in this slide physiological, psychological and social aspects of menopause, Hormonal replacement therapy, surgical menopause , guidance and counselling / role of midwifery nurse practitioner in menopause.
in this slide physiological, psychological and social aspects of menopause, Hormonal replacement therapy, surgical menopause , guidance and counselling / role of midwifery nurse practitioner in menopause.
Menstrual cycle irregularities can have many different causes. For some women, use of birth control pills can help regulate menstrual cycles. However, some menstrual irregularities can't be prevented. Regular pelvic exams can help ensure that problems affecting your reproductive organs are diagnosed as soon as possible.
Allison Taylor, MD, with the Center for Women's Health in Wichita, KS, presented about perimenopause and hormone therapy during a Women's Connection July 9, 2013, at Corporate Caterers. The event is sponsored by Via Christi Health.
Polycystic Ovarian Syndrome is heterogeneous, multisystem endocrinopathy in women of reproductive age characterized by chronic anovulation resulting in infertility, irregular bleeding, obesity and hirsutism. Most common, although the least understood, cause of androgen excess. Initially it was described in 1935.Also known as Stein-Leventhal syndrome
The slide includes:
Introduction
Incidence
Pathophysiology
Pathology
Clinical features
Investigation
Treatment
Menstrual cycle irregularities can have many different causes. For some women, use of birth control pills can help regulate menstrual cycles. However, some menstrual irregularities can't be prevented. Regular pelvic exams can help ensure that problems affecting your reproductive organs are diagnosed as soon as possible.
Allison Taylor, MD, with the Center for Women's Health in Wichita, KS, presented about perimenopause and hormone therapy during a Women's Connection July 9, 2013, at Corporate Caterers. The event is sponsored by Via Christi Health.
Polycystic Ovarian Syndrome is heterogeneous, multisystem endocrinopathy in women of reproductive age characterized by chronic anovulation resulting in infertility, irregular bleeding, obesity and hirsutism. Most common, although the least understood, cause of androgen excess. Initially it was described in 1935.Also known as Stein-Leventhal syndrome
The slide includes:
Introduction
Incidence
Pathophysiology
Pathology
Clinical features
Investigation
Treatment
Menopause: Symptoms, Concerns, and Management StrategiesSummit Health
Presentation about menopause, including information about common symptoms such as hot flashes, sleeplessness, and weight gain as well as other physiologic changes such as bone loss and cardiovascular risks. Dr. Gibbons and Dr. Cummings will offer recommendations on treatment and management options that can help you navigate this important life transition.
prophylactic encerclage for multiple pregnancy is always debated.in this presentation cerclage for MFG is favored as there was a debate in recently held KSOGA conference at manipal on 3-11-11.
Presented by Gunta Lazdane, Programme Manager, Sexual and Reproductive Health, WHO/Europ , at the 64th session of the WHO Regional Committee for Europe.
Delhi IVF Fertility & Research Centre in IndiaDelhi IVF
Delhi-IVF Fertility & Research Centre in India was established in the year 1994 by Dr. Anoop Gupta (an expert consultant and specialist in infertility management) together with a small and dedicated team committed to provide the best fertility care, IVF, Surrogacy, Egg Donation and Infertility Clinic in India.
Absent or irregular periods??
Menstrual cycle disorders can cause a woman’s periods to be absent or infrequent. Although some women do not mind missing their menstrual period, these changes should always be discussed with a healthcare provider because they can signal underlying medical conditions and potentially have long-term health consequences. A woman who misses more than three menstrual periods (either consecutively or over the course of a year) should see a healthcare provider.
The menopause may be
Natural or induced
Natural menopause - the permanent cessation of menstruation for 12 months caused by failure of ovarian function with elevated gonadotropins (FSH, LH).
Average is 51 years
Menopause is the time in a woman's life when her period stops. It usually occurs naturally, most often after age 45. Menopause happens because the woman's ovaries stop producing the hormones estrogen and progesterone. A woman has reached menopause when she has not had a period for one year.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Introduction
• Natural menopause is defined as the permanent
cessation of menstrual periods, determined
retrospectively after a woman has experienced
12 months of amenorrhea without any other
obvious pathological or physiological cause.
