Aquifer Flashcards
1
Q
What is the USPSTF and ACS stance on the practice of breast self-exams
A
The USPSTF and the ACS do NOT recommend that providers teach patients to do breast self-exams. In a Cochrane review, breast self-exams were associated with an almost 2x increase in breast biopsy with no reduction of mortality.
2
Q
Limitations of the clinical breast exam performed by providers for ASYMPTOMATIC patients
A
In 2015, the ACS made a recommendation against clinical breast exams for screening purposes, citing the extremely low sensitivity rate and high false-positive rate of physician-performed CBEs in asymptomatic patients. The USPSTF cites inconclusive evidence to weigh the benefits with risk
3
Q
What are the 2018 USPSTF Guidelines for cervical cancer screening timelines?
A
In 2018, the USPSTF updated their guidelines to recommend that:
At age 21: cervical cancer screening should begin.
Between ages 21 and 29: screening should be performed every three years with cytology alone.
Between ages 30 and 65: screening can be done every five years with high risk HPV (hrHPV) testing alone, every five years with cotesting (hrHPV and cytology), or every three years with cytology alone.
4
Q
What is DES exposure?
A
diethylstilbestrol (DES) exposure in utero. DES is a nonsteroidal estrogen that was given to pregnant females to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and its use was discontinued in 1971
5
Q
Which high risk groups are recommended to have more frequent cervical cancer screenings?
A
Patients who have compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3, or cancer, or have been exposed to diethylstilbestrol (DES) in utero.
6
Q
When do guidelines recommend cervical cancer screening be discontinued?
A
Patients older than 65 years who have had adequate screening within the last 10 years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal Pap tests with cytology alone or two normal Pap tests if combined with HPV testing.
7
Q
What are the guidelines regarding cervical cancer screening for patients with h/o hysterectomy?
A
Patients who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.
8
Q
Virtually all cervical cancers are caused by infection with ….
A
high-risk types of human papillomavirus (HPV 16, 18)
9
Q
What is the relationship between smoking tobacco and cervical cancer?
A
Cigarette smoking, which is strongly correlated with cervical dysplasia and cancer, independently increases the risk by up to fourfold.
10
Q
Sensitivity vs. Specificity
A
Sensitivity measures proportion of actual positives that are correctly identified as such (e.g., percentage of sick people identified as having the condition). The more sensitive the test, the fewer false negative results.
Specificity measures the proportion of negatives that are correctly identified as such (e.g., percentage of well people identified as not having the condition). The more specific the test, the fewer false positives.
11
Q
Sensitivity and specificity of the pap test in screening for cervical cancer
A
Pap test has a sensitivity of only between 30% and 80% and a specificity of 86% to 100%
12
Q
What are the USPSTF, ACOG, and ACP consensus guideline for ovarian cancer screening in asymptomatic patients?
A
The USPSTF, the American College of Obstetricians and Gynecologists, and the American College of Physicians all recommend against routine screening for ovarian cancer in asymptomatic patients.
13
Q
DDx for nipple discharge
A
Pregnancy Excessive breast stimulation Prolactinoma Breast cancer Intraductal papilloma Mammary duct ectasia Paget disease of the breast Ductal carcinoma in situ Hormone imbalance Injury or trauma to breast Breast abscess Use of medications (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)
14
Q
Sensitivity of screening mammograms for breast cancer
A
The sensitivity of mammography is between 60% and 90%. False-negative results are more common in younger females, as denser breast tissue makes it harder to find abnormalities on x-rays.
15
Q
Expected timing of menopause
A
On average, patients with ovaries reach menopause at age 51, but menopause can start earlier or later. A few patients start menopause as young as 40, and a very few as late as 60.
16
Q
Relationship of smoking cigarettes to menopause
A
Those who smoke tend to go through menopause a few years earlier than nonsmokers.
17
Q
2 questions of the PHQ-2
A
“Over the past two weeks, have you often been bothered by either of the following problems?”
- Little interest or pleasure in doing things.
- Feeling down, depressed, or hopeless.
18
Q
Sensitivity and specificity of the MINI-COG for cognitive impairment
A
99% sensitive, 93% specific
19
Q
(4) common side effects of SSRI drug class
A
Headaches Sleep disturbances (drowsiness and, less frequently, insomnia) Gastrointestinal problems such as nausea and diarrhea Sexual dysfunction
20
Q
Timeline of SSRI therapy for depression
A
In a first episode of depression, it’s usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and - in the elderly, who experience increased rates of recurrence - continuous therapy should be considered.
