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Gynecologic, Reproductive, Sexual, and Menopause Health > Ch. 4: Unintended pregnancy & Menopause > Flashcards

Ch. 4: Unintended pregnancy & Menopause Flashcards

1
Q

medication abortion
-FDA approved up to….

A

70 days from LMP

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2
Q

a. Mifepristone MOA

A

-blocks action of progesterone needed to establish and maintain placental attachment
-softens cervix
-stimulates prostaglandin synthesis by cells of early decidua

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3
Q

b. Misoprostol (prostaglandin analogue) MOA

A

-softens cervix
-stimulates uterine contractions
-common short term SE: N/V, diarrhea, temporary elevation of body temperature

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4
Q

with is the mifepristone/misoprostol regimen that is 98% effective through 9 weeks gestation

A

oral mifepristone 200 mg followed by misoprostol 800 mcg**

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5
Q

CI to mifepristone and misoprostol
-lots

A

-known or suspected ectopic pregnancy
-IUD in place; remove prior to giving medication
-hypersensitivity to either medication
-hemorrhagic disorders
-anticoagulant therapy
-chronic renal failure
-long term systemic corticosteroid therapy
-inherited porphyrias

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6
Q

how many clinic visits are required if using mifepristone/misoprostol regimen?
-what meds, where
-what dose can be repeated?

A

two!

mifepristone orally at initial visit
misoprostol at home: vaginal in 6 to 48 hours, buccal or sublingual in 24 to 48 hours

one to two week f/u appointment to assess for complete abortion

may repeat misoprostol or provide aspiration if abortion is not complete

aspiration abortion if pregnancy persists 2-3 weeks after initiation

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7
Q

methotrexate plus misoprostol- less common
-methotrexate MOA

A

inhibits enzyme necessary for DNA synthesis
acts on rapidly dividing cells of placenta

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8
Q

methotrexate + misoprostol requires two office visits

A

-methotrexate IM or orally at initial visit
-misoprostol vaginally at home 3-7 days later

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9
Q

surgical methods for abortion

A
  1. vacuum aspiration (First trimester)
    -suction curettage
    -local anesthetic
  2. dilation and evacuation- can be performed up to 20 weeks gestation
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10
Q

what labs should you get on patient pre-abortion?

A

-urine pregnancy test
-Hgb/Hct
-blood type and Rh
-STI eval if indicated

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11
Q

post-abortion care
-rh immunization

A

Rh immunization if client is Rh negative- give at time of surgical procedure or first visit with medication abortion

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12
Q

potential post abortion complications/warning signs

A

-infection
-retained POC
-trauma to uterus/cervix
-excessive bleeding
WARNING SIGNS:
1. fever
2. persistent/increasing lower abdominal pain
3. prolonged/excessive vaginal bleeding
4. purulent vaginal discharge
5. no return of menses within 6 weeks

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13
Q

menopause
-avg age
-definition

A

one year of permanent menses cessation
average is 52 years old

menopausal status IS genetically predetermined

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14
Q

perimenopause is defined as…

A

beginning of menopause transition until 12 months after final menstrual period (FMP)

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14
Q

premature menopause definition
-age??

A

cessation of ovulation and menses before age 40; spontaneous or induced

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14
Q

STRAW reproductive-aging continuum

A

standardized definition of reproductive aging based on specific criteria, endocrine parameters, and characteristic markers

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14
Q

endocrine parameters, including FSH, are just supportive criteria and NOT typically measured for purposes of staging reproductive aging or menopause
-AMH
-inhibin B
-antral follicle count

A

-AMH: only produced by granulosa cells of pre-antral/small ovarian follicles; inhibits FSH-dependent follicular growth; marker of ovarian reserve; AMH begins to decrease as early as a women’s late twenties and thirties; undetectable 5 years after menopause

-inhibin B: major ovarian peptide; rises and falls in first half of follicular phase, peaks mid cycle, falls to lowest levels in luteal phase; forms negative feedback loop to fine-tune pituitary FSH regulation; as number of ovarian follicles declines, inhibin B levels fall and FSH levels rise

