Peggy J.

Mancuso, PhD, CNM

Assistant Professor Hypothalamus
Texas Womans University Gonadotropin Releasing Hormone (GnRH)
Faculty Associate
UTSW Medical College 1. Estrogen
hypothalamus
Contraception and Hormone secretes GnRh
Replacement Therapy 2. Pulsatile, rhythmical
3. Too much or too
little
No ovulation
4. Stress, decreased
body fat no GnRH

1 2

GNRH Agonists GnRH Agonists

Leuprolide z Sustained use
z z Subcutaneous
Stops reproductive cycles
z Buserelin injection
Flare effect response first 2 weeks
z Nafarelin z Nasal spray
z Histrelin
z Treatment for:
Endometriosis
z Goserelin
Shrink fibroids
z Deslorin
Delay precocious puberty
z Tryptorelin ART infertility prior to gonadotropin therapy
z Side effects
Menopause symptoms
3 4

Anterior Pituitary
Large Fibroids Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)

z FSH stimulates follicle

z Follicle makes
estrogen
z LH stimulates
ovulation

5 6
Corpus Luteum FSH and LH Levels
z Ruptured follicle
becomes corpus
luteum
z Corpus luteum
makes estrogen,
progesterone

7 8

Why do we ovulate? Estrogen and Progesterone Levels

9 10

Follicles and Corpus Luteum Pharmacology Based on FSH

z Human z Used to stimulate

menopausal ovum production
gonadotropins z Side effects
(Pergonal, Repronex)
Multiple ovulation
z Purified urinary Ovarian cysts
FSH Ovarian cancer (?)
(Metrodin, Normegon)
z Recombinant FSH
(Gonal-F, Follistim)

11 12
Ovulation Stimulation with Selective Ovulation Stimulation with Selective
Estrogen Receptor Blocker Clomiphene Estrogen Receptor Blocker Clomiphene
z Weak estrogenic activity z Useful with women z Side Effects
Blinds hypothalamus-pituitary to circulating with polycystic Hot flushes
estrogen FSH/LH ovary disease Visual disturbances
z Clomiphene citrate (Clomid, Milophene,
z Increases twin Headaches
Serophene)
50 mg for 5 days
pregnancies Abdominal bloating
Nausea
Starting at day 3 to 5 of menstrual cycle
(beginning dose) Ovarian
Intercourse every other day enlargement
Ovulation predictor kit
13 14

Ovulation Stimulation
Estrogens
with LH or hCG
z Recombinant LH z Estrone
Weak estrogen
(Lhadi) produced by body
z Recombinant hCG fat
Menopausal
(Ovidrel) estrogen
z Human chorionic gonadotropin
(Pregnyl, Profasi, A.P.L.)
z Used to harvest eggs before in vitro
fertilization
15 16

Estrogens Estrogens
z Estradiol z Estriol
Potent estrogen Weak estrogen
produced by produced by
follicular cells placenta
Reproductive Estrogen in
estrogen pregnancy
When eggs are
gone (age 51.3),
estradiol is gone

17 18
Estrogen Alpha and Beta Receptors
z Estrogen receptors z CNS
are everywhere Both alpha and
z Two types beta receptors
Alpha z Alpha receptors
Beta Brain (the brain
LOVES estrogen)
z Only beginning to
Breasts
map receptor
Endometrium of the
activity
uterus

19 20

Alpha and Beta Receptors Estrogen Levels

z Beta receptors z Menopause
Blood Low estrogen
Stimulate clotting No progesterone
Increase HDL
Decrease LDL
Increase
triglycerides
Bone
Prevents bone
absorption

21 22

Estrogen Levels Estrogen Levels

z Pregnancy & z Reproductive
combined OCPs years
High estrogen, high Cyclic estrogen
progesterone opposed by
progesterone
z Adolescence,
perimenopause
Estrogen with
unopposed
progesterone

23 24
Effects of Estrogen Effects of Estrogen
z Decreases clotting
z MITOGEN time
z Promotes cell z Promotes
multiplication thrombus
formation
z Dose related

25 26

Effects of Estrogen Effects of Estrogen

z Stimulates factors that initiate blood
clot formation z Maintains bone
Prothrombin, Factor VII, Factor VIII, density
Factor IX, and Factor X. z Deficiency causes
z Produces adhesive effect on platelets osteoporosis
clot formation
z Clot inhibiting factor
Antithrombin III

27 28

Effects of Estrogen Effects of Estrogen

z Increases HDL z Maintains skin and
z Decreases LDL mucous
membranes
z Increases z Low estrogen
triglycerides Wrinkles ?
Dry mucous
membranes ?

