2/22 Women's Health Pharm - Pradhan/Pilch

Question 1

hormonal contraception

contents

mech of action

contraceptive failures

Answer 1

typically contain:

• PROGESTIN only
• PROGESTIN/ESTROGEN combo
  
  • monophasic: constant dose of both during cycle
  • biphasic: dosage of one component changes once
  • triphasic: dosage of one or both components changes twice

mech of action: suppress releast of gonadotropins (FSH, LH) from ant pit → inhibit follicular devpt, prevent ovulation

also thicken cervical mucus, decr ovum motility in uterine tubes

contraceptive failure: missed doses or drug interactions (CYP3A4)

• should use pdt containing smallest effect amt of hormone to minimize potential for undesirable physiologic effects

Question 2

hormonal contraceptives

adverse effects

Answer 2

minor effects frequent, major rare

mild adv effects (typically transient)

• headache, nausea, mastalgia, edema
• breakthrough bleeding (typically due to insuff levels of estrogen to maintain endometrial stability)
• withdrawal bleeding sometimes fails to occur on “off” days

moderate adv effects (may require discont)

• breakthrough bleeding (more w progestin-only)
• weight gain, exacerbation of acne/hirsutism (preps containing androgen-like progestins)
• ureteral dilation, bacteriuria more freq
• following cessation: amenorrhea in some pts (up to 3 months)

severe adv effects (rare)

• venous thromboembolic disease (3x)
• MI
• cerebrovascular disease (stroke risk concentrated over 35 with CURRENT, not past, use)
• GI disorders: cholestatic jaundice
• depression

contraindications

1. cardiovascular, cerebrovascular, thromboembolic disorders or history
2. avoid if: migraine with aura, HTN, liver disease, gallbladder disease

careful with drugs that activate hepatic metab! (esp CYP3A4)

Question 3

non-oral contraceptives

Answer 3

1. patch → requires higher dosing
2. vaginal ring
3. subdermal implant
4. IM injection (DepoProvera)
   
   • decr bone density
   • weight gain
   • menstrual irregs
   • slow return of menses after discont
   • depression

Question 4

postcoital contraceptives

“morning after”

Answer 4

admin of estrogens alone, progestins alone, or combination

progesterone receptor antagonist mifepristone → luteolytic effect

99% effective if within 72h

Question 5

contraceptive choice algorithm

Answer 5

Question 6

ovulation-inducing agents

SERMS

Answer 6

selective estrogen receptor modulators

CLOMIPHENE

mech: partial agonist at estrogen receptors

• inhibits action of stronger estrogen
• increase in secretion of gonadotropins and estrogens by inhibiting negative feedback effect of estradiol

good at stimulating ovulation in women with oligomenorrhea or amenorrhea & ovulatory dysfx

• single course typically induces single ovulation - continue till preg achieved

adverse effects

• hot flashes (gone on discont)
• n/v, nervous tension, depression, fatigue, breast soreness, heavy menses, weight gain → due to hormones

Question 7

ovulation inducing agents

GnRH agonists

Answer 7

LEUPROLIDE

reserved for anovulatory women who dont response to other tx

good for COH (controlled ovarian hyperstim) for assisted repro procedures, ex. IVF

Question 8

pharmacotx of PID

Answer 8

pelvic inflammatory disease

• key orgs: Neisseria gonorrhoeae, Chlamydia trachomatis
  
  • gonorrhea: ceftriaxone (parenteral)
    
    • 3rd gen cephalosporin
    • bacteriocidal: beta lactam → inhibits biosynth of bacterial cell wall
  • concomitant oral tx with azithromycin (macrolide) or doxycycline (tetracycline analog) recommended (bc of potential for concomitant chlamydial inf)
    
    • bacteriostatic via block of protein synth

Question 9

STDs that can cause vaginal discharge

Answer 9

chlamydia

gonorrhea

trichomonas vaginitis

herpes vaginitis

Question 10

pharmacotx of Trichomoniasis

Answer 10

pathogen: Trichomonas vaginalis

women > men

• malodorous vaginal discharge of pH > 5
• went0mount exam is best means of dx (pear-shaped flagellating org)

tx: metronidazole

• unique mech: mitroimidazone that kills anaerobic bacteria and susceptible protozoans
  
  • activation requires enzyme pyruvate-ferredoxin oxidoreductase (PFOR) in susceptible microbes : reduction of nitro group → formation of toxic radical
  • radical oxidatively damages microbial DNA → fragmentation, cell death

adverse effects: GI effects (diarrhea) bc wipes out gut flora

• common: headache, nausea, dry mouth
• infreq: vomiting/diarrhea/insomnia/vertigo/dysuria
• rare: neutropenia/pancreatitis/CNS tox

contraindications:

• n/v enhanced with alcohol!
• caution with CNS disease
• contraindicated in first trimester preg
• secreted in breastmilk (stop breastfeeding for 12-24h after ingestion)

Question 11

pharmacotx of Herpes vaginitis

Answer 11

genital disease typically caused by infection with HSV-2

tx: acyclovir, valacyclovir, famciclovir

mech:

• ACYCLOVIR, PENCICLOVIR
  
  • acyclic guanine analogs
  • require viral kinase to activate → selectively activated in inf cells → inhibit viral DNA synth via…
    
    1. competitive inhibition of viral DNA polymerase
    2. chain termination after incorporation into viral DNA
• VALACYCLOVIR, FAMCICLOVIR
  
  • prodrugs of acyclovir, penciclovir respectively

primary goals of tx

• relieve sx, shorten clinical course
• prevent complications and recurrences
• decrease disease transmission

adverse effects

• generally well-tolerated
• some occasional rxn: nausea, headache, diarrhea, vomiting
• valacyclovir at high dose: rare confusion, hallucination, seizure

Question 12

herpes infection algorithm

first episode

recurrent

Answer 12

1st episode

acyclovir, famciclovir, valacyclovir

tx typically associated with:

• reduced viral shedding
• shorter duration of sx
• reduced time for ulcers to heal

recurrent

chronic suppressive tx, high dose episodic tx