1. KIMBERLY CHEATHAM, MD, FACOG DIRECTOR, OU-TULSA PA PROGRAM OCTOBER 26, 2012 Hormone Replacement Therapy: A Primer for the Physician Assistant Modified from Shapiro M, Goldstein SR, Pinkerton JV, Shifren JL. Customizing therapies to manage menopause-related symptoms. Medscape Women’s Health Education. 2012. Retrieved from http://www.medscape.org/viewprogram/32450?src=0_mp_cmenl_0

2. Objectives At the conclusion of this presentation, the physician assistant will be able to:  Recognize the indications and contraindications for patient use of hormone therapy  Create a treatment strategy for patients who desire to use hormone therapy  Provide appropriate counseling to patients considering hormone therapy use

33. Take-Home Message Indications Women < 60 years old or < 10 years from menopause with moderate to severe vasomotor symptoms (hot flashes or night sweats) Postmenopausal women with symptoms from vulvovaginal atrophy  Vaginal dryness  Dyspareunia  Urge incontinence  Recurrent UTI Women experiencing premature menopause (< 40 y) or premature ovarian insufficiency Stuenkel, C. A. et al. (2012). A decade after the WHI – the experts do agree. Fertility and Sterility, 98(2), 313-314.

34. Take-Home Message Treatment Strategy HT is the most effective treatment for menopause-related symptoms and their potential consequences (diminished sleep quality, irritability, QOL) Progestogen therapy is required to prevent endometrial cancer when estrogen is used systemically in women with a uterus Observational data shows that transdermal estrogen leads to fewer strokes and VTE/PE than oral therapy Local low-dose estrogen therapy is effective and preferred for women whose symptoms are limited to vaginal dryness or discomfort with intercourse Stuenkel, C. A. et al. (2012). A decade after the WHI – the experts do agree. Fertility and Sterility, 98(2), 313-314.

35. Take-Home Message Counseling Duration of treatment Benefit-risk ratio The lowest dose of HT should be used for the shortest amount of time to manage symptoms Patient’s risk factors and effects of HT on CHD, stroke, VTE/PE, breast cancer, osteoporosis Discontinuance Stuenkel, C. A. et al. (2012). A decade after the WHI – the experts do agree. Fertility and Sterility, 98(2), 313-314.

36. Resources Hormone products http://www.menopause.org/publications/clinical-practice- materials/hormone-therapy-charts http://www.menopause.org/publications/clinical-practice- materials/hormone-therapy-charts NAMS 2012 Hormone Therapy Position Statement http://www.menopause.org/docs/default-document- library/psht12.pdf?sfvrsn=2 http://www.menopause.org/docs/default-document- library/psht12.pdf?sfvrsn=2 NAMS 2007 Position Statement for Local Vaginal Estrogen Treatment of Vaginal Atrophy http://www.menopause.org/docs/2010/psvagestrogen07.pdf?sfvrs n=2 http://www.menopause.org/docs/2010/psvagestrogen07.pdf?sfvrs n=2 Bioidentical Hormone Therapy http://www.menopause.org/publications/clinical-practice- materials/bioidentical-hormone-therapy http://www.menopause.org/publications/clinical-practice- materials/bioidentical-hormone-therapy

37. References ACOG Committee Opinion. Compounded Bioidentical Hormones. Canonico M, et al. Maturitas. 2006; 54: 372-379. Chen WY, et al. Arch Intern Med. 2006; 8; 166: 1027-1032. Hsia J, et al. Arch Intern Med. 2006; 166: 357-365. LaCroix AZ, et al. JAMA. 2011; 305: 1305-1314. Lisabeth L, et al. Lancet Neurol. 2012; 11: 82-91. MacLennan AH, et al. Cochrane Database Syst Rev. 2004; CD002078. Minkin MJ. J Reprod Med. 2004; 49: 311-320. NAMS. Menopause. 2012; 19: 257-271. NAMS. Menopause Practice: A Clinician’s Guide, 4th edition; 2010. NIH. Annals Int Med 2005; 142: 1003-1013. Prescrire Int. 2006; 15: 137-138. Rada G, et al. Cochrane Database Syst Rev. 2010; CD004923. Rossouw JE, et al. JAMA. 2002; 288: 321-333. Salpeter SR, et al. J Gen Intern Med. 2006; 21: 363-366. Santen RJ. J Clin Endocrinol Metab. 2010; 95: s1-s66. Scarabin PY, et al. Lancet. 2003; 362: 428-432. Shapiro M, et al. Medscape Women’s Health Education. 2012. Retrieved from http://www.medscape.org/viewprogram/32450?src=0_mp_cmenl_0 Stuenkel CA, et al. Fertility and Sterility. 2012; 98(2), 313-314.