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NCC Board Prep > CH4: Gynecologic, Reproductive/Sexual, Menopause > Flashcards

CH4: Gynecologic, Reproductive/Sexual, Menopause Flashcards

1
Q

What is the inframammary ridge

A

firm transverse ridge of compressed tissue which may be present along the lower edge of the breast(s)

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2
Q

What is a breast lobe

A

section of breast composed of glandular tissue and surrounded by the fatty and connective tissues of the breast. There are 15-20 lobes in each breast. Each lobe empties into a single lactiferous duct that opens out through the nipple

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3
Q

What is a breast lobule

A

These are small branching glands within each lobe that contain tiny, hollow sacs called alveoli which are responsible for milk production

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4
Q

What are the breast Montgomery’s glands

A

sebaceous glands that circle the nipple, located in the areola

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5
Q

Perineal muscle that surrounds the vagina and acts as a weak sphincter

A

bulbocavernosus

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6
Q

Perineal muscle that surrounds the clitoris and is responsible for clitoral erection

A

Ischiovernosus

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7
Q

Perineal muscles that converge with the urethral sphincter

A

superficial and deep transverse perineal muscles

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8
Q

Perineal muscle that surrounds the anus

A

External anal sphincter

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9
Q

(3) muscle components of the pelvic floor levator ani

A

pubococcygeus, iliococcygeus, puborectalis

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10
Q

(4) bones of the pelvis

A

two innominate bones (hip bones), sacrum, coccyx

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11
Q

(3) components of the innominate bones that make up the pelvis

A

ilium, ischium, pubis

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12
Q

What is the mons pubis

A

Fatty tissue prominence overlying the symphysis pubis, often covered by coarse hair

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13
Q

What are the name of the glands on each side of the urethral meatus

A

Skene’s glands

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14
Q

What are the name of the glands with openings posteriorly on each side of the vaginal orifice

A

Bartholin’s glands

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15
Q

Approximate size dimensions of the vagina

A

7cm anterior and 10cm posterior in length

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16
Q

What cell type lines the vagina

A

stratified squamous epithelium

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17
Q

What are rugae

A

transverse folds in the vaginal sidewall that allow for distention during coitus and childbirth

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18
Q

Why is the vaginal pH normally acidic

A

prevalence of lactobacilli

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19
Q

Approximate size dimensions of the cervix

A

2-3cm in diameter and 2.5cm in length

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20
Q

What are the translucent nodules sometimes found on cervixes called

A

nabothian cyst - no pathologic significance

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21
Q

Expected change to the cervical os after childbirth

A

change from a round O to larger and slit-like

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22
Q

What is the squamocolumnar junction

A

juncture of the squamous epithelium covering the ectocervix with the columnar epithelium of the endocervix

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23
Q

Broad band of columnar epithelium surrounding the external os, more common in puberty or in folks on OCPs, is called…

A

ectropion

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24
Q

What is the process by which columnar cells of the endocervix are replaced by mature squamous epithelium

A

squamous metaplasia

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25
Q

Approximate size dimensions of the uterus

A

8cm in length, 5cm in width, 2.5cm in thickness

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26
Q

What type of cells lines the uterus and the endocervix

A

columnar epithelium

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27
Q

Estrogen, progesterone, and androgens are types of ________ hormones

A

steroid

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28
Q

Approximate size dimensions of the ovaries

A

3cm x 2cm x 1cm

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29
Q

Gonadotropin-releasing hormone (GnRH) is released from the…..

A

hypothalamus

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30
Q

What are the 2 gonadotropins

A

follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

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31
Q

Where are FSH and LH released from

A

anterior pituitary

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32
Q

What is the negative HPO-axis feedback loop?

A

rising E and P –> E/P reaches above set point –> hypothalamus decreases GnRH –> anterior pituitary decreases FSH/LH secretion –> decreasing E and P levels from ovaries –> E/P reaches below set point –> hypothalamus increases GnRH secretion –> anterior pituitary increases FSH/LH secretion –> rising E and P

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33
Q

What is the positive HPO-axis feedback loop?

