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Ph Gyn HRT
Pharm Gyn
| Question | Answer |
|---|---|
| Before menopause, primary circulating estrogen = | Estradiol (E2); serum estradiol levels 30-200 pg/mL |
| After menopause, primary circulating estrogen = | Estrone (E1); mean serum estradiol levels < 15 ng/mL |
| Higher estrone: estradiol ratio with: | Oral estrogen; Higher doses than systemic therapies |
| More physiologic estradiol: estrone ratio with: | systemic estrogen; lower doses than PO estrogens |
| Most appropriate for urogenital symptoms | vaginal estrogen |
| All approved for vasomotor symptoms | Transdermal estradiol gels (all are QD dosing) |
| Application site rxns | Transdermal estradiol patches |
| In women with a uterus, a progestin must be given: | for ≥ 10 days per cycle to prevent endometrial hyperplasia |
| In woman w/o uterus, give: | estrogen only (don’t need progestin) |
| Most effective tx for hot flashes | Hormone therapy (no effect of progestins on sx) |
| Most effective tx for sx of urogenital atrophy (vaginal dryness and sexual discomfort): | Hormone therapy; may worsen urinary incontinence |
| Estrogen delivered by the vaginal route provides | greater relief than the PO or transdermal route |
| Estrogen tx: osteoporosis | will stabilize the process of osteoporosis or prevent it from occurring |
| Estrogen tx: osteoporosis benefit seen: | primarily within >5 yrs of therapy; max protection requires ≥ 10 yrs tx |
| FDA indications for HRT | vasomotor sx; mod-severed vulva/vag atrophy; prevent menopausal osteoporosis |
| Estrogens and progestins Black Box warning: | should not be used for the prevention of cardiovascular disease |
| Progestin CI | Hypersensitivity to progestins; Active thrombophlebitis, thromboembolic disorders or cerebral hemorrhage; Impaired liver function or dz; BrCa or genital ca; Undiagnosed vaginal bleeding |
| Evaluate pts within several weeks of starting HT | Resolution of menopausal sx; AE, BP, weight; Compliance |
| Most common HRT AE | breast tenderness, HA, irregular bleeding |
| AE: Bleeding: incidence | 15% of ET alone cycles, 18% of combined continuous E/P cycles, 74% of sequential E/P cycles |
| Reevaluate HRT every: | 3-6 months for possible taper or discontinuation |
| Alt tx for hot flashes | Venlafaxine, paxil, Prozac, clonidine, gabapentin |
| Bio-identicals testing | salivary hormone levels |
| Bio-identicals include | Estriol (E3); Biest; Triest; Micronized progesterone; Progesterone gel; Testosterone |
| Estriol is not: | FDA approved |
| Soy isoflavones = | Nonsteroidal compounds with estrogenic activity derived from plants (phytoestrogens) |
| Soy isoflavones have: | Lower potency than estradiol; considered very safe |
| Soy isoflavones: studies in Asians = | lower incidence of breast cancer, hot flushes; no evidence of positive effect on hot flashes |
| Black cohosh AE | GI upset, HA, dizziness; poss hepatotoxicity |
| If a uterus is present and you are putting a woman on hormone replacement therapy always include | Progestin |
| If you are putting a woman on hormone replacement and she has had a hysterectomy __ is not essential | Progesterone |
| Hormones given parenterally may offer more __ ratio | Physiologic estradiol to estrone (estradiol>estrone) |
| What route of hormone replacement is very rarely used (not very patient friendly) | Injection |
| Prometrium is contraindicated in anyone with a __ allergy | Peanut |
| Why is testosterone given to postmenopausal women, what does it improve | Libido, sense of well-being, energy |
| What should be monitored within several weeks of beginning HRT | Resolution of menopausal symptoms, possible adverse SE’s, BP and Wt, assessment of vaginal bleeding, compliance |
| Women should be on the lowest hormone dose that controls symptoms and re-evaluated every __ for possible taper or discontinuation | 3-6 |
| When HRT is tapered what is the most common withdrawal vasomotor symptom | Hot flashes |
| What is the purpose of HRT (indications) | Treatment of moderate to severe vasomotor symptoms associated with the menopause, treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause, prevention of postmenopausal osteoporosis |
| Estrogens and progestins should not be used for the prevention of __ | Cardiovascular disease |
| What are the absolute contraindications for estrogen | Breast cancer, estrogen-dependent neoplasia, undiagnosed abnormal genital bleeding, thromboembolic disease, pregnancy, porphyria, active liver disease |
| Benefits of HRT | Alleviation of vasomotor symptoms, relief of vaginal dryness/atrophy, raised HDL/lowered LDL, alleviation of mood swings and fatigue, reduced risk of fractures, reduced risk of colon cancer, reduced risk of diabetes |
| Risks associated with HRT | Breast cancer, endometrial cancer, thromboembolic events, increased risk of dementia |
| Unopposed estrogen can lead to | Endometrial cancer |
| If your patient doesn’t want to use HRT what are some other options to treat menopausal symptoms | Herbal/complementary, bio-identical estrogens, antidepressants, neuroendocrine agents, lifestyle and behavioral modifications |
| Herbal therapies that may be used in the treatment of menopausal symptoms | Phytoestrogens (soy isoflavones, red clover), black cohosh, dong quai, evening primrose oil, ginseng, wild yam, vitamin E |
| Most studied herb for menopausal symptoms, was show to be somewhat effective for the treatment of hot flashes | Black Cohosh (Remifemin) |
| Gabapentin has shown some effect on __ | Hot flashes |
| __ has the highest percent of elemental calcium | Calcium carbonate |
| Nonsteroidal compounds with estrogenic activity derived from plants (phytoestrogens)= | soy isoflavones |
Created by:
Abarnard
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