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1. Pharmacotherapy of
menopause
Dr Manjuprasad MS
Moderator: Dr Padmaja Udaykumar
1

2. Overview
 Introduction
 History
 Pathophysiology
 Treatment options
 Summary
 Conclusion
 Andropause
2

3. Menopause
It is the permanent cessation of
menstruation that results from loss of
ovarian follicular activity.
 meno – months
 pause – to seize
3

4. Menopausal age : 45 – 55 years
Mean age ( M ) : 50.7 years
Premature menopause < 45 years
Late menopause > 55 years
4

5. Diagnosis
For women > 50 yrs : 12 consecutive
months of amenorrhoea is diagnostic.
For women < 50 years :
* FSH > 30 IU/l
5

6. History
 In ancient Egypt about 2000BC
-if a menopausal woman has pain
Or makes trouble pound hard
on her jaw.
 18th century – menopausal
women wise or evil
 1920-1940- hormones to blame 6

7. Pathophysiology
Climacteric
No ovulation
No progesterone
Graffian follicle fails to develop
↓Estrogen activity
Endometrial atrophy
Amenorrhea 7

8. 8

9. 9

10. Risk factors for menopausal related
problems
• Surgical menopause or radiation.
• Chemotherapy esp alkylating agents.
• Smoking, caffeine, alcohol.
• Family history of menopausal diseases.
• Drugs related such as GnRH, heparin, corticosteroids
and clomiphene(anti- oestrogen) when given over
prolonged period can cause oestrogen deficiency. 10

11. 11

12. Attainment of menopause
 Menstrual
– 3 classic ways in which the menstruation
ceases are :
• Sudden cessation.
• Gradual diminution in the amount of blood loss
with each regular period
• Gradual increase in spacing of periods until they
cease for at least a period of one year.
12

13. Treatment options
1. NATURAL - Live a Healthy Lifestyle
– Enhance and accept what nature has given you.
2. MEDICAL TREATMENT - – treat specific symptoms or
problems with medications as they arise.
3. HORMONAL – replace the original substance that is
missing - prevention.
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14. Natural Menopause
 Woman’s body is genetically programmed to go
through a fertile phase that ends with the onset of
menopause.
 Symptoms –
- Not everyone has them,
- They may be mild, and even if .
uncomfortable, will usually resolve < 5 years.
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15. Hormone Replacement
 Not all women require HRT
 70-85% of women need only good
nutrition and healthy life style.
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16. Indications for HRT
1) Women having climacteric symptoms
 Vasomotor symptoms
 Urinary symptoms
 Sexual dysharmony
 Established osteoporosis on x-ray /B.M.D.
Measurements
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17. All asymptomatic high-risk women having
 Premature menopause (surgical / spontaneous)
 Family history of osteoporosis
 Poor diet, excess alcohol
 CVD, Alzhemeir’s disease, colonic cancer
 Corticosteroid & other medications
 High urinary calcium / creatinine
 Low plasma estradiol
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18. Drugs used in HRT
 Estrogen
 Progesterone
 Tibolone
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19. Estrogen therapy
 Short term estrogen therapy
To releive symptoms like; hot flush, night
sweats, palpitations, disturbed sleep
• In smallest effective dose for 3-6 months
Natural estrogens
• Oral premarin(Conjugated equine estrogen
(CEE): 0.625 mg daily)
• Ethinyl estradiol(0.01mg), Evalon(1-2mg),
micronized oestrogen are effective.
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20.  Medroxyprogestrone(10mg) or primolut-N
(2.5mg) daily for 10-12d each month.
 Combined hormone therapy(femet). 2mg
17-β-oestrodiol & 1mg of norethisterone
acetate.
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21. 2) for dyspareunia, urethral syndrome and
senile vaginitis
• Local estrogen cream(oestriol: 1/2g-
everyday-10-12 days a month for- 3-6
months)
–Short acting
– Cyclic progesterone administration is
not required.
–Postmenopausal withdrawal bleeding
do not occur.
• Estring (vaginal ringreleases 5-
10microgram - 3months) 21