29 30
Effects of Estrogen Effects of Estrogen
z High estrogen
Hyper-pigmentation z Increases liver
Increased mucus binding globulins
secretion
z Increases bile salt
concentration
Promotes
gallstones
Melasma

31 32

Effects of Estrogen Effects of Estrogen

z Stimulates growth z Decrease
of alveoli of the stimulates
breast hypothalamus to
z Increases cell produce GnRH
numbers of glands z Sustained
and ducts of estrogen elevation
breasts for 2-3 days
z Inhibits function of necessary for
prolactin ovulation
33 34

Effects of Estrogen Effects of Estrogen on the Uterus

z Stimulates growth of uterine lining
z Stimulates clear, stretchy cervical
mucus
Spinnbarkeit
z Increases progesterone receptors
z Maintains membranes of vagina and
cervix
35 36
Effects of Progesterone Effects of Progesterone
z In humans there is little progesterone z Inhibits endometrial
proliferation
effect without estrogen production
z Promotes spiral artery
z Opposes estrogen formation in uterus
Anti-estrogen z Promotes endometrial
glandular activity
z Fat-soluble natural anesthetic z Thick, white cervical
mucus

37 38

Effects of Progesterone Effects of Progesterone

z Increases number z Inhibits female
and size of milk facial hair growth
cells z High amounts
z Increases lobular decrease bone
density by
formation in breast opposing estrogen
z Does not inhibit z No effect on
lactation coagulation?
Maybe or maybe
not
39 40

Effects of Progesterone Hormonal Changes of Menses

z Increases LDL
z Decreases HDL
z Decreases
triglycerides
z Converts in kidney
desoxycorticosteroid
Promoting water
and salt retention

41 42
Progesterone Increases BMR and
Contraceptive Effectiveness
Temperature
z Willit work?
z Failure rates?
z Perfect use?
z Typical use?

43 44

Contraceptive Safety Does it protect against STDs?

z Contraindications?
z Side effects?
z Future fertility?
z Sexually
transmitted
infection?

45 46

Contraceptive Benefits Personal Considerations

z Decreased risk of chronic disease
Decreased ovarian and endometrial z Cost
cancer with OCPs
z Sexual Activity
z Improvement of health
z Access
Fewer menstrual problems with no
ovulation z Privacy

z Any decrease in STD transmission z Other

47 48
Costs in the USA Costs in Other Countries
1993, 1995 Thailand, Ecuador -1993
z Combined OCP Thailand Ecuador
From 30 cents to Norplant Depo-Provera
$35/month $9.40/year $6.68/yr.
z Norplant Depo-Provera OCP
$5.00/year $12.98/yr
$365 - $700 / 5
years
z Depo-Provera
$46 - $68/3 months

49 50

What do these contraceptives What do these contraceptive devices

have in common? have in common?
z AvantiCondom z Estrogen z Estrogen-
progesterone injection progesterone vaginal
z Female Condom Monthly ring
Lunelle 3 weeks
z Depo-Provera
z RU-486 NuvaRing
z Norplant Mifepristone z Estrogen-
z Levonorgestrol IUD progesterone patch
5 years Weekly
Merena Evra

51 52

Why do we have so few

New Methods
contraceptive choices?
z Free
Enterprise -
$$$$
z The FDA
z The Press
z The Law

53 54
What about evidence-based practice? What about evidence-based practice?

z Do we base our practice on good z Do we base our

research? practice on what
the press says?
z Do we base our practice on what
z Do we base our
makes sense? practice on the
z Do we base our practice on what the fear of litigation?
experts (textbooks) say?