• It occurs at a median age of 51.4 years in normal
women, and is a reflection of complete, or near
complete, ovarian follicular depletion, with
resulting hypoestrogenemia and high FSH
concentrations.
3. Introduction
• Menopause before age 40 years is considered to
be abnormal and is referred to as primary ovarian
insufficiency (premature ovarian failure).
• The menopausal transition, or perimenopause,
occurs after the reproductive years, but before
menopause, and is characterized by irregular
menstrual cycles, endocrine changes, and
symptoms such as hot flashes.
4.
5.
6. Diagnosis – S/O
• Hot flashes — The most common symptom
during the menopausal transition and
menopause
– occur in up to 80 percent of women in some cultures.
– only about 20 to 30 percent of women seek medical
attention for treatment.
– Some women first develop hot flashes that cluster
around menses during their late reproductive years,
but symptoms are typically mild and do not require
treatment.
7. • Sleep disturbance — women experience sleep
disturbances even in the absence of hot flashes.
• The estimated prevalence of difficulty sleeping based
upon two longitudinal cohort studies was 32 to 46%.
• Anxiety and depression symptoms may also contribute
to sleep disturbances; in one study, they were
predictive of subjective sleep disturbances.
• In addition, perimenopausal women with hot flashes
are more likely to be depressed. Primary sleep
disorders are also common in this population.
8. • Depression — A number of reports indicate that there
is a significant increased risk of new onset depression
in women during the menopausal transition compared
with their premenopausal years. The risk then
decreases in the early postmenopause.
• In a study to determine risk factors for depressive
disorders, a diagnosis of depression was 2.5 times
more likely to occur in the menopausal transition
compared with when the woman was premenopausal
(odds ratio [OR] 2.50; 95% CI 1.25-5.02).
9. • Vaginal dryness — The epithelial lining of the vagina and
urethra are estrogen-dependent tissues, and estrogen
deficiency leads to thinning of the vaginal epithelium. This
results in vaginal atrophy (atrophic vaginitis), causing
symptoms of vaginal dryness, itching, and often
dyspareunia.
• The prevalence of vaginal dryness in one longitudinal study
was 3, 4, 21, and 47 percent of women in the reproductive,
early menopausal transition, late menopausal transition,
and three years postmenopausal stages, respectively.
• Early in the menopause transition, women may notice a
slight decrease in vaginal lubrication upon sexual arousal,
which is often one of the first signs of estrogen
insufficiency.
10. • Sexual function — The cervix also can atrophy
and become flush with the top of the vaginal
vault. The elasticity of the vaginal wall may
decrease and the entire vagina can become
shorter or narrower.
• Continuing sexual activity may prevent these
changes in size and shape of the vagina, even in
the absence of estrogen therapy .
• Symptoms related to genitourinary atrophy are
exquisitely responsive to estrogen therapy, in
particular, vaginal estrogen therapy.
11. • Cognitive changes — Women often describe
problems with memory loss and difficulty
concentrating during the menopausal transition
and menopause, and substantial biologic
evidence supports the importance of estrogen to
cognitive function.
• A decline in cognitive function was not observed
in the SWAN study, but increases in anxiety and
depression had independent, unfavorable effects
on cognitive performance .
12. • Joint pain — While women who are obese or depressed
are more likely to experience joint pain, there also appears
to be an association with menopausal status, with peri- and
postmenopausal women experiencing more joint pain than
premenopausal women.
• It is unclear if the pain is related to estrogen deficiency or a
rheumatologic disorder, but in the Women's Health
Initiative, women with joint pain or stiffness at baseline
were more likely to get relief with either combined
estrogen-progestin therapy or unopposed estrogen than
with placebo.
13. • Other
– Breast pain – Breast pain and tenderness are common
in the early menopausal transition, but begin to
diminish in the late menopausal transition. This is
probably due to the fluctuations in serum estradiol
concentrations.
– Menstrual migraines – Menstrual migraines are
migraine headaches that cluster around the onset of
each menstrual period. In many women, these
headaches worsen in frequency and intensity during
the menopausal transition.
14. Diagnosis summary
• In normal, healthy women over age 45 years:
– We make the diagnosis of the menopausal transition
or “perimenopause” based upon a change in
intermenstrual interval with or without menopausal
symptoms.