21
Q
How long do criteria-meeting mood symptoms have to be present to make the diagnosis of MDD?
A
2 weeks
22
Q
SIG-E-CAPS mnemonic for remembering MDD criteria
A
- SLEEP changes (insomnia or hypersomnia nearly every day)
- Loss of INTEREST (anhedonia) or enjoyment in usual activities
- GUILT or worthlessness
- Loss of ENERGY or fatigue nearly every day
- Decreased CONCENTRATION or indecisiveness nearly every day
- APPETITE changes (increase or decrease)
- PSYCHOMOTOR agitation or restlessness observed by others nearly every day
- SUICIDAL ideation
23
Q
Most common method of suicide in the elderly
A
Drug overdose
24
Q
Most reliable sign/symptom for compartment syndrome
A
loss of normal neurologic sensation (paresthesia) is the most reliable sign
25
Type of ankle sprain: Generally involves the interosseous membrane and the anterior inferior tibiofibular ligament. Pain and disability are often out of proportion to the injury. One would expect a positive ankle squeeze test
Syndesmotic "high" ankle sprain
26
Type of ankle injury: Typically due to an inversion injury and may occur in conjunction with a lateral ankle sprain. Patient may complain of persistent pain posterior to the lateral malleolus. Swelling may or may not be present. May also occur with repetitive trauma
Peroneal tendon tear
27
A common sports injury classically associated with an audible "pop." Incidence increases with age. Patients are unable to plantarflex.
achilles tendon rupture
28
How to use the anterior drawer test in work-up of an ankle injury
The patient is supine, the ankle joint is in 20° of flexion, the heel is resting on the palm of the examiner's hand that is resting on the table. thereby stabilizing the calcaneus. The examiner then stabilises the tibia and fibula whilst drawing the calcaneus anteriorly observing the amount of anterior translation at the lateral aspect of the ankle and the change in end feel. The amount of anterior translation and the eventual weakening of the end feel, changing from hard ligamentous to weak elastic, is observed. An anterior translation greater than 1 cm compared to the healthy contralateral ankle and an evident weakening of the end feel are most indicative of a partial rupture or complete rupture of the anterior talofibular ligament. The test is graded on a 4-point scale. 0 represents no laxity and 3 represents gross laxity.
Evidence
Anterior drawer has sensitivity of 86 percent and specificity of 74 percent for a diagnostic test of 160 patients with an inversion ankle sprain when compared to an arthrogram.[2]
29
Which ligament is the most commonly injured with an inversion injury of the ankle resulting in lateral ankle sprain?
anterior talofibular ligament (ATFL)
30
How to use the inversion stress (talar tilt) test in work-up of an ankle injury
Short answer: Invert the patient's ankle. Laxity indicates injury of the calcaneofibular ligament.
Long answer: The patient is positioned in sitting or supine lying with the knee in full extension. The examiner stabilizes the distal leg with one hand while the other hand holds the heel with the ankle in neutral position. The heel is inverted with respect to the tibia. It is important to hold the talus and calcaneus as one unit to prevent excessive subtalar movement. Pain in the area of the ligament or a sensation of clunk would indicate a positive test. An outward translation in excess of 5 degrees on the injured side compared to the uninjured side, or a spongy or indefinite end feel indicate a complete tear of CFL.
31
Grading Ankle Sprains
Grade I sprain involves stretching and/or a small tear of a ligament. There is mild tenderness and swelling, slight to no functional loss, and no mechanical instability. No excessive stretching or opening of the joint with stress.
Grade II sprain is characterized as an incomplete tear and moderate functional impairment. Symptoms include tenderness over the involved structures, with mild to moderate pain, swelling, and ecchymosis. In this grade, there is some loss of motor function and mild to moderate instability. Stretching of the joint with stress, but with a definite stopping point.
Grade III sprain is characterized as a complete tear and loss of integrity of the ligament. Severe swelling (greater than 4 cm about the fibula) and ecchymosis may be present, along with inability to bear weight and mechanical instability. Significant stretching of the joint with stress, without a definite stopping endpoint.