-antral follicle count: determined by u/s; used primarily as factor in fertility counseling

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14
Q

principal clinical criteria of STRAW
-other characteristic markers/symptoms

A

menstrual cycle changes

other: vasomotor symptoms, urogenital atrophy

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14
Q

menopausal transition (late)

A

duration 1-3 years; intervals of amenorrhea > 60 days; may have extreme fluctuations in hormone levels; FSH fluctuates between postmenopausal and reproductive age levels; AMH low; inhibin B low; vasomotor symptoms likely

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14
Q

menopausal transition (early)

A

duration variable; menses cycle length varies (persistent difference of 7 or more days in length of consecutive cycles) ; FSH in early collicular phase elevated but variable; AMH low, inhibin B low, antral follicle count low

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15
Q

Postmenopause (early) is divided into two phases
1. First 12 months after FMP
2. second post menopausal year until point in time when high FSH and los estradiol levels begin to stabilize

A
  1. First 12 months after FMP: FSH elevated but variable, AMH low, inhibin B low; antral follicle count very low, vasomotor symptoms likely
  2. second post menopausal year until point in time when high FSH and los estradiol levels begin to stabilize- duration 3-6 years, FSH stabilizes, AMH very low inhibin B very low; antral follicle count very low
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16
Q

what is the primary event leading to menopause?

A

ovarian aging with follicular atresia

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17
Q

physiology of menopause
-follicle #
-type of estrogen that dominants
-FSH, inhibin B levels

A

-decrease in # of responsive follicle -> decrease in production of estradiol
-decrease in E2 and inhibin B -> rise in FSH through negative feedback

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18
Q

T/F measurement of E2 and FSH levels is a reliable way to determine menopause

A

FALSE

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19
Q

T/F we generally rely on cessation of menses, hypoestrogenic symptoms, and age for diagnosis of menopause

A

TRUE!

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20
Q

which estrogen dominates after menopause

A

ESTRONE :)

which is primarily derived from adipose tissue

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21
Q

laboratory findings of
-FSH
-LH
-E2
in post menopausal patients

A
  1. FSH- greater than 40
  2. LH_ threefold elevation after menopause (20-100)
  3. E2: less than 20
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22
Q

decreased estrogen effects…
-skin
-bone integrity

A

-skin: skin has significant # of estrogen receptors, hair becomes thinner and drier

-bone integrity: increased bone loss with decreased estrogen; greatest loss in first few years after menopause, then slows but continues

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23
Q

how does the external and internal genitalia change in menopause
-labia
-vagina (pH, epithelium)
-cervix
-uterus and ovaries

A

-labia: decrease in subq fat, elasticity
-vagina:
a. pH: from acidic to alkaline environment; pH >5
b. epithelium becomes thinner (more parabasal cells), vaginal walls appear thin, smooth, pale, vaginal walls may have petechia and be friable to touch

-cervix: decrease in size, can become stenotic

-uterus and ovaries: decrease in size; ovaries not usually palpable

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24
Q

T/F about 1/4th of women report some mood changes during menopause transition

A

true

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25
Q

T/F memory and cognitive skills decline is directly a result of normal menopausal transition

A

FALSE-no evidence of this!!

BUT: ability to concentrate may be reduced by sleep disturbances and fatigue r/t hot flashes

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26
Q

T/F Women’s health initiative memory study (WHIMS) found that risk of dementia increased in healthy women aged 65 to 79 years using estrogen with progesterone therapy

A

TRUE

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27
Q

Wellness visit ages 40-64 include

A

-pmhx, psych and social concerns, sexual hx
-menopausal symptoms, symptoms of pelvic prolapse
-CBE: ACOG says annually for women aged 40 and older, ACS + USPSTF says no
-pelvic exam: if pap test needed or otherwise indicated