A

E reaches a certain peak just before ovulation –> hypothalamus increases GnRH secretion –> FSH and LH from the anterior pituitary surge –> mature ovum is released from the ovary

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34
Q

(3) types of estrogen

A

estradiol (E2), estrone (E1), estriol (E3)

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35
Q

What are prostaglandins

A

A group of lipid compounds derived from fatty acids at different sites in the body via enzymatic actions that act at target sites near their area of secretion. In the uterus, they regulate contraction and relaxation of smooth muscle

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36
Q

Where is sex hormone binding globulin (SHBG) produced

A

liver

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37
Q

What is the role of SHBG

A

a serum protein made in the liver that binds to estrogens and androgens in the blood, carrying them through general circulation so they can reach their target tissues in the body

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38
Q

(3) factors that increase amount of SHBG

A

hyperthyroidism, pregnancy, OCPs that contain estrogen

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39
Q

(3) factors that decrease amount of SHBG

A

obesity, hyperinsulinemia, androgens

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40
Q

Where is prolactin secreted from

A

anterior pituitary

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41
Q

What is the role of prolactin

A

Stimulates the synthesis of milk proteins in mammary tissue and epithelial growth in the breast during pregnancy

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42
Q

Which estrogen is the most potent and plentiful in the reproductive years

A

estradiol

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43
Q

Which estrogen is the major source of estrogen after menopause

A

estrone

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44
Q

Which estrogen is the least potent and the major source during pregnancy

A

estriol

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45
Q

Where is estrogen produced in the body?

A

Primarily ovaries. Also, adrenal cortex, peripheral conversion of androgens in adipose tissues, and the placenta during pregnancy

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46
Q

What are the main functions of estrogen? (6)

A

Maturation of the reproductive organs
Development of secondary sex characteristics
Closure of long bones
Regulation of menstrual cycle
Maternal physiologic adaptations of pregnancy
Metabolic effects on several other organs

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47
Q

Where is progesterone produced in the body?

A

Primarily, ovaries. Also, corpus luteum and adrenal cortex

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48
Q

Where are androgens produced in the body?

A

Ovaries, adrenal cortex

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49
Q

What are the main functions of progesterone? (3)

A

Contributes to mammary gland development
Regulation of menstrual cycle
Maternal physiologic adaptations of pregnancy

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50
Q

Where is testosterone produced in the female body?

A

ovaries, adrenal cortex, and through peripheral conversion in adipose tissues

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51
Q

What are the main functions of testosterone in the female body? (3)

A

Precursor to synthesis of estradiol
Contribute to long bone growth
Growth of pubic and axillary hair

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52
Q

What is androstenedione?

A

A weak androgen that serves as a precursor for estrogen synthesis that is produced by the ovaries and adrenal cortex

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53
Q

What is activin?

A

Produced by the ovaries and anterior pituitary gland, this hormone stimulates FSH secretion

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54
Q

What is inhibin?

A

Produced by the ovaries, this hormone inhibits FSH secretion by binding to activin

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55
Q

What is follistatin?

A

Produced by the ovaries and anterior pituitary, this hormone inhibits FSH by binding to activin

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56
Q

What is Anti-Mullerian Hormone?

A

Produced by ovarian follicles, this hormone plays a role in the selective recruitment of follicles that will continue to grow and develop by inhibiting FSH-dependent follicular growth of the primordial follicles. Expect to be elevated in PCOS

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57
Q

What is insulin-like growth factor?

A

Produced by the liver and ovaries, this hormone is involved in growth and differentiation of tissues in response to growth hormones, and promotes steroidogenesis by stimulating increase in size and number of FSH and LH receptors.

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58
Q

Typical age of puberty onset in females

A

9yo

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59
Q

Onset of breast development is called…

A

thelarche

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60
Q

Onset of pubic and axillary hair development is called….

