OBGYN - Menopause and HRT
From Iusmicm
Menopause and Hormone Replacement Therapy
Menopause
- Loss of reproductive capability
- Marked decline in ovarian hormone production
Terminology
- Perimenopause:
- Menopausal Transition (climacteric):
- Menopause:
Phases of Menopause
Physiology
- Decreasing number of follicles
- Variable follicular phase length
- Decreasing incidence of ovulation
Endocrinology
- Decreasing inhibin
- Increasing FSH
- Variable estradiol levels
- Estrone replaces estradiol as the predominant estrogen
- Testosterone gradually declines with age
Symptomatology
- Menstrual cycle changes
- Declining fertility
- Neuroendocrine complaints
- Multiple organ system changes
Differential Expression of ER-alpha and ER-beta
Is menopause an estrogen deficiency disease?
Benefits of ERT
Vasomotor Symptoms
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?
Osteoporosis
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
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
- Estrogen receptors are found in brain regions involved with cognition
- 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
- Whether there is a critical period of initiation of ET/HT for prevention of
Colon Cancer
- Relative Risk of CRC among HRT pts:
Reservations about ERT
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
Endometrial Cancer
- RR of Endometrial Cancer for HRT pts
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:
Cardiovascular Disease and Thromboembolic Events
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
Potential Treatment Options
- Lifestyle modifications
- Therapies for specific complaints
- Approaches for vasomotor symptoms
- Education
- Environmental modification
- Behavioral modification
- Nonprescription therapies
- Prescription therapies
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
Hormonal Regimens for Menopausal Therapy
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