28
Q

cervical cancer and mammogram screening recommendations

  1. ACS
  2. ACOG
  3. USPSTF
A

CERVICAL CANCER
1. ACS + ACOG: cytology with HPV every 5 years or cytology alone every 3 years
2. USPSTF: includes option of HPV testing alone every 5 years

MAMMOGRAM
1. ACS: yearly beginning at age 45 for women at average risk; women 55 and older can transition to biennial screening; women should have opportunity to begin mammograms at ages 40-44
2. ACOG: offer starting at age 40; initiate at ages 40-49; recommend no later than 50 if woman has not yet initiated
3. USPSTF: biennial screening from 50 to 74

29
Q

colorectal screening recommendations ACS

A

-adults age 45 and older should undergo regular screening with cologaurd or colonoscopy

30
Q

other screenings for wellness visit 40-64
-hep C
-diabetes
-lipids

A

hep c: screen once if born between 1945 and 1965 and no other risk factors

diabetes: every 3 years starting at 45

lipid: periodic assessment of cardiovascular risk factors from ages 40 to 75

31
Q

wellness visit 65 and beyond
-height concerns??
-CBE and pelvic exam recommendations

A

-height loss > 1.5 inches may be associated with vertebral compression fractures and osteoporosis
-CBE not recommended for average risk women at any age (ACS, USPSTF), ACOG says annually
-pelvic exam if pap test indicated; routine pelvic exam is a shared decision between patient and provider

32
Q

cervical cancer screening for 65+
-normal
-hx of CIN2

A

-stop screening @ 65 if adequate prior negative screening results (three consecutive negative cytology results or two consecutive co-testing results within previous 10 years and most recent test within past 5 years)

-hx of CIN2 or higher: continue screening 20 years after spontaneous regression

33
Q

T/F once screening has stopped, do not resume cervical cancer screening even if individual reports new sexual partner

A

True

34
Q

colorectal and mammogram screening in 65+
-ACS recommends..

A

MAMMOGRAM
-ACS and ACOG: annual or biennial interval; no definitive age to d/c; based on health history
-USPSTF: biennial screening 50-74

COLON CANCER SCREENING
adults age 45 and older should undergo regular screening

35
Q

Bone mineral density scan recommendations

A

-screen all women 65 and older for osteoporosis/osteopenia
-no specific recommendation on frequency of screening or when to d/c

36
Q

Vasomotor symptoms (VMS)
definition/symptoms

A

recurrent, transient episodes of flushing accompanied by sensation of warmth to intense heat on upper body and face
may include profuse sweating and palpitations
may awaken during night, leading to insomnia, sleep disturbance, memory and anxiety disruptions with loss of REM sleep

37
Q

how many women experience VMS during perimenopause? how long does it last?

A

75%
lasts 5-7 years but may continue up to 15 years
greatest severity within first 2 years after LMP

38
Q

mild to moderate VMS management- NON pharm

A

Level I: CBT- group or self guided; clinical hypnosis
Level II: weight loss for obese and overweight individuals, mindfulness-based stress reduction

39
Q

T/F exercise, yoga, and acupuncture have been show to alleviate VMS

A

FALSE

40
Q

Pharm management for VMS
1. estrogen therapy (ET)

A

unopposed estrogen prescribed for women without a uterus

41
Q

Pharm management for VMS
2. estrogen-progesterone therapy (EPT)

A

combination of E and P; progestins main purpose is to reduce risk of endometrial cancer in women with a uterus associated with unopposed estrogen

42
Q

estrogen types (3)

A
  1. 17b estradiol- only human estrogen available in FDA-approved, single-estrogen product
  2. conjugated equine estrogen (CEE)- mixture of estrogen isolated from urine of pregnant mares
  3. synthetic estrogens- estrified estrogen, conjugated estrogen, ethinyl estradiol
43
Q

progestogen type

A
  1. progesterone- compound identical to endogenous steroid hormone produced by the ovaries, or micronized progesterone
  2. progestin- synthetic product that has progesterone-like activity but is not identical to endogenous progesterone (medroxyprogesterone acetate, norethindrone acetate, levonorgestrel)
44
Q