32
What are the Ottowa Ankle Rules for imaging of ankle injuries?
The Ottawa ankle rules are a clinical decision tool designed to help in evaluation of adults (age 18 and up) with acute ankle and midfoot injuries. These have been reported to have a sensitivity of 97% to 100%.
The rules suggest that radiographs of the ANKLE are needed if:
There is pain in the malleolar zone AND either bony tenderness along the distal 6 cm of the posterior edge of either malleolus OR inability to bear weight 4 steps both immediately after the injury and in the emergency department.
Radiographs of the FOOT are needed if:
There is pain in the midfoot region AND one of the following: (a) bony tenderness at either the navicular bone or base of the fifth metatarsal OR (b) inability to bear weight four steps immediately after the injury and in the emergency department.
33
Crossed leg test for evaluating ankle injuries
Have the patient cross their legs with the injured leg resting at midcalf on the knee to detect high ankle sprains (syndesmotic injury between the tibia and fibula).
34
RICE for ankle injuries: patient counseling regarding REST
Rest for the first 72 hours after an ankle sprain, as it may help with reduction of swelling and healing. Stretching is helpful after the first few days to improve range of motion and improve the function of forming scar tissue. Don't rest the ankle for too long, as not moving the ankle for extended periods of time can actually cause more harm such as decreased range of motion, persistent pain and swelling, and chronic joint instability.
35
Types of support braces after an ankle sprain
There are various braces that may be useful after an ankle sprain. The two most common are a semirigid stirrup (e.g. an Aircast) or a soft lace-up brace.
An Aircast is usually constructed of a hard plastic and has inflatable air chambers inside to provide more stability. It allows for some plantarflexion, dorsiflexion but controls inversion/eversion. This device is appropriate for more severe ankle sprains and not mild ones.
A soft lace-up brace is usually made of canvas and provides more limited support. This may be useful in an individual who has had a previous sprain or is returning to active sport competition.
36
A 41-year-old male with no significant past medical history is brought to the Emergency Department after falling to the ground in the middle of a pick-up basketball game with friends. He did not lose consciousness nor hit his head when he fell. As he landed on the ball of his foot after having taken a shot, he recalls hearing a popping sound followed by immediate pain in the posterior right ankle. On physical exam, the posterior right ankle is edematous and tender to palpation. He is unable to plantarflex his right foot. What is the most likely diagnosis of his current condition?
Achilles tendon rupture
37
A 19-year-old female with no significant past medical history is the driver in a motor vehicle accident and is brought to the Emergency Department by EMS. She is complaining of severe pain in her right lower extremity that has worsened since the accident. In addition, she has started to notice what she describes as "burning and tingling" in her right foot. On physical exam, her right calf is edematous and tender with tense overlying skin. There is no swelling or tenderness of the right foot or ankle but the right dorsalis pedis and posterior tibial artery pulses are barely palpable. She cannot confirm light touch of the foot and cannot wiggle her toes on command. What is the next best step in the management of this patient?
Emergent surgical evaluation for fasciotomy in suspected compartment syndrome
38
A 21-year-old female with no significant past medical history experienced an inversion-type injury to her right ankle while playing soccer a day prior to presentation to the family medicine ambulatory practice. She remembers immediate pain and swelling but was able to weight bear and limp off the field. She has noticed some significant swelling which is mostly still present. She has been icing the ankle since the injury as her coach recommended. Pain is still present near the lateral malleolus. Physical examination reveals an edematous lateral right ankle with purplish hue and intact bilateral pulses. Sensation of the bilateral lower extremities is intact and symmetric motor function is preserved. Palpation of the posterior edge of the lateral malleolus elicits significant pain from the patient. There is mild tenderness to palpation of the anterior talofibular ligament and the calcaneofibular ligament. The anterior drawer test and squeeze test are both normal. What is the next best step in the management of this patient?
xray imaging of the ankle. Based on the Ottawa Ankle Rules, tenderness of the lower 6 cm of the posterior lateral malleolus may predict fracture and justifies X-ray imaging of the ankle.
39
Clinical presentation of hyperthyroidism
In patients under the age of 50, the most common signs and symptoms of hyperthyroidism are:
Heat intolerance (92%)
Tachycardia (96%) due to increased adrenergic tone and heightened conduction
Fatigue (84%)
Weight loss (50%) due to increased calorigenesis and gut motility causing hyperdefecation and malabsorption.