55 56

Oral Contraceptive Pills

z High estrogen
What does it mean to z High
be a professional
progesterone
in the United
States today? z Why estrogen?

57 58

How does the pill work? How does estrogen work?

z No ovulation
Possible lower
FSH?
z Uterine
secretions
change
z Corpus luteum
destruction

59 60
What makes the pill work? How does progesterone work?
z No ovulation
Inhibits LH
z Cervical mucus
thicker
z Implantation more
difficult
z Sperm cant
penetrate egg
Sperm DUDS!

61 62

Is there any difference in OCPs? Estrogen Levels of Pill

z Same estrogen
Ethinyl estradiol
20 g - 35 g -50 g
z Mestranol
50 g estradiol
z Different progestins
19 nortestosterone
z Does it matter which
pill to choose???
63 64

Definitions of OCP Definitions of OCP

Epidemiological Studies Epidemiological Studies
z First Generation
Contain > 50 g ethinyl estradiol z Third Generation
z Low-Dose OCPs 20 or 30 g ethinyl estradiol
Less than 50 g ethinyl estradiol Desogestrel or gestodene
z Second Generation z Yasmin
30 or 35 g ethinyl estradiol Drospirenone 3.0 mg
Levonorgestrel, norgestimate, Spironolactone derivative for progestin
norethindrone z Gest or No Gest or Yasmin
65 66
 Women who should not take
Who can get combined OCPs? estrogen:
z Pregnancy
z Breastfeeding
Most important question,
z Smoking and over 35
Is estrogen safe for this z Moderate or severe uncontrolled

woman now? hypertension (160/100)

67 68

Women who should not take Women who should not take
estrogen: estrogen:
z Diabeteswith known vascular z Current or past
complications history of breast
z DVT or pulmonary embolus cancer
May consult if more
Current or history
than 5 years
z Headaches focal neurological
symptoms
Migraines with aura
History of stroke

69 70

Women who should not take Women who should not take
estrogen: estrogen:
z Undiagnosed abnormal vaginal z Major surgery with
bleeding immobilization
within one month
z Past history of cholestasis with use
z Active viral
z Family history thrombosis hepatitis, cirrhosis,
Factor V Leiden most common mutation sick liver
Consult for testing

71 72
Women who benefit from COCs: Women who benefit from COCs
z Dysfunctional z Hypothalamic amenorrhea
uterine bleeding Decreases osteoporosis
z Endometriosis
z Control of bleeding
z Dysmenorrhea
Pathology
z Mittelschmerz
Anovulation
z Hirsutism
z Functionalovarian cysts (?)
z Acne
z Premenstrual syndrome (?)

73 74

Effectiveness Benefits

z Perfect use z Reversible

.01% pregnant z Less hirsutism
first year
z Effective and safe
z Typical use
z Menstrual benefits
5% pregnant
first year z Menstrual cycle control
z Emergency contraception
z No reason to stop until menopause
75 76

Benefits Benefits
Protection Against Disease! Protection Against Disease!
z Ovarian cancer
z Endometrial z Osteoporosis
cancer z Endometriosis
z Ovarian cysts z Atherogenesis
z Benign breast z Rheumatoid
disease arthritis
z Ectopic pregnancy z Gonococcal PID ?
z Acne z Better sex?
77 78
Disadvantages Disadvantages
z STDs z Take daily
No protection
z Headaches
z Nausea
Estrogen related z Worse sex (who knows?)
z Expensive z Easier to get chlamydia (possible)
z Spotting first 3
z Increased depression (who knows?)
months
z Periods decrease?
z Breasts increase?
79 80

Increase in risk for women who clot! Side Effects

z Over 50, z Less milk
sedentary, z Breast cancer?
overweight z Cervical cancer?
z Early postpartum Adenocarcinoma
z Surgery z Like pregnancy
z Uncontrolled Nausea
hypertension Chloasma
z Thrombotic CV
disease
81 82