– A high serum follicle-stimulating hormone (FSH)
concentration is not required to make the diagnosis.
– We diagnose menopause as 12 months of
amenorrhea in the absence of other biological or
physiological causes.
15. • In women between the ages of 40 and 45
years:
– same as that for women over 45 years, except that
other causes of menstrual cycle dysfunction must
first be ruled out (eg, endocrine evaluation for
non-menopausal causes of oligo/amenorrheamust
be normal including serum human chorionic
gonadotropin [hCG], prolactin, and thyroid
stimulating hormone [TSH]).
16. • For women under age 40 years:
– Women in this age group should not be diagnosed
with either the menopausal transition or
menopause. They have primary ovarian
insufficiency (premature ovarian failure).
17. • Special situations
– Women with underlying menstrual cycle disorders — the
STRAW staging system does not apply to women with
underlying menstrual disorders such as polycystic ovary
syndrome (PCOS) or hypothalamic amenorrhea. we
suggest measuring FSH concentration for diagnostic
purposes.
– Women taking oral contraceptives — We suggest stopping
the pill and measuring serum FSH two to four weeks later.
A level ≥25 IU/L indicates that the patient has likely
entered the menopausal transition. However, there is no
FSH value that would provide absolute reassurance that
she is postmenopausal.
– Post-hysterectomy or endometrial ablation —In this
setting, we suggest measurement of FSH concentration. A
serum FSH >25 IU/L, particularly in the setting of hot
flashes, is suggestive of the late menopausal transition. For
a postmenopausal woman, FSH would be considerably
higher (in the 70 to 100 IU/L range).
20. Treatment – Risk factors for VMS
•Obesity
•Smoking
•Reduced physical activity
•Socioeconomic factors
•Hormonal concentrations – Annual serum follicle-
stimulating hormone (FSH) levels is associated with both
the prevalence and frequency of VMS.
•Ethnic factors – African-American women report more
frequent hot flashes than Caucasian women,
and Japanese and Chinese women less so.
21. TREATMENT – NON HORMONAL
• simple behavioral measures, such as:
• lowering room temperature
• using fans
• dressing in layers of clothing that can be easily
shed
• avoiding triggers (such as spicy foods and
stressful situations)
• Some clinicians recommend vitamin E to women
with mild hot flashes because, at low doses, it is
well tolerated and not associated with toxicity.
22. TREATMENT- INCONSISTENT EVIDENCE
• Isoflavones present in soy containing foods.
• Black cohosh األسود الثعبان جذور
• Acupuncture
• Paced respiration
• Mind-body based therapies
• Weight loss
• Exercise
23. TREATMENT - INEFFECTIVE
• Evening primrose oil (EPO)
• Flaxseed الكتان بذور
• Other: ginseng or dong quai, Wild yam and
progesterone creams ,Traditional medicinal
Chinese herbs, reflexology, and magnetic
devices have all been studied and appear to
have no beneficial effect.
24. TREATMENT - HORMONAL
• The goal of MHT is to relieve menopausal
symptoms, most importantly hot flashes
(vasomotor symptoms).
• In the past, hormone therapy (HT) was also used
long-term for prevention of chronic disease
(coronary heart disease [CHD] and
osteoporosis). However, we do not recommend
HT for prevention of disease, given the results of
the Women’s Health Initiative (WHI), a set of
two large randomized trials that demonstrated
an unfavorable risk-benefit profile of HT.
25. TREATMENT - HORMONAL
• Candidates/indications for most women in their
late 40s or 50s with moderate to severe
vasomotor symptoms with the exception of those
with a history of:
– breast cancer
– CHD
– a previous venous thromboembolic event or stroke
– active liver disease
– those at high risk for these complications.
26. TREATMENT - HORMONAL
• Inconsistent benefit:
– Vaginal atrophy
– Depression
– Joint aches and pains
– Cognitive function and dementia
– Prevention dementia.
– Prevention of CHD.
– Osteoporosis: we now recommend bisphosphonates.
However, in the occasional patient with persistent
menopausal symptoms who cannot tolerate first and
second line therapies for osteoporosis, estrogen may be a
reasonable option.
27. TREATMENT - HORMONAL
• Estrogen therapy remains the gold standard
for relief of menopausal symptoms, in
particular, hot flashes.