A

adrenarche

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61
Q

Average age and timing of menarche

A

average age of 12.5, typically follows peak height velocity

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62
Q

Scale used to assess the progressive sexual maturity changes during puberty

A

Tanner stages

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63
Q

Definition of “delayed onset of puberty”

A

No breast growth by age 14yo, or no skeletal growth spurt by age 15yo. Usually a normal variant and catch-up occurs

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64
Q

Definition of “precocious puberty”

A

Thelarche or adrenarche before age 7yo in Caucasian females and 6yo in African American females - evaluate for congenital or neoplastic causes, however 75% are ideopathic

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65
Q

Average timing, duration, and blood loss during menstrual cycle

A

28 day cycle (+/-2 days), 4-6 days of bleeding (+/- 2 days), 40cc volume of blood loss

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66
Q

Describe the follicular phase of the menstrual cycle

A

Begins on Day 1 of the menstrual cycle and is variable in length. E and P levels are low from the end of the last cycle. Sensing low E/P levels, the hypothalamus increases GnRH which stimulates the anterior pituitary to release FSH and LH. FSH in particular stimulates ovarian follicular development, and the maturing follicles produce higher and higher levels of Estrogen. The dominant follicle emerges because it has the highest level of Estrogen Receptors. As the dominant follicle begins producing high levels of E2, the LH surge begins to initiate ovulation

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67
Q

Describe the ovulation phase of the menstrual cycle

A

After the LH surge, prostaglandins and proteolytic enzymes break down the follicular wall and ruptures the dominant ovarian follicle, releasing an egg (oocyte). The oocyte can be fertilized for 12-24 hours after being released

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68
Q

The oocyte can be fertilized for ________ after being released

A

12-24 hours

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69
Q

LH surge peaks _________ before ovulation occurs

A

10-12 hours

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70
Q

Describe the luteal phase of the menstrual cycle

A

Begins after ovulation occurs and lasts for approximately 14 days (+/- 2 days). The corpus luteum forms from the ruptured follicle and produces high levels of progesterone, which peaks 7-8 days after ovulation. The corpus luteum also produces moderate amounts of estrogen. If a pregnancy does not occur, then the corpus luteum regresses and levels of both E and P will drop, triggering shedding of the endometrial lining called menses.

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71
Q

What are the (3) phases of the ovarian menstrual cycle

A

follicular, ovulation, luteal

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72
Q

What are the (3) phases of the uterine menstrual cycle

A

menstruation, proliferative, secretory

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73
Q

Describe the proliferative phase of the menstrual cycle

A

The endometrium grows and thickens under the influence of ESTROGEN. Lasts from the end of bleeding (menses) until ovulation (~10 days)

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74
Q

Describe the secretory phase of the menstrual cycle

A

After the proliferative phase, the endometrium hypertrophies and becomes more vascularized under the influence of PROGESTERONE from the oocyte’s corpus luteum. This creates a favorable environment for possible implantation. This lasts, on average, 12-16 days

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75
Q

Describe the menstrual phase of the menstrual cycle

A

After the secretory phase and implantation has not occurred, the corpus luteum regresses. Under the influence of declining E/P, the endometrium undergoes involution, necrosis, and sloughing which causes bleeding. Typically lasts 3-6 days

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76
Q

Expected characteristics of cervical mucus at ovulation

A

Abundant, highly elastic, thin, clear (under the influence of high estrogen) – clinically, can stretch between thumb and forefingers (spinnbarkeit). Will cause ferning appearance under microscope

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77
Q

Use of basal body temperature in detecting ovulation

A

BBT is the temperature of the body at rest. It is lowest in the follicular phase and peaks AFTER ovulation under the influence of progesterone. It will remain elevated until 2-4 days before menses

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78
Q

ROUTINE screening pelvic and breast exams are not recommended before age…..

A

21yo

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79
Q

What are the ACS, ACOG, and USPSTF differences in recommendations for routine clinical breast exams

A

ACS & USPSTF do NOT recommend for those at average risk of breast cancer. ACOG recommends offering Q1-3 years ages 25-39, and annually >40

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80
Q

What is the basic pap test schedule for patients age 21-29yo

A

cytology alone Q3 years

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81
Q

What is the recommendation regarding patient self-breast exams

A

20yo and older, educate about breast self-awareness but it is no longer recommended to teach routine, systematic breast self-exams for any age group

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82
Q

What is the basic pap test schedule for patients age 30-65yo, per ACS, ACOG, and USPSTF

A

ACS & ACOG: Preferred is co-testing Q5 years; acceptable alternative is cytology alone Q3 years
USPSTF: Option for HPV alone Q5 years

