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CC Jan 2018 Menopause-related vasomotor symptoms (VMS)

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echoecho's version from 2018-03-11 17:53

Section

Question Answer
Menopause is reached when a women has no menses for ____ months?12
What is the median age for menopause in the USA?51.4 years
When is perimenopause or menopause transition seen?several years earlier before menopause
Perimenopause is marked by loss of usual cyclic hormonal ________, resulting in an initial lengthening of the _________ interval?fluctuations; intermenstrual
Due to ovarian function decline, estrogen levels drop resulting in what symptoms of menopause?VMS (vasomotor symptoms) such as hot flashes and genitourinary symptoms of menopause (GSM) such as vulvaginal atrophya and associated urinary symptoms
What % of menopausal women experience VMS?75
The prevalence of GSM increases as the interval from the last menstrual period increases (___% of women in early menopause transition, ____% of women 3 years postmenopause)?4; 47%
Initial interventions for mild VMS include what?nonpharmacologic measure
*** A Cochrane review found insufficient evidence to determine the efficacy of ________ for the treatment of VMS?accupuncture
What therapy (either estrogen alone or combination estrogen-progesterone) is the most effective rx for VMS (esp women w/ significant s/s and those who have not responded to nonpharmacologic interventions)?HT (hormonal therapy)
Why did the use of HT drop markedly in 2002? What can be said if further evaluation of study subsets is done?1) the Women's Health Initiate study results showed increased risk of heart disease, breast cancer, stroke and VTE associated with hormone use 2) further evaluation of study subsets found risks were NOT universal to all women so it is critical to consider in patients who are considering HT to be aware of the risks and benefits based on the patient's individual characteristics
In 2017, the North American Menopause Society (NAMS) released a position statement regarding HT in menopause, what was the statement?Statement took in to account all evidence regarding risks and benefits
Is there benefits to nonoral administation?there may be but no head-to-head studies exist to substantiate this
List the 4 indications for HT?1) VMS 2) GSM 3) prevention of bone loss 4) treatment of hypogonadism
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ESTROGEN
Question Answer
List the most commonly prescribed estrogens?1) conjugated equine estrogen (CEE) 2) synthetic estrogens (17-beta-estradiol) 3) ethinyl estradiol
Did a meta-analysis find any difference between CEE and estradiol in terms of efficacy in treating VMS?no
Of all the estrogens, which estrogen has the best efficacy or the treatment of anxiety and depression symptoms?estradiol
What is the recommendation for dose and duration of treatment for estrogens?1) smallest effective dose 2) shortest period of time
List the types of estrogen preparations?1) pills 2) transdermal patch 3) vaginal ring 4) topical gel 5) topical spray
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PROGESTIN
Question Answer
*** Why do women with an intact uterus receiving estrogen must also receive progestin in addition to the estrogen?to prevent endometrial hyperplasia and uterine cancer that can occur as a result of unopposed estrogen administration
List the most commonly used progestins?1) medroxyprogesterone acetate 2) norgestimate 3) norethindrone 4) drospirenone
Preparations of progestin?1) in combination with estrogen in a pill 2) in combination with estrogen in a patch 3) orally micronized progesterone
True or false? Adequately dosed progestins, given either continuously or cyclically, result in an endometrial neoplasia rate that is the same as women not on HT?true
*** Describe the patient that the benefit-risk ratio for HT is most favorable?1) < 60 y.o. 2) within 10 years of menopause with no contraindications who have bothersome VMS or are at increased risk for bone loss or fracture
What the are the risks in the above patient type?1) rare increased breast cancer risk with combined estrogen-progestin therapy (but NOT estrogen alone) 2) endometrial hyperplasia 3) cancer if unopposed estrogen given with an intact uterus 4) VTE 5) biliary issues
For women > 60 years of age or those who are more than 10 or 20 years from menopause, the benefit-risk ratio is LESS favorable with increases in absolute risk for what conditions?1) CHD 2) CVA 3) VTE 4) dementia
What medication is an alternative to combined estrogen-progestin therapy and because it contains NO progestin, it is not associated with vaginal bleeding (however long-term risks of DVT/PE are a concern)?1) combination of bazedoxifene and conjugated estrogen marketed as Duavee (0.45 mg conjugated estrogen / 20 mg bazedoifene) is indicated for the treatment of moderate to severe VMS 2) this pill may reduced risk of developing osteoporosis
What is Bazedoxifene?it is a SERM (selective estrogen receptor modifier) and has antagonistic effects on the breast and uterus, thus neutralizing the potential adverse effects of estrogen
For women with significant VMS who have contraindications for HT (breast cancer hx) or prefer nonhormonal treatment, what does the ACOG recommend?1) SSRI 2) SSNRI 3) gabapentin 4) clonidine 5) paroxetine (marketed as Brisdelle) is the only antidepressant that the FDA indicates for treatment of VMS
Why are TCAs (amitriptyline) NOT effective for VMS?they cause flushing
What med may be helpful for stress-related flushing but not effective for VMS? What med may be helpful for alcohol-related flushing but not effective for VMS?beta blockers (metoprolol); antihistamines
Regarding nonpharmacologic therapies for VMS, what 3 agents are recommended with the level of evidence for each?1) weight loss (recommended with caution {lesser quality evidence} - 1 randomized, controlled (RCT) supports; other studies show support but VMS were not the primary outcome measured 2) clinical hyponosis (recommended {high-quality evidence} - RCTs demonstrated benefit for frequency and severity 3) Cognitive behavorial therapy (CBT) (recommended {high-quality evidence} - RCTs demonstrate benefit for symptom severity but not frequency
Regarding nonpharmacologic therapies for VMS, what 9 agents are NOT recommended with the level of evidence for each?1) cooling techniques - clothing adjustments (e.g. layering natural fiber clothing), environmental controls (e.g. fans, ice water) (not recommended {export opinion} - no clinical trial evidence to support efficacy 2) avoiding triggers (alcohol, spicy foods) (not recommended {expert opinion} - no clinical trial evidence to support efficacy 3) exercise - regular, aerobic exercise (not recommended {high-quality evidence) - randomized trials do not support efficacy 4) yoga (regular practice)(not recommended {high level of evidence} - randomized trials do not support efficacy 5) relaxation (not recommended {lesser quality evidence} - limited and inconsistent results from studies 6) Soy foods and soy extracts (phytoestrogens)(RECOMMENDED with caution {lesser quality evidence} - inconsistent results, may be beneficial for a subset of women 7) black cohosh (not recommended {high-quality evidence} - randomized trials do not support efficacy 8) Dong quai, flaxseed, evening primrose, ginseng, hops, pine bark (not recommended {high quality evidence} - no evidence of benefit 9) vit E, omega - 3 fatty acids (not recommended {lesser quality evidence} - no evidence of significant clinical benefit
*** SUMMARY = What % of menopausal women experience VMS which can significantly affect quality of life?75%
*** SUMMARY = List 3 recommended nonpharmacologic measures to treat VMS?1) clinical hypnosis 2) cognitive behavioral therapy (CBT) 3) weight loss
*** SUMMARY = What therapy is the most effective treatment for VMS; treatment should be at the lowest ___necessary to management symptoms and for the _____ period of time?1) HT (hormonal therapy) 2) dose 3) shortest
*** SUMMARY = Nonhormonal treatments include?1) SSRIs 2) SSNRIs 3) gabapentin 4) clonidine
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