566 Final Exam Study Guide Week 5

Prevention of osteoporosis with hormone replacement therapy (p. 433)
Hormone therapy (HT) reduces postmenopausal bone loss & thereby decreases the risk for osteoporosis & related
fractures. Unfortunately, when HT is stopped, bone mass rapidly decreases by approximately 12%. Hence to maintain
bone health, HT must continue lifelong. As a result, the risk for harm is increased. Accordingly, alternative treatments are
preferred. Effective alternatives to HT include raloxifene (Evista) & bisphosphonates like alendronate (Fosamax),
calcitonin (Miacalcin), & teriparatide (Forteo). All patients should practice primary prevention of bone loss by ensuring
adequate intake of calcium & vitamin D, performing regular weight-bearing exercise, & avoiding smoking & excessive
alcohol use.
When and when not to use progestin for hormone replacement therapy and why (pp. 430-433)
Goals for noncontraceptive uses of progestins are to counteract endometrial hyperplasia caused by unopposed estrogen
during hormone therapy; management of dysfunctional uterine bleeding, amenorrhea, & endometriosis; & support of
pregnancy in women with corpus luteum deficiency. Progestins are also used in in vitro fertilization cycles & to prevent
prematurity in women at high risk for preterm birth.
Progestins are contraindicated in the presence of undiagnosed abnormal vaginal bleeding. Relative contraindications
include active thrombophlebitis or a history of thromboembolic disorders (DVT, CVA), active liver disease, & carcinoma of
the breast. Progestins should not be prescribed for women who have undergone hysterectomy.
Local vs. systemic estrogen options and why one would be chosen over the other (p. 428)
Local estrogen options:
Transdermal: Transdermal estradiol is available is 4 formulations:
 Emulsion (Estrasorb): Applied once daily to the top of both thighs & the back of both calves.
 Spray (Evamist): Applied once daily to the forearm.
 Gels (EstroGel, Elestrin, Divigel): Applied once daily to one arm, from the shoulder to the wrist or to
the thigh (Divigel).
 Patches (Alora, Climara, Estraderm, Menostar, Vivelle-Dot): Applied to the skin of the trunk (but not
the breast).
Intravaginal: Estrogens for intravaginal administration are available as inserts, creams, & vaginal rings. All are
used primarily for the treatment of vulval & vaginal atrophy associated with menopause. NOTE: Femring is also
used for systemic effects to control hot flashes & night sweats.
 Inserts (Imvexxy, Vagifem, Yuvafem)
 Creams (Estrace Vaginal, Premarin Vaginal)
 Vaginal rings (Estring, Femring)
Systemic estrogen options:
Oral: Owing to convenience, the oral route is used more than any other. The most active estrogenic compound—
estradiol—is available alone & in combination with progestins.
Parenteral: Although estrogens are formulated for IV & IM administration, use of these routes is rare. IV
administration is generally limited to acute, emergency control of heavy uterine bleeding.
Transdermal estrogen therapy has fewer adverse effects (p. 428)
Compared with oral formulations, the transdermal formulations have 4 advantages:
 The total dose of estrogen is greatly reduced (because the liver is bypassed).
 There is less nausea & vomiting.
 Blood levels of estrogen fluctuate less.
 There is a lower risk for DVT, PE, & CVA.
Management of oral contraceptives (OCs)
-How to change patient from one combination oral contraceptive to another. (p. 441)
When one combination OC is being substituted for another, the change is best made at the beginning of a new cycle.
-How to initiate treatment (when in the cycle is it best to start- may vary based on type of contraceptive) (p. 442)