22. Oral Preparations of estrogen
 Oral: -
– Conjugated equine estrogen (CEE): 0.625 mg
daily
– Ethinyl estradiol : 0.01mg
– Micronised estrogen : 1-2g
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23. Oral Estrogen
 Advantages
*Easy to take
cheap.
*Good control due to short t½ .
 Disadvantages
*High dose required.
*first pass effect in liver.
*daily intake
*tablet contain lactose& not suit to women who are
allergic to lactose.
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24. Transdermal Preparations of
estrogen
 estradiol Patches:
-contains: 3-4mg;
-releases 50 micro gm / 24 hour twice
weekly.
 Gel :for improving collagen in skin
-75 micro gm / 24 hours daily.
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25. ESTROGEN: TRANSDERMAL
 Advantages.
– Low dose, pure estradiol.
– Avoids intestinal & liver metabolism.
– Reduces serum triglyceride & insulin
resistance.
– No thromboembolic risk or hypertension
 Disadvantages.
– More expensive
– Not well tolerated in warm climates
– Variable absorption.
25

26. ESTROGEN: IMPLANTS
 Subcutaneous implant (estradiol): -
– 25 / 50 / 100 mg. 6 monthly.
 Advantages.
– Pure estradiol, 6 monthly insertion, high level of
estradiol in blood.
– Avoids first pass effects
– Better response in severe osteoporosis.
 Disadvantages.
– Needs surgical procedure
– Unable to control absorption
– Difficult to remove pellet
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27. Progesterone
 Role in HRT
• Prevents endometrial hyperplasia and cancer .
• Implant may replace oestrogen, where estrogen is c/I
or sensitive
• Prevents breast cancer
• Improves bone mineral density
– primolut-N 2.5mg ,
– medroxyprogestrone & duphaston
– Mirena IUCD- levonorgestrel
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28. Tibolone
 Synthetic derivative of 19-nor-testosterone.
 Weak oestrogenic, progestogenic, &
androgenic action.
 Endometrial hyperplasia
 Elevates the mood, relieves the VM
symptom, improves sex drive & reduces
bone resorption.
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29.  Cardioprotective
 SE: wt gain, oedema, tenderness in breast,
GI symptoms & vaginal bleed.
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30. Raloxifene
 Nonsteroidal comp., SERM, reduces the
risk of fracture by 50%
 causes 10% reduction in total cholesterol &
LDL & HDL level.
 does not raise the triglycerides levels →
cardio protective for long term.
 ↓osteoporosis.
 ↓ risk of Br Ca by 65-70%
 Dose- 60mg/day
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31.  Side effects
*hot flushes, cramps, venous thrombosis,
retinopathy.
• Contraindications
*venous thrombosis
*hepatic dysfunction
*stop the drug 72 hr before surgery
*indomethacin, naproxen, ibuprofen,
diazepam.
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32. Contraindications of HRT
 Breast cancer, uterine cancer or family
history of cancer.
 Previous history of thromboembolic
episode.
 Liver & gall bladder disease.
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33. How to stop HRT?
Slow taper
 Options
↓dose of estrogen in
the pill
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34. Bisphosphonates
 etidronate, tiludronate reduce bone resorption
through the inhibition of osteoclastic activity.
 Etidronate
10mg/Kg f body wt-2W followed by a gap of 2-3M &
this course is repeated for 10 such cycles.
 Not given with Ca (absorption ↓)
 Overdose- hypocalcemia.
 Milk &antacid - gastric irritation.
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35.  alendronate (5mg daily or 35mg weakly)
overdose-hypocalcemia.
 Risedronate (5mg/D or35mg/M)- gastric side
effect.
 Zolendronic acid(once yr i.v 5mg over 15min)
SE: osteonecrosis of the jaw & visual dis.
 Calcitonin-inh. Osteoclast activity
*nasal spray(single dose of 200IU daily for 3M)
NS can cause flushes, rhinitis, allergic reaction
. &nasal bleeding.
* ↓ fracture by 30%
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36. *SC inj. Of Calcitonin-GI symptoms
aneamia &inflammation of joint cause
poor compliants so also the high cost.
 Teriparatide-rec. formation of PIH
*abt 20μg once daily SC inj. Verti.
Fracture-65% others-50% ,if used <2yr
*nausea, headache are the complication.
 Strontium ranelate(1-2g daily orally)
↑ BMD-50%, very expensive
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37. Treatment of hot flushes
 Megestral acetate
A synthetic progeston
20mg BD shown to↓ hot flushes frequency by 85%
 Clonidine
α2 adrenergic agonist
20% ↓ in frequency & severity
Can be given orally or transdermally
0.2-0.4mg
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38.  Venlafaxine – 75mg/day
 Paroxetine – 12.5mg ↓ 62% in 6wks
25mg/day ↓ 65% in 6wks
 Fluoxetine – 20mg/day
 Citalopram – good results with standard dosing.
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39.  Gabapentine
900mg/day
↓ hot flushes by 45%
Evening dose of 300mg for night symptoms
 Vit E – minimal ↓ in hot flushes
 Soy Products- 45-60mg/day→modest benefit
 Red cloves
 Black cohosh
 Dong quai 39