Tremor (84%)
Increased sweating (96%)
Exertional dyspnea caused by O2 consumption, CO2 production, and respiratory muscle weakness
Depression and hyperreflexia are less common but can be present.
Gynecomastia
Diarrhea and light periods can also occur with hyperthyroidism.
Many of the typical symptoms of hyperthyroidism are absent in patients older than age 70.
Patients who are older than 70 may present with sinus tachycardia (71%) and/or fatigue (56%), but they can also present with atrial fibrillation or weight loss, and no other symptoms.
40
What is the most common cause of hyperthyroidism in adults and children?
Toxic diffuse goiter (grave's disease) - 60-80% of cases
41
What is graves disease?
Also known as toxic diffuse goiter, it is an autoimmune disease caused by an antibody that acts at the thyroid-stimulating hormone (TSH) receptor and stimulates the gland to synthesize and secrete excess thyroid hormone.
Women are five to 10 times more likely than men to get it.
Peak incidence is between ages 40 and 60.
Often occurs with family history of thyroid disease; can also be associated with other autoimmune diseases.
Triggers include stressful life events, high iodine intake, or a recent pregnancy.
42
HPA axis and thyroid hormones
The hypothalamus releases thyrotropin releasing hormone (TRH) which stimulates the pituitary to produce and release thyroid stimulating hormone (TSH). TSH stimulates the thyroid to make thyroid hormone (T3 and T4).
43
What result would you expect on antibody screen and a radioactive iodine uptake test and scan for the workup of hyperthyroidism if the diagnosis is Grave's disease?
High RAIU (>30%); excess circulating thyroid hormone which occurs in Graves disease as a result of increased creation of thyroid hormone results in increased radioactive iodine uptake used to synthesize the thyroid hormone.
Presence of anti-thyrotropin receptor antibodies (TRAb) are 97% sensitive and 99% specific for Graves
44
Your patient is confirmed to have hyperthyroidism from their initial lab results of TSH/T4. What are your next steps in diagnosis to determine the underlying etiology?
- radioactive iodine uptake test (RAIU) and scan
| - Anti-thyrotropin receptor antibodies (TRAb)
45
What is the role of US or MRI in the work-up of lab-findings of hyperthyroidism?
A thyroid ultrasound is used in the evaluation of thyroid nodules and thyroid enlargement but not hyperthyroidism. Ultrasound characteristics of a nodule can be used to stratify risk of malignancy and ultrasound can guide the fine needle aspiration of nodules that are not easily palpated. Ultrasound is starting to be used to differentiate Graves disease from other causes of hyperthyroidism when RAI scanning is not available or is contraindicated. Some experts predict that color-flow Doppler ultrasound may replace RAI scanning since it has similar accuracy but is safer, less costly and easier to administer.
An MRI of the thyroid gland is not necessary to diagnose hyperthyroid disease.
46
The most common manifestations of Graves ophthalmopathy (eye problems) are (2)
eyelid retraction and exophthalmos
47
Patient education points with the initiation of methimazole for hyperthyroid
Side effects are rare, but less than 1% of people who take methimazole have a serious side effect known as agranulocytosis in which the bone marrow stops producing white blood cells. This leaves patients vulnerable to serious infections.
It takes up to three months to suppress thyroid production, although patients usually start to notice improvement in their symptoms after one month.
Patients typically need to stay on medications for several years. More than half of patients return to hyperthyroidism if they try stopping medications.
The appropriate dose of medication fluctuates over time and people on medication need to come in for blood work often for adjustments. People on medication are more likely to have symptoms because fluctuations are hard to predict.
48
Patient education points with the initiation of radioactive iodine PO as treatment for hyperthyroid
Alternative to thyroid hormone suppressant medication. More commonly used in the United States.
Iodine concentrated in the thyroid and has very few side effects. Most people only need a single dose.
During the course of a few months the iodine destroys most of the overactive thyroid cells and the level of thyroid hormone falls and the thyroid gland shrinks in size.
Eventually most people who have this treatment start having too little thyroid in their bloodstream so that they need to start taking small doses of thyroid hormone to replace it.
Low thyroid is relatively easy to manage once you have found a dose where the patient feels normal and the TSH is in the normal range. Blood levels usually need to be drawn once or twice yearly and the dose of thyroid replacement usually stays about the same.
