Gyn Hormone Replacement Therapy
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| Progestin Therapy | Decreases incidence of endometrial hyperplasia, used continuously or cyclically with estrogen, 10-13 days of progestin provide maximal maturation of endometrium and eliminates hyperplasia
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| Endometrial Hyperplasia | Increases risk for cancer. IF UTERUS PRESENT, ALWAYS USE A COMBO OF ESTROGEN + PROGESTIN. If hysterectomy, progesterone is not essential
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| Regimens of only Estrogen and minimal progestin in women with uterus intact was found to result in | higher rates of hyperplasia; this tx is not recommended
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| Benefits of Parenteral administration of HRT | Bypasses GI tract and avoids 1st pass metabolism, may offer more physiologic estradiol to estrone ratio (estradiol>estrone), Good for high TG's or abnormal LFTs
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| Which administration route of HRT avoids significant systemic effects? | Local application
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| Transdermal administration of HRT | Delivers estradiol to venous circulation at a continuous rate; no 1st pass metabolism. Application site rxn: 5-10% of women. Need to rotate site
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| ____ is a naturally occuring mixture of conjugated equine estrogens | Premarin
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| Estrogen oral tablets | Premarin, Cenest (syn. conjugated estrogens), Ogen and Ortho-Est (estropipate), Menest (esterified estrogens), Estrace and Gynodiol (estradiol)
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| Transdermal Patches of Estrogen | All contain estradiol. Apply to skin once weekly (Climara only) or twice weekly. Do not make dosage increases until after the 1st month of therapy
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| Estrogen Injections | Premarin IV (conjugated estrogen),Delestrogen IM (estradiol valerate in oil), Depo-Estrodiol IM (estrodiol cypionate in oil)
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| Micronized progesterone USP in peanut oil | Prometrium
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| Conjugated equine estrogens and medroxyprogesterone acetate | Premphase and Prempro
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| Benefits of testosterone | Increased libido, sense of well-being, more energy. (lecturer's notes: no compelling reason for rx. some women notice benefits.)
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| Monitoring of HRT upon initiation | re-evaluate within several wks of beginning HRT for resolution of menopausal sx, AEs, BP and Wt, assessment of vaginal bldg, compliance. Lowest dose and evaluate every 3-6months for possible taper or d/c
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| Withdrawal vasomotor sx | hot flashes
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| HRT indications | Tx of moderate to severe vasomotor sx associated with menopause. Tx of mod-severe sx of vulvar and vaginal atrophy associated with menopause. Prevention of postmenopausal osteoporosis
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| Black box warning of HRT | E+P should not be used for prevention of CVD. Use lowest dose for the shortest amt of time
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| Absolute CIs of HRT | Known of suspected breast CA, estrogen-dependent neoplasia, undiagnosed abnl genital bldg, active or hx of thromboembolic dz, pregnancy, porphyria: RBC abn + liver dz, active liver dz
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| Relative CIs of HRT | Hx of endometriosis, uterine fibroids, PMS. Migraine HAs, Gallbladder dz, hypertriglyceridemia (consider transdermal), Seizure disorder, Breast or endometrial CA
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| CIs of Progestins | Allergy to Progestins, active thrombophlebitis, thromboembolic dz, cerebral hemorrhage, impaired liver fxn or dz, CA of breast or genital organs. Undiagnosed vaginal bldg
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| Details of Women's Health Initiative study | >161,000 women age 50-79, 15 yr project begun in 1991. RCTs: hormone trials, dietary modification, calcium and vit. D
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| Benefits of HRT | Alleviation of Vasomotor sx (80-90%), relief of vaginal sx, raised HDL, lower LDL, alleviation of mood swings and fatigue, reduced fractures, less colon CA and decreased risk of DM
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| Risks associated with HRT | breast CA (24% increase), Endometrial CA (unopposed estrogen), thromboembolic events (DVT, MI, CVA), increased risk of dementia, urinary incontinence
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| Alternatives for Menopausal sx | Herbal/complementary therapies, bio-identical estrogens, antidepressants, neuroendocrine agents, lifestyle and behavioral modifications
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| Herbal Therapies | Phytoestrogens (soy isoflavones, red clover), Black cohosh, Dong quai, evening primrose oil, ginseng, wild yam, vitamin E, others
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| Phytoestrogens | Nonsteroidal plants compounds wtih weak estrogenic activity: Coumestans, Lignans, Isoflavones. Ex: promensil (red clover)
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| These are also known as "nature's SERMS (selective estrogen receptor modulators)" like raloxifene | Soy Isoflavones
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| Trifolium pretense | Red Clover. Compounds that are metabolized to genistein and daidzein. Promensil (novogen) is the most studied. Red clover has been studied and shown to have no sig. diff in hot flash frequency. data conflicting
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| The most studied herb for menopausal sx | Black Cohosh (actaea racemosa/Cimicifuga racemosa). Remifemin (GSK). AE's: GI upset, HA, dizziness
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| Angelica sinensis | Dong Quai. Traditional Chinese herb. Very little data. Contains coumarins and potentiates warfarin, may cause photosensitivity
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| This alternative therapy contains high concentrations of linoleic and linoleic acid | Primrose Oil. Oenothera biennis. Used in Native American medicine. No published evdience of vasomotor sx relief. Increases HDLs. AE's: upset stomach, mild HA, may lower seizure threshold
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| Ginseng | Panax ginseng. Active components of ginsenosides (possible estrogenic effects), inconclusive data (no benefit for menopausal sx, imroved QOL/mood)
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| Wild Yam | Dioscorea villosa, topical, thought to have progestogenic properties, human body cannot convert diosgenin, no published evidence of sx improvement
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| Natural Hormone therapy | hormone tx wtih individually compounded recipes of certain steroids in various dosage forms. Based on saliva testing used to quantify endogenous hormones. Ex: Biest, Triest
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| Benefits of testosterone | build and promote muscle tone, decrease fatigue, enhance well-being, maintain energy, increase libido, aid in new formation of bone
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| E1 | Estrone: predominant post-menopausally
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| E2 | Estradiol: considered most potent, highest levels pre-menopausally
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| E3 | Estriol: Considered least potent
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| Risks of Bio HRT | the same as "traditional" HRT. Patient couseling essential
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| Neuroendocrine agents | Clonidine and methyldopa can reduce hot flash frequency by >50%. Gabapentin has shown some effect on hot flashes. Significant AE profile
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| Antidepressants | Venlafaxine, Paroxetine (paxil), Fluoxetine (Prozac), Desvenlafaxine (Pristique)
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| Nonpharmacologic Therapy | regular exercise, weight control (b/c estrogen can collect in fat deposits), layer clothing, cold water on face and wrists
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| Osteoporosis: Estrogen and Bone loss | Decreased estrogen triggers increase in osteoclast activity with no increse in osteoblast activity. Decreases CA absorption from GI tract, Increases urinary excretion of CA, may impair calcitonin secretion leading to increased bone resorption.
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| Calcium | slows the rate of bone loss after menopause.
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| Recommended Calcium dose if >50 and not on estrogen | 1500mg/day
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| Recommended Calcium dose is >50 on estrogen | 1000mg/day
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| Recommended Calcium dose if >65 | 1500mg/day. If pregnant and nursing then 1200-1500mg/day
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| Form of Calcium with the highest percentage of Calcium | Carbonate (40%) 3 tabs of tums, oscal, etc is 1000 mg.
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| Vit D RDU | Adults 400IU/day, Adults >70 yo 800 IU/day. Adequate levels required for calcium absorption from the GI tract.
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