• All routes of administration appear to be
equally effective for symptom relief (and bone
density), but their metabolic effects differ.
28. • Oral estrogen has more favorable effects on lipid
profiles, but there is no evidence that this results
in long-term clinical benefit.
• On the other hand, oral estrogens are associated
with:
– negative impact on libido and sexual function, but this
has not been proven.
– Similar effects on thyroid-binding globulin (TBG):
increased TBG and lower bioavailable T4.
– Lastly, the risks of venous thromboembolism (VTE)
and stroke appear to be higher with oral when
compared with transdermal estrogen.
29. • We suggest transdermal 17-beta estradiol for
most women because of the potential
advantages outlined above, However, the
baseline risk of both VTE and stroke is very
low in otherwise healthy, young
postmenopausal women. Therefore, if a
patient prefers an oral preparation over a
transdermal one (cost or personal preference),
we consider oral estrogen to be safe.
30. • In addition to oral and transdermal estrogen
preparations, estrogen is available as a vaginal
ring and as a topical spray, cream, or gel. The
topical spray has been linked to adverse
effects in children and pets exposed to the
drug via skin contact.
31. TREATMENT - HORMONAL
• Dose — We typically begin with a transdermal estradiol
0.025 mg patch (or if using oral estradiol, 0.5 mg/day).
• If hot flashes are still present after one month, we
increase transdermal estradiol to 0.0375 mg and
reassess one month later.
• If symptoms are still not relieved, we increase further
to 0.05 mg.
• An exception to this approach is the patient with
severe symptoms; we start with a transdermal dose of
0.05 mg to achieve more rapid relief of symptoms.
32. • “Standard” doses of estrogen given daily
(Conjugated Estrogen 0.625 mg or its
equivalent) are sufficient to reduce hot flash
frequency and severity by approximately 75
percent relative to placebo.
• In a systematic review and meta-analysis of
trials of estrogen for hot flashes, CE and 17-
beta estradiol (oral or transdermal) were
equally effective.
33. • Estrogen should be administered
continuously; past regimens where estrogen
was administered days 1 to 25 of the calendar
month are considered to be obsolete.
• Women will often get hot flashes during the
days off, and there is no known advantage to
stopping for several days each month.
34. • These doses of estrogen (transdermal
estradiol 0.025 to 0.050 mg or their
equivalent) are adequate for symptom relief in
the majority of women.
• An exception is younger women after bilateral
oophorectomy. They often require higher
doses (eg, up to 0.1 mg transdermal estradiol)
for the first two to three years after surgery;
the dose can subsequently be tapered down.
35. • Factors affecting oral estrogen metabolism :
• The above dosing suggestions may need to be increased in:
– women taking anticonvulsant drugs
(phenytoin, carbamazepine), which increase the hepatic
clearance of estrogens. However, there is no way to predict how
much more estrogen is needed so a transdermal estrogen may
be better since it avoids the first pass hepatic metabolism.
– In women receiving T4 replacement therapy, the addition of oral
estrogen therapy may increase T4 requirements.
• The above dosing suggestions may need to be decreased
in:
– Concurrent acute alcohol ingestion.
– Women with end-stage renal disease.
36. Adding a progestin
• All women with an intact uterus need a progestin
in addition to estrogen to prevent endometrial
hyperplasia, which can occur after as little as six
months of unopposed estrogen therapy (ET).
• While MPA is endometrial protective, it was
associated with an excess risk of coronary heart
disease (CHD) and breast cancer.
• In addition, regimens using continuous versus
cyclic MPA may be associated with a higher risk of
breast cancer.
37. • An alternative progestin, natural micronized
progesterone, is also considered to be
endometrial protective (200 mg/day for
12 days/month or 100 mg daily
• In practice, we prescribe oral micronized
progesterone as our first-line progestin.
38. • For women who are perimenopausal or newly
menopausal, we start with cyclic
administration. Continuous administration in
this population is associated with irregular,
unscheduled bleeding due to the exogenous
hormones and the continued endogenous
ovarian function.
39. • For women who are ≥2 to 3 years
postmenopause, we use a continuous
regimen. While there is often early
breakthrough bleeding even after menopause,
most women do eventually develop
amenorrhea, a desired goal of continuous
administration
40. • Mood symptoms and/or withdrawal bleeding —
Some women are unable to tolerate cyclic
progestin administration because of mood side
effects, bloating and monthly bleeding.