Obtain a pregnancy test before initiating radioactive iodine treatment.
Advise patients that they should not be near pregnant women or young children for several days following radioactive iodine treatment because the radioactive iodine is excreted in urine and stool. Fetuses or young children exposed to this could have deleterious effects on their thyroid. Side effects include transient soreness of the neck or brief worsening of symptoms but they should resolve within a few days. Furthermore, people with ophthalmopathy can have worsening of eye symptoms.
49
(2) medications first line for grave's disease/hyperthyroidism treatment
methimazole, oral radioactive iodine
50
Priority side effect to look out for with Methimazole
agranulocytosis
51
What are some common symptoms of hypothyroid?
Weight gain, cold intolerance, pedal edema, heavy periods, and fatigue all arise from slowed metabolism. Fatigue is common to both hyper- and hypothyroidism.
52
A typical starting dose in primary hypothyroidism (such as that which occurs following radioactive iodine treatment) is ....
75 mcg levothyroxine
53
Most individuals with primary hypothyroidism will achieve euthryoid status on dose of what amount of levothyroxine?
1.5 to 1.8 mcg per kilogram.
54
The best initial imaging for a thyroid nodule is...
thyroid ultrasound
55
(5) main causes of heart palpitations
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Cardiac arrhythmias
Structural (valvular) heart disease
Psychiatric disorders
Systemic causes
Effects of medical or recreational drugs
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56
Chest pain that is worsened by respiration and may be exacerbated when lying down
pleuritic chest pain
57
Causes of pleuritic chest pain include (5)
pulmonary embolism, pneumothorax, viral or idiopathic pleurisy, pneumonia, and pleuropericarditis.
58
Cardiac-related chest pain that typically improves with sitting up and leaning forward. You suspect....
pericarditis
59
Prodromal symptoms of acute coronary syndrome in women may include (10)
```
Fatigue
Dyspnea
Neck and jaw pain
Palpitations
Cough
Nausea and vomiting
Indigestion
Back pain
Dizziness
Numbness
```
60
Sensitivity and specificity of exercise treadmill stress tests for females for CHD
The sensitivity and specificity of exercise treadmill testing in women is 70% and 61%, respectively.
61
How often do you measure A1c in diabetic patients?
Current standards of care recommend initial A1C testing at diagnosis, and follow-up testing at least two times a year in patients who are stable and meeting goal of A1C < 7; perform the A1C quarterly in patients when therapy is changing or they are not meeting goal.
62
How often do you measure kidney function in diabetic patients?
Screening for and monitoring diabetic nephropathy is important for assessing end organ damage. It is recommended at diagnosis and annually according to ADA guidelines. In addition, many diabetes medications are excreted through the kidneys and require annual monitoring to identify renal insufficiency and avoid drug toxicity (e.g. metformin, which can cause metabolic acidosis).
63
The spot urine albumin-to-creatinine ratio is the screening test for ....
microalbuminuria
64
Why might you routinely follow serum B12 levels in your diabetic patients?
During clinical trials, up to 7% of patients receiving metformin developed asymptomatic subnormal serum vitamin B12 levels. In the setting of neuropathy, too, serum B12 levels would be a very reasonable diagnostic test to order.
65
How often do you measure lipid panel in diabetic patients?
In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every five years thereafter if under the age of 40 years. Also, obtain a lipid profile at initiation of statins or other lipid-lowering therapy, four to 12 weeks after initiation or a change in dose, and annually thereafter.
66
(4) first line medication classes for HTN
thiazides, ACE inhibitors, angiotensin receptor blockers (ARBs), or calcium channel blockers
67
Which diabetic patients should be on statins?
The American College of Cardiology and American Heart Association (ACC/AHA) recommends the following blood cholesterol treatment for patients with diabetes and LDL-c 70-189 mg/dL:
· Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (Level of Evidence A)
· High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated. (Level of Evidence B)
· In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (Level of Evidence C). Note, the ACC/AHA recommends all patients > 21 years old (with or without diabetes) who have an LDL-c >190 should be started on statin therapy (Level of Evidence B).
68
Whats the deal with aspirin and diabetes?