Side Effects Teaching

z Headaches z How do I take the
z Hypertension pill?
(rare) z What do I do if I
miss a pill?
z Benign liver
z What about nausea
tumors or diarrhea?
Hepatocellular
adenoma
z What about back-
up contraception?
z Drug interactions
z Do I need to bleed?
Rifampin
Seizure drugs 83 84
When to start pill! When to start pill!
z First day of menses z After IUD or Norplant
Day removed
z Sunday after first day of menses z After DMPA
z Now if not pregnant Last day of efficacy (91)
Back-up first pack z Secondary amenorrhea, not pregnant now
z After emergency contraception pills
z Postpartum, not breastfeeding First day of period or immediately after
Day 21 z Restarting COC
Breastfeeding - better choices First day of period
Sunday start
z Same day of first trimester abortion Now if pregnancy excluded

85 86

Warning Signs Last Years News

z 20 mcg ethinyl estradiol pills
z A - Abdominal pain
Allesse
z C - Chest pain
z H - Headache
Levlite
z E - Eye problems Loestrin
z S - Severe leg pain Mircette
z Perimenopause
z When to change to HRT?

87 88

This Years News! Do we have to bleed?

z Decreased pill-free interval Bi-cycling 42 days 6 weeks
Use only 2 to 4 placebo pills
Mircette - 2 placebo pills Tri-cycling 63 days 9 weeks
z Increased active-pill interval Quad-cycling 84 days 9 weeks
Spotting after 12 weeks
z Should I prescribe HRT? Variable Continuous until spotting

89 90
Do we have to bleed? New Pills!
z Advantages z Seasonale
Greater contraceptive effectiveness 84 weeks active pills
Decreased menstrual symptoms 7 days placebo pills
(endometriosis) FDA trials
Personal control z Clinical trials
z Disadvantages Nordette vs. Alesse
Will insurance pay?

91 92

New Pills! New Pills!

z Yasmin z Cyclessa
30 mcg ethinyl estradiol & drospirenone 25 mcg ethinyl estradiol & desogestrel
Anti-androgen 100/125/150 mg)
Anti-meneralcorticoid Clinical trial completed
Estrogenic lipid profiles Compared to Ortho-Novum 777

93 94

New Methods! Lunelle

z Lunnelle z Was being marketed
Combined monthly injection 25 mg medroxy progesterone acetate
Recently pulled from market 5 mg estradiol cypionate
z NuvaRing z Monthly injection
Contraceptive Vaginal Ring z Same labeling as COCs
z EVRA
Contraceptive Patch

95 96
Administration of Lunelle Advantages of Lunelle
z First dose z Effective
Within 5 days of menses Failure rate 1% or less
Vaginal bleeding 14-21 days Typical use = Perfect use

z Subsequent doses z Regular bleeding pattern

23-33 days after injection z Privacy
z Maintains bone
z Quick return of fertility

97 98

Disadvantages NuvaRing
z Monthly injection! z Flexible,
transparent ring
z Decreases lactation z Ectonogesterel and ethinyl estradiol
z Expensive z Low serum estrogen
z Weight? Bleeding? z Pregnancies 0.6-1.8/100 woman
z No protection against STDs years
z Back-up or EC if late

99 100

NuvaRing NuvaRing
z Placein posterior fornix z Advantages
z Leave in place 3 weeks z Cycle control
z Remove for 1 week (menses) z Self-administration
z Vaginal medication possible
z No association with cervical disease

101 102
NuvaRing Evra Contraceptive Patch
z Disadvantages z 20 cm square patch
z Need vaginal tone z Deactylnorgestimate & ethinyl
z Should not wash estradiol
z Should not remove z Place on trunk for 7 days

z Must be able to insert

103 104

Evra Contraceptive Patch Evra Contraceptive Patch

z Remove for menses z Advantages
z Pregnancy rates still being Cycle control!
researched Apply once a week
z Progesterone & follicle size = OCP Provider not needed for application

105 106

Evra Contraceptive Patch Evra Contraceptive Patch

z Advantages z Disadvantages
High compliance Big patch?
Patch irritation?
Less break-through bleeding
Revealing
Low consistent hormone levels clothing?

