566 Final Exam Study Guide

Week 5

 Prevention of osteoporosis with hormone replacement therapy

o Selective Estrogen Receptor Modulators (SERMs)

 Tamoxifen (Nolvadex-D), Toremifene (Fareston), Raloxifene (Evista),

and Bazedoxifene (Duavee - postmenopausal women drug)

 These drugs provide benefits of estrogen (protection against

osteoporosis, maintenance of the urogenital tract, reduction

of LDL cholesterol) while avoiding its drawbacks (promotion

of breast cancer, uterine cancer, and thromboembolism)

o Prevention of osteoporosis requires lifelong hormone replacement

 When stopped, bone loss decreases by 12%.

 LIfelong treatment increases health risks.

o All women (and men) should practice primary prevention of bone loss by

ensuring adequate intake of calcium and vitamin D, performing regular

weight-bearing exercise, and avoiding smoking and excessive alcohol use.

- When and when not to use progestin for hormone replacement therapy and why -

 When To Use:

o Menopausal Hormone Therapy

 Counteracts adverse effects of estrogen on endometrium in women

undergoing menopausal hormone therapy.

o Dysfunctional Uterine Bleeding

 Cessation of bleeding can be achieved with 10-14 day treatment.

 Withdrawal bleeding can take place when treatment stops.

o Amenorrhea

 Progestin helps induce menstrual flow in select women experiencing

amenorrhea.

 If endogenous estrogen levels are normal, give progestin for 5-10

days.

 If estrogen levels are low, need to induce endometrial proliferation

with estrogen before giving progestin.

o Endometrial Hyperplasia and Carcinoma

 Can provide palliation in women with metastatic endometrial

carcinoma - do not prolong life.

 Only approved long-term progestin therapy is for protection against

endometrial cancer.

 Progestin can suppress endometrial hyperplasia - a potentially

precancerous condition

o Help Support early pregnancy with the corpus luteum deficiency syndrome

and in women undergoing IVF.

o Hydroxyprogesterone Acetate (Makena) - helps prevent preterm birth.

 When Not To Use (Contraindications):

o Absolute Contraindications

 Undiagnosed abnormal vaginal bleeding.

o Relative Contraindications

 Active Thrombophlebitis

 Hx of thromboembolic disorders

 Active Liver Disease

 Carcinoma of the breast

o Do Not Use:

 Prepubertal Children

 High-dose therapy in first 4 months of pregnancy (birth defects)

Local vs. systemic estrogen options and why one would be chosen over the other -

 Systemic Options

o Oral

 Most active estrogenic compound - ESTRADIOL

 Estradiol is available alone or in combination with

progestins

 Popular because of its convenience.

o Transdermal

 Four Formulations

 Emulsion (Estrasorb), Spray (Evamist), Gels

(EstroGel, Elestrin, and Divigel)

 Four Advantages Over Oral Formulations:

 The total dose of estrogen is greatly reduced

(because the liver is bypassed).

 There is less nausea and vomiting.

 Blood levels of estrogen fluctuate less.

 There is a lower risk for DVT, pulmonary embolism,

and stroke.

o Intravaginal

 Femring

 Control hot flashes and night sweats as well as local

effects (treatment of vulval and vagnial atrophy).

o Parental

 IV and IM administrations - use of these routes are rare.

 Used in acute, emergency control of heavy uterine

bleeding.

 Local Options

o Intravaginal

 Primarily treatment for vulvar and vaginal atrophy associated

with menopause.

 Available as inserts, creams, and vaginal rings

 Intravaginal Inserts - Imvexxy, Vagifem, and Yuvafem

 Creams - Estrace Vaginal, Premarin Vaginal

 Rings - Estring (other vaginal ring, Femring, is

systemic effects)

Transdermal estrogen therapy has fewer adverse effects.

- Management of oral contraceptives (OCs)

o How to change patients from one combination oral contraceptive to another.

 Go straight from one type to the other, without taking a gap in between. Start the

new pill the day after taking the last active pill in the last pill packet. This also applies

with 'placebo' pills.