40. Summary of Recommendations
for HRT
 Hormone replacement therapy should not be used
for chronic disease prevention in post-
menopausal women
 Primary indication for use of HRT in women is
for management of post-menopausal symptoms
– In healthy women the absolute risk for an
adverse event is extremely low so therapy
should not be withheld from patient’s with
severe symptoms
– Therapy should be used for shortest duration
possible at the lowest dose possible
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41. Andropause
41

42.  “Andras” in Greek meaning human male
 “Pause” in Greek meaning a cessation
 A syndrome in which the changes
accompanying ageing are associated with
the signs and symptoms of androgen
deficiency in the older male (traditionally
age >50). Signs and symptoms are
accompanied by a low serum testosterone
level.
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43. Signs and symptoms
 Endocrine,
 Somatic
 Sexual
 Psychological.
43

44. TRT
Testosterone Esters for IM Injection
Testosterone cypionate and enanthate
100mg-200mg every 7 to 14 days
 Inexpensive
 Well tolerated
 Provides robust T levels
 Up to 25% of users develop polycythemia
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45. Transdermal Patches
 Restores normal circadian variations in T levels
 Patches are applied daily
 Scrotal (Testoderm), apply in the morning
 Non-scrotal (Androderm, Testoderm TTS), apply at bedtime
 Skin irritation common
 Patches may fall off during exercise
 More expensive than injections
 Dosages more difficult to adjust
 Require monitoring of peak a.m. T levels
 Lower incidence of erythrocytosis than I.M. preparations
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46. Transdermal Testosterone Gel
 1% testosterone gel
 Provides steady serum T levels within reference range
 10% of T is absorbed
 Dose 5g-10g daily, easy to titrate
 Pump now available
 Disadvantages: $$$, transfer to intimate contacts, need to
check a.m. peak T. Skin irritation rare
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47. Buccal Delivery (Striant)
Buccal tablets are applied to the gums bid. The
tablet swells and adheres to the gum. Testosterone
levels are maintained within the normal physiologic
range
Oral Preparations
Alkylated androgens not used for tx of
hypogonadism. Hepatotoxicity
Andriol—not alkylated, not widely used.
-Absorbed via intestinal lymphatics
-must be taken with a fatty meal
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48. TRT Monitoring
 Baseline
 Voiding hx
 Hx of sleep apnea
 Digital rectal examination
 Baseline Hb/Hct, PSA, T
 Prostate bx if PSA above 4.0 ng/ml or abnormal prostate
exam
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