From Iusmicm

Contents 1 Menopause and Hormone Replacement Therapy 1.1 Menopause 1.1.1 Terminology 1.1.2 Phases of Menopause 1.1.3 Physiology 1.1.4 Endocrinology 1.1.5 Symptomatology 1.1.6 Differential Expression of ER-alpha and ER-beta 1.1.7 Is menopause an estrogen deficiency disease? 1.1.8 Benefits of ERT 1.1.8.1 Vasomotor Symptoms 1.1.8.2 Urogenital Atrophy 1.1.8.3 Osteoporosis 1.1.8.4 Possible Cardiovascular Protection 1.1.8.5 Possible Effect on Memory, Alzheimer’s Disease 1.1.8.6 Colon Cancer 1.1.9 Reservations about ERT 1.1.9.1 Contraindications 1.1.9.2 Endometrial Cancer 1.1.9.3 Breast Cancer 1.1.9.4 Cardiovascular Disease and Thromboembolic Events 1.1.10 Evaluating the Menopausal Patient 1.1.11 Potential Treatment Options 1.1.11.1 Hormonal Agents for Menopausal Therapy 1.1.11.2 Hormonal Regimens for Menopausal Therapy 1.1.11.3 General Principles of Menopausal ET / EPT

[edit] Menopause and Hormone Replacement Therapy

[edit] Menopause

• Loss of reproductive capability
• Marked decline in ovarian hormone production

[edit] Terminology

• Perimenopause:
• Menopausal Transition (climacteric):
• Menopause:

[edit] Phases of Menopause

[edit] Physiology

• Decreasing number of follicles
• Variable follicular phase length
• Decreasing incidence of ovulation

[edit] Endocrinology

• Decreasing inhibin
• Increasing FSH
• Variable estradiol levels
• Estrone replaces estradiol as the predominant estrogen
• Testosterone gradually declines with age

[edit] Symptomatology

• Menstrual cycle changes
• Declining fertility
• Neuroendocrine complaints
• Multiple organ system changes

[edit] Differential Expression of ER-alpha and ER-beta

[edit] Is menopause an estrogen deficiency disease?

[edit] Benefits of ERT

[edit] Vasomotor Symptoms

[edit] Urogenital Atrophy

• Atrophic vaginitis
• Frequent UTI
• Incontinence

• Is the decline in estrogen associated with chronic diseases of aging, i.e., cardiovascular disease, Alzheimer’s Disease, osteoporosis, cancer?

[edit] Osteoporosis

[edit] Possible Cardiovascular Protection

• Incidence of Cardiovascular Disease: Relation to Menopause Status
• CVD is the leading cause of death among women
• Observational Studies of CVD Risk and ERT/HRT
• WHI: Revised Results

• Hypothetical Pathogenetic Sequence

[edit] Possible Effect on Memory, Alzheimer’s Disease

• Estrogen and Cognition
  • Estrogen receptors are found in brain regions involved with cognition
    • Cerebral cortex
    • Hippocampus
    • Basal forebrain
  • Estrogen increases cholinergic responsivity after menopause
  • These findings suggest that estrogen may affect cognitive function

• Mechanisms:

**

• Estrogen / Hormone Therapy and AD Risk:

• What WHIMS and WHISCA Cannot Address=====
  • Whether there is a critical period of initiation of ET/HT for prevention of
    • Cognitive aging
    • AD
  • Whether dose and types of HT and duration of treatment may have different effects

[edit] Colon Cancer

• Relative Risk of CRC among HRT pts:

[edit] Reservations about ERT

[edit] Contraindications

• Known or suspected cancer of the breast
• Known or suspected estrogen-dependent neoplasia
• Known or suspected pregnancy
• Undiagnosed abnormal genital bleeding
• Active thrombosis or thromboembolic disorders
• A past history of thrombosis, thrombophlebitis or thromboembolic disorders associated with estrogen use

[edit] Endometrial Cancer

• RR of Endometrial Cancer for HRT pts

[edit] Breast Cancer

• Perceived leading cause of death in women is breast cancer.
• Risk of Breast Cancer with HRT:
• Breast cancer mortality with HRT:
• Relative risk of breast cancer:

[edit] Cardiovascular Disease and Thromboembolic Events

[edit] Evaluating the Menopausal Patient

• History and physical exam
  • Menopausal stage
  • Symptoms, impact on QOL
  • Medical diagnoses, medications
  • Relevant risks, contraindications

• Labs, studies
  • Mammogram
  • r/o pregnancy
  • Evaluate abnormal bleeding
  • Evaluate relevant risks

[edit] Potential Treatment Options

• Lifestyle modifications
• Therapies for specific complaints
• Approaches for vasomotor symptoms
  • Education
  • Environmental modification
  • Behavioral modification
  • Nonprescription therapies
  • Prescription therapies

[edit] Hormonal Agents for Menopausal Therapy

• Estrogens
  • Oral
  • Transdermal: patches, gels, creams, spray
  • Vaginal: creams, rings, tablets

• Progestogens:
  • Oral
  • Intrauterine system
  • Vaginal: gel, insert

• Combination estrogen / progestogen:
  • Oral
  • Transdermal

[edit] Hormonal Regimens for Menopausal Therapy

[edit] General Principles of Menopausal ET / EPT

• Identify the reason for treatment
• Include a progestin if the uterus is present
• Use the lowest dose for the shortest time necessary to correct the problem
• Re-evaluate regularly for safety, efficacy, side effects