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BCPS study guide

hormone therapy/menopause and osteoporosis

QuestionAnswer
benefits of estrogen decreases vasomotor ADEs (i.e. hot flashes), decreases genitourinary ADEs (i.e. painful intercourse, vaginal atrophy). may also help with mood. decreases bone resorption but does not regenerate bone mass.
benefits of progestogen protects against unopposed estrogen ADEs such as breast cancer, endometrial cancer, irregular bleeding. may also help augment osteoporosis benefits of estrogen.
two most problematic issues related to menopause genitourinary atrophy and vasomotor instability
risks of estrogen breast and endometrial cancers, CHD, bloating, headache, breast tenderness
risks of progestogen irritability, weight gain irritability, depression - all dose related irregular endometrial bleeding
studies have found risks associated with hormone replacement therapy. what are these risks increased risk of VTE and gallbladder disease, stroke particularly in women getting only estrogen, conflicting evidence regarding coronary heart disease (younger women may have lower risk but older women greater). weak evidence of ovarian and lung CA
therapy duration for HRT try to limit to 3 months at a time. and less than 5 years. if sx recur after 3 months do another 3 months. if sx continue after 3 months continue but recheck after 3 months to 1 year.
when should vaginal bleeding be evaluated in women in menopause if on HRT, any time if on ET only. if cyclic progestogen then any time other than during expected withdrawal bleed.
precautions that should be taken with ospemifene and MOA SERM (selective estrogen receptor modulator) give with progestin in pts with uterus. presents same risks as estrogen
drug interactions with ospemifene rifampin decreases effects, fluconazole increases levels, avoid with other protein bound drugs it is highly protein bound
MOA of bazedoxifene SERM used instead of progestin. can be used in women with uteruses.
indications for SSRIs and SNRIs in women with menopause. agents recommended. alternatives to HT in women with vasomotor symptoms venlafaxine, fluoxetine, paroxetine, sertraline
natural products occasionally used for menopausal symptoms. black cohosh, evening primrose oil, soy, bioidentical hormones
role of clonidine and gabapentin and megestrol in menopause treatment alternatives for vasomotor symptoms
T scores for normal bone mineral density within 1 SD of young adult mean
T scores for low bone mineral density (AKA osteopenia) between -1 and -2.5 SD below young adult mean
T scores for osteoporosis bone mineral density below -2.5 SD below young adult mean.
drugs that increase risk for osteoporotic fractures corticosteroids, heparin, anticonvulsants, excessive levothyroxine, GnRH agonists, lithium, cancer drugs
adequate intake of calcium and vitamin D at least 1000 mg calcium in women under 51 and men under 70. 1200 in women over 51 and men over 70. and ~800-1000 IU vit D for pts older than 70 yrs and 600 IU for under 70 yrs
when to begin screening for osteoporosis over 65 in women and 70 in men. 50-69 in men with additional risk factors or causes of secondary osteoporosis. postmenopausal women under 65 with previous fractures or risk factors or very thin
when to initiate drug therapy in patients with osteoporosis if hip or spine fracture, if BMD T score <-2.5 at spine, hip or femoral neck. or between -1 and-2.5 if high fracture risk.
drug treatment options for osteoporosis other than calcium and vit D bisphosphonates, SERMS (raloxifine, conjugated estrogens + bazedoxifene) calcitonin salmon, teriparatide, denosumab, HRT
ADEs associated with bisphosphonates GI, headache, musculoskeletal pain, rash, osteonecrosis of the jaw (BRONJ). atypical fractures, esophageal cancer, atrial fibrillation
food related concerns with bisphosphonates must wait for 30 minutes before ingesting anything other than water. exceptions include ibandronate (Boniva) which is 60 minutes and risendronate which must be taken with food.
target vitamin D levels 30 ng/ml in adults, may be ok for 20 ng/ML
raloxifene has been shown to prevent specific fracture types. what are these reduces risk of vertebral fractures by 30-50% but has not shown similar decrease in hip fractures
drug interactions exist between raloxifene and warfarin, thyroid hormone and bile acid resins. what is the resulting interaction and any required management warfarin decreases PT by ~10%. thyroid hormone administration should be separated by 12 hours. bile acid resins decrease raloxifene absortion by 60%
MOA of teriparatide (Forteo) recombinant human PTHwhich regulates bone metabolism, intestinal calcium absorption and renal tubular calcium and phosphate reabsorption
drug interactions associated with teriparatide may increase risk of digoxin toxicity and increases serum calcium levels
indications of denosumab use in postmenopausal women with osteoporosis and in patients with bone loss associated with prostate or breast cancer
safety issues associated with denosumab opportunistic infections, skin infections such as cellulitis, hypocalcemia especially in pts with renal dysfunction and patients should take calcium and D with denosumab.
Created by: mjuhlin