, ___, and ___ increases in women who do not meet the criteria for MHT.

heart disease, stroke, VTE, and dementia

What is the primary focus of MHT during the menopause transition?

Alleviation of VMS and GSM

What type of therapy should women with an intact uterus use for MHT? Why?

• Estrogen + progestogen therapy

• To prevent unopposed estrogen activity, which can overstimulate the uterine lining and progress to endometrial hyperplasia or cancer

True or false: Estrogen alone is recommended for women with an intact uterus.

False. Estrogen alone can cause overstimulation of the uterine lining, leading to endometrial hyperplasia or cancer

What is the first-line option for reducing the frequency and severity of vasomotor symptoms (VMS)?

Oral estrogen therapy

True or false: Vaginal estrogen formulations are ideal for treating GSM and preventing recurrent UTIs.

True

Vaginal estrogen products minimize ___ absorption while providing adequate relief for GSM.

Systemic

True or false: Systemic estrogen therapy can help improve urinary stress incontinence.

False. Systemic agents may worsen urinary stress incontinence

True or false: Estradiol is bioidentical and the most common form of estrogen therapy.

True

What are CEEs, and how do they differ from estradiol?

CEEs (conjugated equine estrogens) are mixtures, not bioidentical, but are better studied than estradiol

Oral estrogens are affected by ___ and ___ metabolism, which may increase the risk of VTE.

gut; liver

How can oral estrogens impact lipid profiles?

They lower LDL, increase HDL, but may also increase triglycerides

What is a key advantage of transdermal estrogens compared to oral estrogens?

First-pass gut/liver metabolism is avoided, leading to decreased VTE risk and less negative impact on triglycerides

True or False: Transdermal estrogens have a higher risk of VTE compared to oral estrogens.

False. Transdermal estrogens have a decreased VTE risk due to avoiding first-pass gut/liver metabolism

What is a key consideration when using vaginal estrogens?

No systemic progestogen is needed with typical doses because there is little systemic absorption of estrogen (except with the ring, where the dose is higher)

True or False: Vaginal estrogen use at typical doses carries a known risk of systemic absorption.

False. Vaginal estrogens typically have no systemic absorption, so no systemic progestogen is needed

What is the role of progestogens in menopausal hormone therapy?

They protect against endometrial hyperplasia and cancer risk related to unopposed estrogen

True or false: Drospirenone has anti-aldosterone activity and a risk of hyperkalemia.

True

True or False: Micronized progesterone is manufactured in sunflower oil.

False. Micronized progesterone is manufactured in peanut oil (make sure to check patient’s allergies)

Who are progestogens ideal for in menopausal hormone therapy?

Those with contraceptive needs or those who do not tolerate oral or transdermal options

What is ospemifene (Osphena®), and what is it approved for?

Ospemifene is a selective estrogen receptor modulator (SERM) approved for dyspareunia and vaginal dryness/atrophy

True or False: Ospemifene (Osphena®) requires progestogen therapy.

False. Ospemifene does not require progestogen therapy because it has selective tissue activity

When might intravaginal DHEA be considered in menopause therapy?

When non-estrogen therapy is needed

What is the purpose of Tissue-selective Estrogen Complex (TSEC) + Estrogen Agonist Antagonist (EAA, aka SERM)?

It is ideal for those who cannot tolerate progestogen therapy but need to oppose estrogen effects to protect the endometrium

What combination is used in Duavee®?

Conjugated equine estrogens (CEE) + bazedoxifene (a SERM)

What is the role of testosterone in menopausal therapy?

It is of interest for low libido management or sexual dysfunction, though it has no FDA approval and unclear dosing for use

How is the risk of endometrial cancer minimized in menopausal hormone therapy (MHT)?

By using a combination of estrogen and progestogen therapy

True or False: Progestogens can be used either continuously or cyclically, with cyclic therapy preferred if 12 months of amenorrhea have not occurred

True

When is estrogen therapy alone appropriate in menopausal hormone therapy?

In women without a uterus

What are contraindications to menopausal hormone therapy (MHT)?

Undiagnosed vaginal bleeding, treatment of hormone-dependent malignancy, history of estrogen-dependent malignancy, MI, stroke, VTE, dementia, and severe liver disease

What benefits does MHT have on bone health?

It reduces bone turnover, increases bone mineral density (BMD), and decreases hip fracture rates

How should menopausal hormone therapy (MHT) be used to minimize risks?

Limit use/duration and use the lowest doses possible to manage symptoms

True or False: Improvement in vasomotor symptoms (VMS) is typically seen 8-12 weeks after initiating MHT.

True. Full impact assessment may take 8-12 weeks

How often should follow-up occur after initiating MHT?

Follow-up should be every 1-2 months, with an annual evaluation strongly encouraged

Which classes of drugs are effective alternatives for reducing hot flushes and improving mood disorders in menopause?

SSRI/SNRI

True or False: Paroxetine can be used safely with tamoxifen.

False. Paroxetine should be avoided with tamoxifen due to a DDI that inhibits the conversion of tamoxifen to its active metabolite (CYP2D6 inhibition)

What is the role of gabapentin and pregabalin in menopause management?

They have some efficacy in reducing vasomotor symptoms (VMS) based on small studies

How does clonidine work in menopause management?

Clonidine elevates the "flush threshold" and can reduce symptoms, but it is less effective than other options like SSRIs/SNRIs

True or False: Menopausal hormone therapy (MHT) is effective for pregnancy prevention.

False. MHT alone is not effective for pregnancy prevention