107 108
Progesterone Contraceptives How does progesterone work?
z Depo-Provera z No ovulation
z Mini-Pill z Thin endometrium
z Levonorgestrel z Thick cervical mucus
intrauterine z Destroys corpus luteum
system z Fallopian tube doesnt work
z Decreases progesterone receptors

109 110

Effectiveness Advantages
Method Perfect Use Typical Use z Reversible
z No estrogen
Norplant .05% .05%
z Milk not decreased
Depo-Provera .3% About equal z Light or no periods
z Fewer drug interactions
Mini-Pill .5% 5%
z Decreased anemia and cramping

111 112

Advantages
Protection against disease! Good Candidates
z PID z Breastfeeding
z Endometriosis z Women who must
avoid estrogen
z Ovarian cancer
DVT, PE
z Ectopic pregnancy Smoker over 35
z Endometrial z Diabetic and obese
cancer z Hypertensive
z Migraines with
Endometriosis focal symptoms on
OCPs
113 114
Good Candidates Advantages of Depo-Provera
z Older women
No thrombus
z Women who forget z Decreases
Mirena seizures
z Seizure disorders z Culturally
Depo-Provera
acceptable
z Need temporary contraception
Acutane, Rubella vaccine z Cytodren major
Depo-Provera drug interaction

115 116

Advantages of Minipills Advantages of Mirena

z Not confusing z Levonorgestrel
Take every day IUD
Polyethylene frame
z Emergency contraception 20 mcg/day
z Health benefits of progesterone only levonorgestrel
methods z Effective 5 years
7 years in France
z Different insertion
than Copper T
117 118

How Mirena Works Mirena

z Advantages
Decreased PID
Less vaginal
bleeding
No effect on
breastfeeding

Pelvic Inflammatory
Disease
119 120
 Disadvantages of All Progesterone
Mirena
Methods
z Therapeutic uses: z Hair loss (?)
Dysmenorrhea z Depression (?)
Menorrhagia z Weight gain (?)
DUB z Breast tenderness
Adenomyosis z No STD protection
Fibroids z Irregular vaginal
ERT progesterone bleeding

Adenomyosis

121 122

Disadvantages of Depo-Provera Depo-Provera Warnings

z Can not discontinue z Repeated, painful
immediately headaches
z Return visit every 12
weeks
z Heavy bleeding
z Lipid changes (LDL) z Depression
z Decreased bone z Abdominal pain
density (pregnancy)
z Return to fertility z Pus, pain at
delayed
injection site

123 124

Disadvantages of Minipills Minipill Warnings

z Less available z Delayed period

z Vulnerable efficacy z Abdominal pain
z Low dose z Severe headaches
progesterone z MUST USE BACK-
No antiseizure UP IF MORE THAN
drugs or rifampin 27 HOURS
z Unforgiving!!! WITHOUT PILL

125 126
Caution! Contraindications for Mirena IUS

z Pregnancy z Pregnancy
z Breast cancer z Genital infection
z Undiagnosed z Cervical or uterine
vaginal bleeding malignancy
z Impaired liver z Undiagnosed
function vaginal bleeding

127 128

Contraindications for Mirena IUS Disadvantages of Mirena

z Manufacturer recommendations do z Expulsion
not insert if: z Expensive
Active liver disease z Progesterone side
Acute thrombophlebitis effects?
Other thromboembolic disorder z If pregnancy
occurs ectopic risk
increases Ectopic twin
pregnancy

129 130

Emergency Contraception Emergency Contraception

z OCP z Minipills
Within 72 hrs (20 + 20 Ovrette)
within 72 hours
Antiemetic
Plan B
Meclizine
Preven

131 132
 Emergency Contraception Emergency Contraception
z Copper T IUD z Mifepristone (RU
Within 5-7 days 486)
Do not insert if Within 5 days as
high-risk for STDs emergency
Can not use Mirena contraception
May also induce
early abortion

133 134

Dosage of Combined Oral Contraceptive

Pills for EC You cant remember this?
z Allesse
5 pink pills
Repeat in 12 hours
z Lo-Ovral, Nordette, Levelen, Triphasil, Trilevlen, CALL
Levora or Trivor
4 pills of highest dose estrogen
Color varies per manufacturer
1-888-NOT-
z
Repeat in 12 hours
Preven or Ovral
2-LATE
2 white pills
Repeat in 12 hours

135 136

Effectiveness of Emergency
Cost
Contraception
z With no contraception
10 pregnancies/100 exposures z Preven and Plan B
$19.00
z With emergency contraception
z OCPs - up to $50
2 pregnancies/100 exposures
z IUD - $500
z Not harmful to fetus
z RU 486 - who
knows?