Pharm management for VMS
3. Selective estrogen-receptor modulators (SERMs) aka estrogen receptor agonists/antagonists

A

-estrogen-like compound that act as estrogen agonists or antagonists depending on the SERM and target tissue
-BAZEDOXIFENE (BZA)- SERM with estrogen antagoi

45
Q

the SERM Bazedoxifene (BZA)

A

-BAZEDOXIFENE (BZA)- SERM with estrogen antagonist effects on endometrial and breast tissue and estrogen agonist effects on bone

46
Q

BZA combined with CEE

A

alternative to adding a progestogen to prevent endometrial hyperplasia

47
Q

Pharm management for VMS
4. bioidentical hormones

A

hormones chemically identical to hormones produced by women during their reproductive years (17B-estradiol, estrone, estradiol, testosterone, progesterone)

48
Q

Indications for HT (4)

A
  1. treatment of moderate to severe VMS due to menopause
  2. treatment of moderate-severe vulvar and vaginal atrophy due to menopause 2a. prevention of postmenopausal osteoporosis
49
Q

T/F HT should be used to prevent coronary heart disease, stroke, and dementia

A

FALSE
NOT TO BE USED

50
Q

contraindications to use of hormone therapy (perimenopause-menopause)

A
  1. undiagnosed abnormal genitalia bleeding
  2. known, suspected, or hx of breast cancer
  3. known or suspected estrogen-dependent neoplasia
  4. active or history of DVT or PE
  5. active or history of arterial thromboembolic disease (stroke, myocardial infarction)
  6. known liver dysfunction or disease
  7. known protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders
  8. known or suspected pregnancy
51
Q

T/F low dose vaginal ET with minimal systemic absorption may be considered for survivors of breast cancer with bothersome genitourinary syndrome of menopause

A

TRUE
consult with oncologist!!

52
Q

potential risks of HT
1. endometrial hyperplasia/cancer
2. breast cancer
3. thromboembolic disorders
4. dementia

A
  1. endometrial hyperplasia/cancer- estrogen alone
  2. breast cancer- inconclusive; small but significant increase of breast cancer with long-term use
  3. thromboembolic disorders- inconclusive; women who start HT at or close to menopause do NOT incur same risk as those who start several years after menopause
  4. dementia- inconclusive; small but significant increase in risk if EPT is initiated in individuals > 65
53
Q

positive and negative effects of oral ET on cardiovascular markers
-HDL, LDL, triglycerides, C-reactive protein

A

-increases HDL, lowers LDL
-but increases triglycerides and c-reactive proteins

NOTE: HT should never be used for prevention of cardiovascular disease

54
Q

routes of administration

A

-oral: first pass metabolism

-transdermal/topical: patch, lower doses as not dependent on GI absorption and no first-pass effect, no significant impact on HDL, LDL like oral

estrogen vaginal ring- systemic absorption, approved for treatment of VMS and vulvovaginal atrophy; needed added progestogen if uterus present

55
Q

what are vaginal estrogen creams and tablets good for in postmenopausal women?

A

-used for tx of VULVOVAGINAL ATROPHY
-little or no systemic absorption
-will NOT provide relief from VMS
-progestogen does NOT need to be added with low-dose vaginal estrogens

56
Q

Progestogens
-oral vs transdermal vs intrauterine

A

oral: MPA, norethindrone acetate, micronized progesterone

transdermal EPT patches: norethindrone acetate, levonorgestrel

intrauterine: LNG-IUS

57
Q

regimen options for HT
1. recs for progestogen use for endometrial protection with standard estrogen dosing

A

a. 12-14 days each month of 5 mg MPA
b. daily doses of 2.5 mg MPA
c. LNG-IUD
d. vaginal progesterone gel 45 mg daily or 12-14 days each month

58
Q

regimen options for HT
2. continuous-cyclic EPT

A

a. estrogen every day
b. progestogen added 12-14 days each month
c. no estrogen-free period during which VMS can occur
d. withdrawal bleeding when progestogen withdrawn each month; may start 1-2 days earlier

