Menopause and Hormone Therapy

perimenopause

 Transition period prior to menopause
→Heavier menstrual flow, Longer duration, irregular menses 

menopause

the natural cessation of a woman's menstrual cycles, typically occurring between ages 45 and 55, marking the end of reproductive years

Vasomotor symptoms of menopause

Hot flashes, night sweats

Genitourinary symptoms of menopause

Vaginal atrophy- dyness, burning, irritation
Dyspareunia
Diminished libido
Urinary symptoms- urgency, dysuria, recurrent UTIs

Psychological symptoms of menopause

mood changes

General apporach to menopause treatment algorithm

Risks of hormone therapy

Coronary heart disease
Stroke
Venous thromboembolism
Breast cancer

Define the age group and time from menopause onset that is most likely to have a favorable benefit/risk ratio in using hormone therapy

50-59 years or <10 years after the onset of menopause

Which estrogen formulations are systemic

Transfermal, Oral

Which estrogen formulations are local

Vaginal

What has a higher risk of VTW: the estrogen contraceptive patch or the pill?

ethinyl estradiol is more potent so the contraceptive patch (ethinyl estradiol) has greater risk for VTE compared to the pill due to more exposure of potent estrogen

What has a higher risk of VTW: the estrogen menopasal patch or the pill?

menopausal patch (estradiol) has a lower risk of VTE compared to oral options due to bypassion first pass

ET vs EPT

Progestogen is required for women with an intact uterus

Contraindications to hormone therapy

Unexplained vaginal bleeding
Severe liver disease
Known, suspected or history of estrogen sensitive breast or endometrial cancer
MI
Stroke
Dementia
High VTE risk
Initiating treatment >60 years or 10 years post menopause

Vasomotor (hot flashes) treatment - Pharm

• Hormone therapy is the most effective treatment option

• SSRI/SNRI- relief can occur within 1 week

• Gabapentin, pregabalin

• Clonidine- lower efficacy and more adverse effects

• Veozah (fezolinetant) - Neurokinin 3 receptor antagonist

Vasomotor (hot flashes) treatment - NonPharm

Avoidance of triggers
Cooling techniques
Regular aerobic exercise
Yoga

Perimenopausal Menstrual Symptoms Treatment

Symptom management must be combined with contraceptive if engaging in sex

Combined hormonal contraception

GSM treatment- Vulvovaginal symptoms only

Mild—>Vaginal moisturizers and lubricants
Moderate- Severe —>Vaginal estrogen or ospemifene

GSM treatment- Vulvovaginal + Vasmotor sx

Consider systemic HT

Ospemifene

Improves intercourse pain
BBW: endometrial cancr

Options for women with mdoerate-severe GSM and those who do not respond to lubricants and moisturizers

Low dose vaginal estrogen
Vaginal DHEA
Ospemifene
Systemic HT