Background

• Menopausal women experience vasomotor symptoms, due to ↓ in estrogen and progesterone can cause an ↑ in FSH, result in vasomotor symptoms: hot flashes, heat sensation and night sweats. Natural products for vasomotor symptoms include black cohosh, red clover, soy and evening primrose.
• The most effective therapy for vasomotor symptoms is systemic hormone therapy with estrogen, which can ↓ LH and lead to more stable temperature control.
• In women with a uterus, estrogen should not be used alone, this will put them at risk for endometrial cancer (without progesterone).
• Short term, lowest dose possible.
• In women with history of breast cancer: avoid hormonal contraception, suggest copper IUD.

 

HRT SE and warnings:

• Estrogen ↑ risk of stroke, dementia, breast/endometrial cancer, thromboembolic events, increase TG and HDL, helps with bones.
• Progestin ↓ bone mineral density, and may cause mood disturbance.

 

SSRI

• Paroxetine (Brisdelle) is used for moderate-severe vasomotor symptoms, it is a 2D6 inhibitor and will block effectiveness of tamoxifen, and ↑ risk of bleeding with warfarn.

 

Formulations

• Topical formulation bypass first pass metabolism, and allows for lower systemic dose, which is linked with ↓ risk of VTE.
• Remove patch before MRI, can cause burn; Never apply patch to breasts.
• Femring (higher dose, systemic effect) vs Estring (lower dose, local vaginal effect)
• Estradiol patches (Climara, Menostar – weekly patch; Combipatch, Vivelle-Dot, Alora, Minivelle – twice weekly)
• Topical gel (Divigel): apply to alternate upper thigh daily.

 

Intrarosa (prasterone)

• a new Rx option to treat pain during intercourse (dyspareunia) in postmenopausal women.
• It's a vaginal insert used nightly for moderate to severe symptoms. Think of Intrarosa as an alternative to low-dose vaginal estrogen (Estrace Cream, Estring, Vagifem, etc) with local effects and limited systemic absorption.
• First-line options for mild vaginal dryness symptoms include a vaginal moisturizer plus a lubricant. For more severe symptoms, advise adding low-dose vaginal estrogen or Intrarosa.
• Intrarosa will be promoted as a non-estrogen, but it contains prasterone, known as dehydroepiandrosterone (DHEA), which is converted in vaginal tissues to estrogens and androgens.
• Suggest saving oral Osphena (ospemifene) for women who don’t want to use vaginal estrogen or Intrarosa. It’s a selective estrogen receptor modulator (SERM) with estrogenic effects on vaginal tissue, avoid using other estrogen-containing products (worsen hot flashes, ↑ clotting risk)

 

Testosterone therapy

• Hypogonadism: resulted from disease, age, procedures.
• Medications ↓ testosterone: opioids (esp. methadone), chemo for prostate cancer, cimetidine, spironolactone (both the last two drugs have anti-androgenic effect)
• Testosterone warnings: ↑ clotting risk (↑ hematocrits), CV events, prostate growth.
• SE: baldness, gynecomastia, acne, ↓ sperm count, edema, hepatotoxicity.
• Apply to arms or thighs, avoid genital area, wash hands thoroughly, avoid contaminating others (risk of early virilization in exposure in children)
• Formulations: under the gum (Striant), transdermal patch (Androderm), cream, gel (Androgel), oral capsule, pellet implants (Testopel), IM inj, transderm soln (Axiron), nasal gel.

 

 

Quiz

In which of the following clinical scenarios would hormone replacement therapy be contraindicated?

A.Breast cancer

B.Obesity

C.Stage 3 CKD

D.Diabetes mellitus

E.History of hysterectomy

Hormone replacement therapy is contraindicated in patients with breast cancer due to the potential to exacerbate tumor growth. Obesity, kidney disease, and diabetes are not contraindications to hormone replacement therapy. Patients with a history of hysterectomy may take unopposed estrogen but do not need progestin.

 

 

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