137 138
Medical Abortion or
Emergency Contraception
z RU 486 - Antiprogesterone
Methotrexate - Antifolate
What do we talk about?
So often we talk about technical points,
when we should ask how do we get these
good contraceptives for our patients at a
reasonable price.
What does it mean to be a health care
provider in the US today? What if you
care about womens health?
Dr. Denniston

139 140

Hormone Replacement Therapy Symptoms of Menopause

z Physiological z Dysfunctional uterine bleeding
replacement of
estrogen Shortened cycles (decreased inhibin)
z Approximately 1/4 Increase in fraternal twins
less than z Hot flash or hot flush
contraceptive
amount z Psychological and cognitive
z Add progesterone functioning
if woman has Sleep deprivation?
uterus
141 142

Pharmacologic Management of
Symptoms of Menopause Menopause
z Urogenital atrophy z Estrogens
Conjugated equine
z Sexuality changes estrogen
Premarin
z Osteoporosis Synthetic conjugated
z Cardiovascular estrogen
Cenestin
disease Esterified estrogen
Estratabe , Menest
Estropipate
Ogen
Micronized 17-beta
estradiol
Estrace
143 144
Pharmacologic Management of Pharmacologic Management of
Menopause Menopause
z Natural progesterone z Derivedfrom 19-nortestosterone
Progesterone USP in peanut oil progestin
Prometrium Norethindrone
z Progesterone derivatives Micronor . Nor-QD

Medroxyprogesterone acetate Norethndrone acetate

Amen , Cycrin , Provera Aygestin

Megestrol acetate Norgestrel

Megace Ovrette

145 146

Pharmacologic Management of
Menopause
The future
z Androgens z Selective
progesterone receptor
Natural
testosterone
modulators
Dehydroepiandro- SPRMs (sperms)
sterone
Synthetic z Progesterone mimetics
testosterone Fiddles with spironolactone molecule
z Libido younger Yasmin new OCP
women bilateral
oophorectomy Angelique new HRT with drospirinone

147 148

The future??? Current Vehicles for ERT

z Selective androgen z Estrogen products
receptor Vaginal cream
modulators Estrace, Ortho Dinestrol, Permarin
(SARMs)
Vaginal tablet
z MORE AND Vagifem
BETTER SERMs
Vaginal ring
z More and better Estring
vehicles
Skin patches (Several products)
149 150
Current Vehicles for HRT Oral Hormone Therapy Schedules
z Progesterone z Cyclic
Vaginal gel Estrogen for 25 or 30 days/month
Crinone
Progestin added for 10-14 days
IUD
Bleed with progestin withdrawal
Mirena
z Continuous combined estrogen-
z Combined products
progestin daily
Combipatch, Ortho-Prefest
May spot for 3 months

151 152

Combined Oral Estrogen and

Dosage
Progesterone
z Premphase (Premarin and MPA) z Cyclic z Continuous
.625 CEE (or .625 CEE (or
z Prempro (Premarin and MPA) equivalent) days 1- equivalent) with 2.5
12
z Femhrt (Ethinylestradiol and NETA) mg MPA (or
Add MPA 10 mg (or equivalent) daily
z Activella (17-beta-estradiol and NETA) equivalent) on days
13-25 If estrogen dose is
z Ortho-Prefest (17-beta-estradiol and Withdrawal bleed increased, increase
norgestimate) progestin,
progesterone

