TOPIC 00: Menopause - Before and After Menopausal Phase

**Symptomatic menopause**

• HRT is combined estrogen/progesterone therapy that MUST be used in a woman with an intact uterus
• Cyclic or continuous treatment
• ERT is estrogen only replacement therapy and is used with a woman that has undergone a hysterectomy

• Decrease vasomotor symptoms
• Improvement in QOL
• Improvement in urogenital symptoms
• Decrease osteoporosis risk
• May protect against dementia

Hormone therapy is approved by FDA for four indications:

• Bothersome VMS
• Prevention of bone loss
• Hypoestrogenism caused by hypogonadism, castration, or POI
• Genitourinary symptoms

• Undiagnosed vaginal bleeding
• Known or suspected pregnancy
• Vascular thromboembolic episodes (CVA,MI, DVT, Thrombophlebitis)
• Active liver disease acute or chronic
• Known or suspected cancer of the breast or reproductive tract

• Type I DM
• Active gallbladder disease
• > 1ppd smoker
• Obesity
• FMH breast cancer
• Fibroid uterus
• HX of peripheral vascular episode
• Migraines
• Elevated triglycerides

• Newly menopausal (within 5 years)
• Good health
• No risk factors for heart disease or breast CA (no first degree relative and neg fmx for BRCA1 or 2)
• Non smoker
• Non-obese
• Normal Blood sugar and blood pressure
• Moderate to severe vasomotor s/s or menopausal s/s

• Blood Clots
• Gallbladder Disease
• Breast Cancer
  • < 4yr no increase risk
  •    4-10 years questionable
  • > 10 year increase risk
• Increased cardiac events in 1st year use with patient with prior heart disease – HERS II

• Cardiac protection-counsel on other methods
• Osteoporosis prevention-alternatives
• Short term use for Vasomotor S/S 1-4 years
• Long term use for Vasomotor S/S-creams, mood elevators, sleeping pills
• Estrogen with Progesterone 5  years use ok
• Estrogen alone can be used up to 7 years

1. Conjugated estrogen – Premarin (0.3/0.45/0.625,0.9,1.25mg/d)
2. Esterified estrogen – Menest (0.3/0.625,1.25,2.5mg/d)
3. Transdermal estrogen – Vivelle dot, Vivelle, Estraderm, Alora, Climara, Esclim, Menostar, FemPatch **avoids liver effects and less effect on triglycerides and lipids compared to oral formulations.
4. Micronized estrogen – Estradiol 1.0mg/d

• MUST be used in ALL patients intact uterus - protect uterine lining from estrogen effects
• Provera or Prometrium

1. Cyclic – taken the first 10-15 days of the month with estrogen
2. Continuous – taken everyday that estrogen is taken, usually 2.5-5.0 mg qd of MPA
3. Combined products – Prempro, Premphase, FemHRT, Activella, Ortho-Prefest, CombiPatch
4. Duavee – conjugated estrogen/bazedoxifene (SERM)

• BTB or withdrawal bleeding
• Progesterone: breast tenderness, fluid retention, wgt gain, depression, irritability
• Increase fibroids
• Allergic reaction to patch
• Virilization with testosterone products

• Proper way to take meds
• Report bleeding
• SBE
• Exercise and calcium 1200 mg/qd + Vit D 1000IU
• Preventative health measure (pap,mammo,fobt, colonoscopy)
• S/S of danger signs (CVA, MI, Endo CA)

• Brisdelle 7.5 mg QHS (paroxetine)
• Venlafexine- venlafaxine ER 37.5 qd x 1 week then 75mg once a day or Immediate release 37.5mg qd x 1 week then 37.5 mg bid
• Gabapentin- 600mg q hs or 300mg TID depending on when the flashes take place (Hot flashes or night sweats)
• Clonidine – 50-75 mcg/day
• SSRI some effect+/-
  • Paroxetine 25mg qd
  • Fluoxetine 10-20mg qd
  • Sertraline 50mg qd

Improve sleep habits

• Melatonin
• Gabapentin - 300mg 1-2 hours before bedtime, some patients may need 600mg
• Lunesta - 2mg qhs
• Ambien - 5mg qhs (no longer 10mg)

• May be effective - Estroven, Black Cohash, Soy, Vitamin E
• No evidence – Dong quai, acupuncture, yoga, Evening primrose, Ginseng, Kava, Red Clover, Flaxseed