Z.KARIMI MD FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY - PowerPoint Presentation

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Z.KARIMI MDFEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY(FPMRS) FELLOWSHIP

Menopausal Hormone Therapy

Definitions and goals

1

hot

flashes

2

genitourinary

syndrome of menopause (GSM)

3

sleep disturbances4mood lability/depression5joint aches and pains

All types of estrogen are effective

for relieving hot flashes oral, transdermal, topical gels and lotions, vaginal rings and

subcutaneous implant

We most often start women on either a transdermal or oral preparation

.

The

transdermal route

is particularly important in women with hypertriglyceridemia, active gallbladder disease, or known thrombophilias such as factor V Leiden (without a personal history of VTE).

ESTROGEN PREPARATIONS

Oral micronized 17-beta estradiol

is structurally identical ,poorly absorbed unless it is micronized , absorbed through the lymphatic system.

Conjugated equine estrogens (CEEs)

are derived from pregnant mares' urine.

Ethinyl

estradiol

the estrogen used in almost all oral contraceptive preparations. much more potent ,used in very low doses (5 mcg). We prefer 17-beta estradiol over other estrogens such as conjugated equine estrogens (CEE

)Oral estrogen

The potency, and therefore the doses, of these estrogen preparations differ,

but they differ little in efficacy .

0.625 mg of conjugated estrogens

1 mg of micronized 17-beta estradiol,

0.05 mg of

transdermal

estradiol

, 5 mcg of ethinyl estradiol

Oral estrogen Dose

after bilateral oophorectomy (

eg, 2 mg oral estradiol or 0.1 mg transdermal estradiol or their equivalent) for the first two to three years after surgery

Oral CEE (0.625 mg/day) were commonly used in the past

In the past, a "one-size-firsts-all

" approach to estrogen dosing in postmenopausal women was used, eg,

all women were started on the same dose ("standard

doses.

However, the current approach is to start with lower doses, such as transdermal estradiol (0.025 mg) or oral estradiol (0.5 mg/day

), and titrate up to relieve symptomsDose

contain 17-beta

estradiol with a wide range of dosing options, from 14 to 100 mcg/day. The lowest-dose patch containing 0.014 mg of 17-beta estradiol is approved for

prevention of osteoporosis. In some women, that dose is also adequate for

relief of hot flashes in

some women .

One

gel is packaged in a non-aerosol, metered-dose pump and is applied once daily on

one arm (from wrist to shoulder). topical skin spray is available that delivers 1.53 mg of estradiol with each sprayTransdermal estrogen

High dose (systemic estrogen)

treat vasomotor symptoms, for systemic use .As an example, a vaginal ring

We do not recommend these higher vaginal estrogen doses

for genitourinary symptoms

Low dose

Vaginal

estrogen is

used in very low doses for the management of vaginal atrophy (now known as GSM). These low-dose vaginal preparations are

not associated with cardiovascular or oncologic complications. Vaginal estrogen

All women with an intact uterus need a progestin to be added to their estrogen

to prevent endometrial hyperplasia, which can occur after as little as six months of

unopposed estrogen

.

Women who have undergone

hysterectomy should not receive a progestin

,

as there are no other health benefits other than prevention of endometrial hyperplasia and carcinoma. Progestins

natural micronized progesterone

200 mg/day for 12 days/month [ie, a cyclic regimen] or

100 mg daily [continuous regimen]).at

bedtime ,safer for the

cardiovascular system and

breast.

medroxyprogesterone

acetate (MPA; 2.5 mg daily). associated with an excess risk of coronary heart disease (CHD

) and breast cancer when administered with conjugated estrogen ,continuous versus cyclic MPA may be associated with a higher risk of breast cancer. Dosing

Women taking standard doses of estrogen require monthly progestins.

Other progestins that have been used include quarterly regimens

(progestin administered only every third month). However, quarterly progestin administration is

not considered to be adequately protective and cannot be recommended for women taking standard doses of estrogen.

Women

taking lower doses of estrogen

(

eg, 0.014 mg transdermal estradiol), however, require very little progestin (two 12-day courses every six months). Frequency

Vaginal use of micronized progesterone

Levonorgestrel-releasing IUDs Conjugated estrogen/bazedoxifene

unable to tolerate

oral progesterone

patient age, severity of symptoms, and

the patient's calculated risks for cardiovascular disease and breast cancer Patient

age and years post-menopauseHot

FLashesMood lability

/depression Sleep disturbances

Joint aches and pains

Vulvovaginal

atrophy symptoms only No longer indicated: Prevention of chronic diseases Clinical indications

breast cancer CHD a previous venous thromboembolic (VTE) event or stroke

active liver diseaseunexplained vaginal bleedinghigh-risk endometrial cancer transient ischemic attack

Contraindications

We choose our initial regimen based upon the patient's menopausal stage Women in late menopausal transition or early

postmenopauseCyclic combined regimens/Withdrawal bleeding B

. Women >2 to 3 years post-Final menstrual

periodContinuous combined regimensPREFERRED REGIMENS

Dose adjustments

Endometrial monitoring

MammographyFOLLOW-UP AND MONITORING

Endometrial monitoring

Eendometrial biopsy postmenopausal women with irregular bleeding

Perimenopausal women +

irregular bleeding+bleeding is very heavy

bleeding

persists beyond first six months after

beginning

continuous combined heavier or bleeding occurs after a long period of no bleeding after estrogen therapy TVUS :

standard clinical indications, such as to assess adnexal pathologyendometrial biopsy cannot be easily obtained.

Standard recommendations

Extended use of MHTStopping hormone

therapy

TaperingDURATION OF USE

SPECIAL POPULATIONSPrimary ovarian

insuficiency: younger age /HIGHER DOSE

Breast cancer patients:not

recommend History of ovarian or endometrial

cancer:intermediate- or

high-risk

disease

……Nonhormonallow-risk disease, younger women…candidates for hormone therapyWomen with migraines:

continuous transdermal hormone

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