• For any of these concerns, we suggest switching
to a continuous regimen. This often resolves the
issue of mood symptoms and bloating. However,
for women who are newly menopausal,
breakthrough bleeding can be anticipated.
41. • Women who cannot tolerate oral
progestins — Some women are unable to
tolerate any oral progestin, whether given in a
cyclic or continuous regimen. In this case, we
often suggest off-label use of the lower dose
levonorgestrel-releasing intrauterine device
(IUD).
42. • Duration — Short-term therapy is considered
to be two to three years, and generally not
more than five years.
• Only the minority of women who are unable
to successfully discontinue estrogen (because
of persistent symptoms) should consider
extended use of estrogen therapy.
43. • Side effects — Common side effects of estrogen
include breast soreness, which can often be
minimized by using lower doses.
• As noted above, some women experience mood
symptoms and bloating with progestin therapy.
• Vaginal bleeding occurs in almost all women
receiving cyclic estrogen-progestin regimens and
is common in the early months of continuous
estrogen-progestin regimen.
44. STOPPING HORMONE THERAPY
• Abrupt withdrawal of exogenous estrogen at any age may
result in (55%) the return of hot flashes and other
menopausal symptoms.
• When tapering, one suggested approach is to decrease the
estrogen by one pill per week (ie, six pills per week, then
five pills per week, etc) until the taper is completed. The
progestin is tapered on the same schedule.
• In our experience, women who are unable to tolerate a six-
week taper temporarily resume their estrogen, and we
then try a much slower taper, sometimes over one year (six
pills per week for two months, five pills per week for one
month, etc).
45. • Managing recurrent symptoms — Unfortunately, in women
who have recurrent vasomotor symptoms after stopping
therapy, there is currently no way to determine whether the
symptoms will resolve quickly or persist for a prolonged
time.
• In women who develop recurrent hot flashes, we first
encourage them to monitor their symptoms over the
subsequent few months to see if they resolve or improve.
• If there is no improvement, or if the recurrent flushes
during or immediately after the taper are difficult to
tolerate, we try a non-estrogen alternative, such as a
selective serotonin reuptake inhibitor (SSRI) or gabapentin.
46. Special Issues
• Migraines — not considered to be a
contraindication to menopausal hormone
therapy (MHT).
• For women with hot flashes and estrogen-
associated migraines (which typically worsen
during perimenopause), estrogen therapy often
improves both symptoms.
• In this setting we suggest continuous transdermal
hormone regimens (as opposed to cyclic
regimens) to avoid triggering estrogen-
withdrawal headaches.
47. • Depression — The risk of depression during perimenopause is
higher than during the pre- or postmenopausal years.
• Selective serotonin reuptake inhibitors (SSRIs) are effective for
perimenopausal depression, and some provide modest benefit for
hot flashes as well.
• Our approach is to choose initial therapy based upon the woman’s
predominant symptom. If her main concern is depression, and hot
flashes are not severe, we start with an SSRI.
• On the other hand, if vasomotor symptoms are the major symptom
and depression or mood symptoms are mild, we start with HT.
• For women in whom depression and vasomotor symptoms are both
severe, we start both estrogen and an SSRI and refer to a
psychopharmacologist for further consultation and monitoring.
48. • Primary ovarian insufficiency — HT is started
at a younger age in these women, and current
guidelines suggest that therapy should be
continued until the average age of menopause
(age 50 to 51 years) to prevent premature
bone loss, coronary heart disease (CHD), and
stroke.
49. • Breast cancer patients experience early
menopause due to adjuvant chemotherapy
and may have vasomotor symptoms due
to tamoxifen therapy.
• We therefore do not recommend estrogen for
women with a personal history of breast
cancer.
50. • Known thrombophilia — MHT increases the risk
of venous thrombosis by approximately twofold.
• This appears to be true for oral preparations, but
perhaps not for transdermal preparations.
• Data suggest that women who have factor V
Leiden and use oral HT have a 15-fold increased
risk of venous thromboembolism (VTE).
• Therefore, HT should be avoided in
postmenopausal women with prothrombotic
mutations.