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REPRODUCTIVE ENDOCRINOLOGY . . . CONT.

a t r o p h i c c h a n g e s ( v a g i n a , u r e t h r a , b l a d d e r ) d y s p a r e u n i a , v a g i n a l i t c h i n g , b l e e d i n g u r i n a r y f r e q u e n c y , u r g e n c y , i n c o n t i n e n c e s k e l e t a l ( o s t e o p o r o s i s ) d e c r e a s e d b r e a s t s i z e s k i n t h i n n i n g a n d l o s s o f e l a s t i c i t y s l e e p / w a k e d i s t u r b a n c e s ( i n s o m n i a ) m o o d d i s t u r b a n c e s

  • depression, irritability, fatigue

Diagnosis increased levels of FSH (> 40 IU/L) decreased levels of estradiol

Treatment hormone replacement treatment (doses much lower than OCP) • transdermal or oral • cyclic estrogen (Premarin) 0.625 mg OD 1-25 plus progesterone (Provera) 10 mg OD, day 14 (or 15, 16) to day 25, or • long cycling Premarin 0.625 mg daily plus Provera 5 mg for 14 days q3 months, or • continuous combined Premarin 0.625 mg plus Provera 2.5 mg daily • unopposed estrogen increases the risk of endometrial cancer without the addition of Provera, but Provera is not needed if previous hysterectomy calcium supplement physical exercise evening primrose oil

Indications for Hormone Replacement Therapy relief of symptoms - see above (vasomotor, atrophy, insomnia) protection against osteoporosis osteoporotic risk factors • caucasian or oriental race • thin habitus • immobilization or physical inactivity • estrogen deficiency/premature menopause • drugs: chronic corticosteroid therapy, chronic use of heparin, anticonvulsants, or thyroid replacement • diet: low calcium, low vitamin D, high caffeine high alcohol, or high protein • other factors: smoking, family history cardiovascular protection • estrogen significantly reduces risk of CAD • decreases LDL and increases HDL

Side Effects of HRT abnormal uterine bleeding - requires endometrial biopsy if bleeding other than withdrawal bleeding with combined E/P therapy mastodynia worse in progesterone phase of combined therapy edema, weight gain, heartburn, nausea controversy with respect to HRT and breast cancer risk

Contraindications of HRT absolute u n d i a g n o s e d v a g i n a l b l e e d i n g k n o w n o r s u s p e c t e d c a n c e r o f b r e a s t o r u t e r u s a c u t e l i v e r d i s e a s e o r c h r o n i c a l l y i m p a i r e d l i v e r f u n c t i o n a c u t e v a s c u l a r t h r o m b o s i s o r h i s t o r y o f s e v e r e t h r o m b o p h l e b i t i s o r t h r o m b o e m b o l i c d i s e a s e r e l a t i v e p r e - e x i s t i n g u n c o n t r o l l e d h y p e r t e n s i o n u t e r i n e f i b r o i d s a n d e n d o m e t r i o s i s f a m i l i a l h y p e r l i p i d e m i a s m i g r a i n e h e a d a c h e s f a m i l y h i s t o r y o f e s t r o g e n - d e p e n d e n t c a n c e r c h r o n i c t h r o m b o p h l e b i t i s d i a b e t e s m e l l i t u s • gallbladder disease

MCCQE 2000 Review Notes and Lecture Series

Notes

Gynecology 15

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