59
Q

regimen option for HT
3. continuous-combined EPT

A

a. estrogen and progestogen every day
b. lower cumulative dose of progestogen than with cyclic regimens
c. may initially have unpredictable bleeding
d. after several months, endometrium atrophies and amenorrhea usually results
e. no estrogen-free period during which vasomotor symptoms can occur

60
Q

regimen option for HT
-combination CEE/BZA

A

FDA approved treatment for moderate-severe VMS and prevention of osteoporosis

61
Q

continuous unopposed estrogen

A

for individual without uterus

62
Q

side effects of HT
(5)

A

-breast tenderness (E + P, subsides after first few weeks)
-nausea (E- take at mealtime or bedtime)
-skin irritation with transdermal patches
-fluid retention and bloating (E + P)
-alterations in mood (P)

63
Q

how do we manage HT side effects?

A
  1. lower the dose
  2. alter the route
  3. change the formulation
64
Q

management of bleeding during HT
a. continuous cyclic regiment

A

some uterine bleeding normal; starts last few days of progestogen admin or during progestogen-free days; earlier bleeding, heavy or persistent bleeding may indicate endometrial hyperplasia and warrants endometrial eval

65
Q

management of bleeding during HT
b. continuous combined regimen

A

erratic spotting and light bleeding 1-5 days duration in first year; need endometrial eval if bleeding heavier or longer than usual or if resumes after several months of amenorrhea

66
Q

management of VMS (nonhormonal options) (1)

A

SSRIS!!!
-paroxetine 7.5 mg taken once daily at bedtime is the only nonhormonal FDA approved tx of VMS

NOTE: gabapentin (anticonvulsant) has been shown to be effective in reduction of severity and frequency of hot flashes

67
Q

GSM (genitourinary syndrome of menopause)

A

collection of symptoms and physical findings associated with decreased estrogen
a. genital dryness, burning, irritation
b. sexual symptoms of lack of lubrication, discomfort or pain, impaired function
c. urinary symptoms of frequency, nocturia, urgency, dysuria and recurrent UTI

68
Q

low circulating levels of estrogen result in anatomic and physiologic changes in urogenital tissues like…

A

-reduced collagen, decreased elastin, epithelium thinning, fewer blood vessels
-decreased vaginal blood flow, diminished lubrication
-thinning and regression of labia minora
-more prominent urethral meatus
-decreased vaginal lactobacilli and increased vaginal pH

69
Q

management/treatment of GSM
-nonhormonal

A
  1. vaginal lubricants
  2. vaginal moisturizers
  3. regular sexual activity- promotes blood flow to genital area
  4. noncoital methods of sexual expression if penetration is painful
70
Q

management/treatment of GSM
-hormonal therapies

A
  1. low dose vaginal estrogen- consider if nonhormonal therapies do not relieve symptoms or if GSM symptoms are severe
  2. Osemifine- SERM
  3. Prasterone
71
Q

what is Osemifine approved for?

A

SERM approved for tx of moderate-severe dyspareunia related to vulvovaginal atrophy; daily oral dose

-estrogen agonist effect on vaginal tissue to thicken and make less fragile; decreases pH; may take SEVERAL WEEKS for full relief of symptoms
-should NOT be used with estrogen or other SERM

72
Q

most common side effects with Osemifine

A

hot flashes, vaginal discharge, muscle spasm, increased swelling

73
Q

What is Prasterone approved for?

A

treatment of moderate-severe dyspareunia related to vulvovaginal atrophy; once-daily vaginal dose at bedtime

-improves vaginal epithlium maturation index and lowers vaginal pH

CI: abnormal genital bleeding of unknown cause
Caution: has not been studied in women with breast cancer

NOTE: abnormal pap tests have been reported with Prasterone use

74
Q

most common SE of Prosterone

A

vaginal discharge

75
Q
A

Gynecologic, Reproductive, Sexual, and Menopause Health (3 decks)

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