Ch. 9 GU/Repro Flashcards
What are examples of combined hormonal contraceptives?
COCs
Vaginal ring (Nuvaring)
Patch (Ortha Evra)
How do combined hormonal contraceptives work?
Steady levels of estrogen and progesterones trick the pituitary gland into thinking you are pregnant –> stops releasing hormones that stimulate ovulation
Progestin: inhibits ovulation by suppressing LH, thickening the endocervical mucus, and thinning the endometrium.
Estrogen: ovulation is inhibited by suppression of FSH and LH and alteration of endometrial cellular structure
When does fertility return after stopping COC?
Fertility returns promptly.
What are non-contraceptive benefits of CHCs?
-Decreased risk of ovarian, endometrial, and colon cancer
- Decreased dysmenorrhea
- Helps acne
- Helps hirsutism
- Lighter periods / decreased IDA
- Decreased rates of ovarian cysts
Common adverse effects of CHCs
- Breakthrough bleeding (highest reason for drop out)
- Nausea
Absolute CI for CHC use
- Current breast cancer
- Postpartum <21 days
- Acute hepatitis
- Migraine WITH aura
- Age 35+ AND smoking 15+ cigarettes per day
- HTN (>160/100)
- History of DVT/PE AND 1+ risk factor for recurrent DVT/PE
- Known clotting / thrombotic disorder
- Hx ischemic heart disease or stroke
- Mod or severely impaired cardiac function
Common COC medication interactions
- Anti-epileptics (phenytoin, carbamazepine, topiramate)
- St. John’s Wort
Patient education: missing COCs
- Pill missed 12+ hours but only one pill missed in a day: Take today’s pill immediately. No additional or emergency contraception needed. Continue with pack.
- More than one pill is missed: Take today’s pill and the last forgotten pill today (two tabs in one day). If she has at least 7 more active pills in pack - take the rest of the active pills, skip the placebo pills, and start the next pack without interruption + use condoms/abstain x7 days. OR they can take the pills as in the pack and use condoms until she has taken 7 days of active pills.
- Should also encourage emergency contraception if she had unprotected sex in last 7 days.
How do progestin-only pills / Depo work?
Thickening of the endocervical mucus to prevent sperm from reaching uterus / upper genital tract
When does fertility return after stopping depo?
Delayed - usually 6-12 months after discontinuation.
Recommended for women who do not wish to get pregnant in next 18 months.
Common side effects of POPs
bleeding irregularity - prolonged flow or amenorrhea
Depo adverse effects
weight gain
loss of bone density with prolonged use (not to be used for >2 years)
irregular bleeding during first few months
When does fertility return after removing nexplanon?
Soon - typically ovulation returns within 7 days of removal
Nexplanon common adverse effects
Irregular bleeding
Headaches
Copper IUD common adverse effects
increase in menstrual bleeding
upper reproductive tract infections
how long is the copper IUD effective?
10 years
how long is nexplanon effective?
3 years
when should Plan B be taken?
recommended 72 hours after coitus, but effective up to 120 hours after
how long does perimenopause last?
typically lasts 4 years but can range from a few months to 10 years
what is the average age of menopause?
51.3 years
when is a woman considered to be in menopause?
when she has not had a naturally occurring period for 12 months
Perimenopause: clinical presentation
-menstrual irregularities (heavier or lighter, less or more frequent)
-vasomotor symptoms (hot flashes, trouble sleeping, mood changes)
-vaginal atrophy
what causes hot flashes?
thought to be due to shifting levels of multiple biological substrates, especially elevated FSH
Pharmacologic management of menopausal symptoms
- HT - estrogen supplements - ACOG recommends using lowest dose for shortest amount of time. ALWAYS give with progesterone if patient has uterus (risk of endometrial cancer)
- low dose SSRI/SNRI (ex: sertraline, venlafaxine)
- gabapentine
- low dose COCs can be used for women who continue to menstruate but are having vasomotor sx
- topical estrogen (cream, ring, tablet)
CI to postmenopausal HT
-unexplained vaginal bleeding
- acute liver disease
- chronic impaired liver function
- Thrombotic disease
- Endometrial cancer
- current, past, or suspected breast cancer
- high risk cardiovascular disease
non-pharmacologic management of menopausal symptoms
- avoid spicy foods
- avoid alcohol
- loose fitted clothing
- cool room / climate control
- avoid cigarette smoking
- avoid hot showers/baths
what causes BV?
occurs when there is a disruption of the normal vaginal flora (usually lactobacilli) which allows for overgrowth of anaerobes
risk factors for BV
-recent abx
- douching
- tub bathing (esp with bubble bath)
- OTC intravaginal hygiene product use
- IUD
- frequent sexual intercourse
- presence of other STIs
BV s/sx
- thin gray vaginal discharge
- amine or fishy vaginal odor
Less common: vulvovaginal irritation, dysuria
BV treatment in symptomatic non-pregnant adults
metronidazole 500mg BID x7 days OR metronidazole gel QD x5 days
BV treatment in symptomatic pregnant adults
metronidazole 500mg BID x7 days OR clindamycin 300mg BID x7 days
BV diagnosis
history: risk factors (douching, bubble baths, recent abx, frequent intercourse, IUD)
PE: thin gray discharge, usually no inflammation
wet prep / vaginal swab + clue cells
risk factors for candida vulvovaginitis
- recent abx
- high dose estrogen therapy
- pregnancy
- immunosuppression (ex: HIV)
- diabetes
candida vulvovaginitis s/sx
- vulvovaginal itching/burning
- thick white/yellow curd-like discharge
- vulvovaginal excoriation and redness
candida vulvovaginitis diagnosis
history: risks - recent abx, DM, immunosuppressed, pregnant, high dose estrogen therapy
PE: vulvovaginal redness/excoriation, thick white/curd discharge, itching
Micro: hyphae and pseudohyphae on wet prep
vulvovaginitis treatment
-fluconazole 150mg PO single dose
- miconazole (Monistat suppository OTC) 1200mg single dose vaginally
- Monistat vaginal cream OTC 1 applicator-ful at bedtime x7 days
Lots of creams/suppositories OTC. Can choose any based on patient preference.
what is trichomoniasis?
- a common STD
- caused by motile protozoan “trichomonads vaginalis”
adverse outcomes of untreated trichomoniasis vaginalis
- adverse pregnancy outcomes
- infertility
- postoperative infections
- cervical neoplasia
- increase risk of HIV transmission
trichomoniasis s/sx
females: dysuria, itching, vulvovaginal irritation, dyspareunia, yellow/green vaginal discharge, cervical petechialhemorrhages (strawberry spots)
males: usually no symptoms
trichomoniasis diagnosis
wet mount: flagellated, motile organisms and large number of PMNs
trichomoniasis treatment
- metronidazole PO one time dose OR metronidazole x7 days
*partners needs to be treated.
*both partners should refrain from sex until therapy completed and symptoms resolved.