153 154

Pharmacologic Management of
Dosage Menopause

z Transdermal z HRT not for prevention of heart disease

.05 mg estradiol every 3-4 days most common z Do not prescribe if heart disease present
Estradiol/norethindrone acetate patch z Womens Health Initiative
available 26% breast cancer (8/10,000 women years)
Rotate sites 41% strokes (8/10,000 women years)
More likely to avoid liver interactions 29% heart attack (7/10,000 women years)
z Added testosterone? blood clots (18/10,000 women years)
Improve libido ?
Androgenic side effects
155 156
Pharmacologic Management of What are possible consequences of
Menopause HRT/ERT?
z Benefits of HRT from WHI z HERS II study
Increased risk first year
37% less colorectal cancer of death
5/10,000 women years Equal risk after 5 years

34% fewer hip fractures z WHI study

Increased breast
6/10,000 women years cancer
Increased cardiac
disease
No increase in death

157 158

Should I offer HRT or ERT? Contraindications for HRT

What is risk? Estrogen
Heart disease? z Breast cancer
Osteoporosis? z Estrogen-dependent
Cancer? neoplasia
Alzheimers? z Undiagnosed vaginal
Temporary relief? bleeding
Permanent tx? z Active
thrombophlebitis
z Pregnancy
z Malignant melanoma
159 z Active liver disease 160

Contraindications for HRT Risk Factors for Heart Disease

z Progestin z Obesity
Thrombophlebitis z Hypertension
(manufacturer)
z Diabetes mellitus
Active liver disease
z Cigarette smoking
Breast cancer
Undiagnosed z Sedentary lifestyle
vaginal bleeding z Estrogen
Pregnancy deficiency
z Increased blood
161
viscosity 162
Risk Factors for Osteoporosis How do we prevent osteoporosis?
z Caucasian or Asian z Bone absorption
z Family history inhibitors
Alendronate sodium
z Low body mass index
z Early menopause z Calcium supplements
Calcium carbonate
z Oligomenorrhea Calcium citrate
z Early childbearing Calcium lactate
Calcium gluconate
z Smoking, alcohol,
caffeine z SERMS
z ERT/HRT?

163 164

Calcium Supplements Calcium Supplements

z Recommendations z Calcium carbonate z Contraindication
1000 mg/day prior 40% Hypercalcituria
to menopause TUMS Hypercalcemia
1000-1500 mg/day z Calcium citrate Ventricular fibrillation
after menopause 21.2% z Drug interactions
Menopause on HRT Better absorbed Fiber
500 mg/day z Calcium lactate Tetracycline
13% Iron
Not practical Minerals
z Calcium phosphate
38%

165 166

Risk Factors for Breast Cancer What to do?

z Female z Assess risk
z Increasing age z Educate woman
Allow her to make her own decision
z Personal history
z If she has irregular bleeding
z Family history Endometrial biopsy or vaginal ultrasound
z Atypical z Assess lipids
hyperplasia z Mammogram
z Nulliparity
z First birth after 30
167 168
Selective Estrogen Receptor Modulators
Selective Estrogen Receptor Modulator
Tamoxifen
Raloxifene
z Blocks alpha receptor in breast z Blocks estrogen receptors from breast
But not in uterus z Blocks estrogen receptors from
Locks estrogen out of breast cells endometrium
z Serum cholesterol reduction z Increases bone mass
z Bone density maintained z Lowers cholesterol
z Endometrial cancer risk increased z ? HDL
z Estrogen effects on bone and blood z Hot flashes much worse
z Dry mucous membranes
169 170

Other Treatments for Menopausal

Counseling about HRT
Symptoms
z Exercise z Progesterone if uterus
z Phytoestrogens z Estrogen improves
Soy (dietary) lipids
Black cohosh?
MPA mediates
z Stress reduction? improvement
z Antidepressants z Increase risk
Effexor, Paxil, Prozac Cardiac disease
z Bellergal? (Wow!) Breast cancer
z Clonidine? Gallbladder disease
z Counseling?

171 172

Counseling about HRT The End Run While You Can!

z Decreases risk
Osteoporosis
Rheumatoid arthritis
Colon cancer
z Telephone follow-up
1 month, 3 months
z Clinic visit at 6
months

173 174
175