A recent meta-analysis has demonstrated that aspirin does not reduce the likelihood of cardiovascular events in patients with diabetes without pre-existing disease, except to decrease the risk of myocardial infarction in men. Therefore, we do not need to specifically target patients with diabetes for aspirin therapy; we should consider them for aspirin therapy just as we would any patient without diabetes.
Aspirin therapy should be considered for primary prevention in diabetic patients with a 10-year risk >10%, which is updated to include women with diabetes aged ≥50 years who have at least one additional major risk factor, i.e., HTN. You would need to discuss a risk of bleeding, and have a discussion of the benefits and risks with the patient.
The American Diabetes Association (ADA) recommends:
```
Aspirin therapy (75 to 162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding. (Level of Evidence C)
Use aspirin therapy (75 to 162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. (Level of Evidence A)
For patients with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used. (Level of Evidence B)
Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome (Level of Evidence A) and may have benefits beyond this period. (Level of Evidence B)
```
69
In patients with diabetes and established ASCVD or CKD, the best choice for a second agent (after metformin) is.... (2)
GLP-1 receptor agonist or SGLT2 inhibitor because of the demonstrated cardiovascular risk reduction.
70
Role of Pneumovax in diabetes care
Pneumococcal 23-valent polysaccharide (Pneumovax) should be provided to all patients with diabetes over 2 years of age. At age 65 (or older), a patient will need a dose of Prevnar (if haven’t received it previously) and a second dose of Pneumovax, provided at least five years have passed since the first dose. Prevnar and Pneumovax are usually spaced one year apart.
71
How often do diabetic patients need eye exams?
Type 1 diabetes patients should have their first annual eye exam 5 years after diagnosis. However, type 2 diabetes patients should have their first dilated exam when they are first diagnosed (evidence level B) because roughly 20% of patients will already have some degree of retinopathy at diagnosis.
Early detection and treatment of diabetic retinopathy can improve outcomes. Yearly dilated ophthalmoscopic exams are needed because many patients with retinopathy may not notice symptoms. The dilated exam is very sensitive for detecting retinal thickening from macular edema and for early neovascularization. The use of fundus photography is more sensitive for detecting retinopathy, but is more difficult to obtain because of the need for a trained photographer and reader.
72
Optimal ranges for blood sugar for home-sugar checks in diabetic patients
Optimal range for blood glucose:
fasting blood glucose should be 80 -120 mg/dl
postprandial blood glucose between 1-2 hours after a meal should be < 180 mg/dl
73
Combined estrogen and progestogen use beyond ______ in length increases the risk of breast cancer.
three years
74
Use of unopposed systemic estrogen in females with a uterus increases _________ risk
endometrial cancer
75
Beginning hormone therapy after age ______ increases the risk of coronary artery disease.
60yo
76
Hormone therapy increases the risk of stroke when?
for at least for the first one to two years of use.
77
Hormone therapy for menopausal symptoms should use the _______ effective doses for the _______ possible times.
lowest, shortest
78
Hormone therapy can be helpful for the symptoms of ______ and it will help delay _______, but it can increase the risk of (3)
```
helpful = hot flashes, delay bone loss
harmful = breast cancer, heart attack, and stroke.
```
79
(4) medication classes that can be used in osteoporosis
Biphosphonates are potent inhibitors of bone resorption and reduce bone turnover, resulting in increase in bone mineral density. Biphosphonates have been shown to decrease the risk of vertebral and non-vertebral fractures. -- alendronate (Fosamax), risendronate (Actonel), ibandronate (Boniva).
```
Zoledronic acid, an intravenous preparation, is given annually and can be used in patients who do not tolerate the oral bisphosphonates.
Parathyroid hormone (Forteo) is an anabolic drug and is approved by the FDA for those with osteoporosis at high risk for fracture. It is given subcutaneously and has been shown to decrease fracture risk by 50% to 65%. It does not have demonstrated efficacy and safety beyond two years and is quite costly.
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Raloxifene is a selective estrogen receptor modulator (SERM) which is used if bisphosphonates are not tolerated, but only work to prevent vertebral fractures.
Calcitonin has been shown to reduce vertebral fractures, but not hip or other fractures. For most women, more effective treatments are available.
80
(5) classes of medications that can be used in the treatment of menopausal vasomotor symptoms (hot flashes, night sweats, flushing)
hormone therapy, SSRIs, SNRIs, clonidine, gabapentin