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83
Q

What are the ACS, ACOG, and USPSTF differences in recommendations for mammography screening

A

ACS: Acceptable to begin earlier at ages 40-44 otherwise offer yearly at 45yo, 55yo+ can continue annual or choose biennial
ACOG: Offer starting at age 40 but acceptable to initiate anywhere from 40 - 49, annual or biennial is acceptable
USPSTF: Biennial screening ages 50-74yo

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84
Q

% of couples having unprotected coitus who will get pregnant by 3, 6, 12, and 24 months

A

3 months = 57%
6 months = 72%
12 months = 85%
24 months = 93%

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85
Q

Definition of infertility

A

inability to conceive after 1 year of unprotected coitus ages <35yo, if 35 or older is after 6 months

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86
Q

Estimated infertility rate in the US of females

A

6-15%

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87
Q

Healthy sperm can survive in female reproductive tract and retain ability to fertilize an egg for ______

A

3-5 days

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88
Q

% of infertility that is female-factor, male-factor, and unexplained

A

female factor 25-50%
male factor 25-50%
combined 30%
unexplained 10-25%

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89
Q

Female infertility factors (8)

A

anovulation, luteal-phase insufficiency, poor ovarian reserve, inadequate cervical mucus, uterine anomalies, surgical adhesions, tubal occlusion, endometriosis

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90
Q

Male infertility factors (10)

A

low testosterone (hypogonadism), varicocele, toxin exposures (radiation, chemicals, drugs), chronic overheating of testicles, mumps orchitis (testicular inflammation), adhesions, hypospadias, phimosis, retrograde ejaculation, erectile dysfunction

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91
Q

Penile phimosis

A

tight foreskin that cannot be retracted which can be congenital or a result of recurrent infections

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92
Q

Penile hypospadias

A

congenital defect in which the urethral meatus is located on the ventral surface of the glans, penile shaft, or perineal area

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93
Q

Varicocele

A

Abnormal dilation of the peri-testicular veins resulting in varicose veins in the spermatic cord

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94
Q

What (2) tests in the infertility work-up determine ovarian reserve

A

AMH level (serum) and antral follicle count (US)

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95
Q

Basic laboratory and diagnostics work-up for infertility

A

HOME: basal body temperature, ovulation prediction kits

LABS: AMH, FSH, LH, estradiol (E2), progesterone, TSH, prolactin, STI screening, semen analysis

IMAGING: pelvic US (for uterine anomalies, antral follicle count, and persistent ovarian cyst), & hysterosalpingogram (for tubal patency, shape of uterine cavity)

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96
Q

How do you manage ovulatory dysfunction as cause of female factor infertility

A

ovulation induction with clomiphene citrate or letrozole

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97
Q

How do you manage luteal-phase defect as cause of female factor infertility

A

vaginal or IM progesterone

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98
Q

What is IVF and its success rate

A

In vitro fertilization is the most common assisted reproductive technology used and has a 15-20% success rate overall. Oocytes are extracted, fertilized in a laboratory, and then transferred through the cervix into the uterus

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99
Q

What is gamete intrafallopian transfer (GIFT)

A

Placement of oocytes and sperm directly into the fallopian tube, carries a 25% success rate

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100
Q

What is zygote intrafallopian transfer (ZIFT)

A

Placement of a fertilized oocyte (zygote) into the fallopian tube, carries an 18-20% success rate

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101
Q

What are the only contraceptive options that have <1 pregnancy per 100 users per year with TYPICAL use (3)

A

progestin-only implant, IUD, sterilization

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102
Q

Examples of common inducers of CYP450 which may lessen the effectiveness of OCPs due to rapid clearance

A

rifampin, some anticonvulsants, some antiretrovirals and TB medications, griseofulvin (antifungal), St. John’s wort

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103
Q

What is the only birth control method that is not affected in efficacy by concomitant use of CYP450 inducer medications (like anticonvulsants), excepting sterilization?

A

DMPA (Depo Provera)

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104
Q

What does DMPA stand for

A

Depot medroxyprogesterone acetate

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105
Q

If you use the “quick start” method for switching between contraceptive medications, do you need back-up contraception?

A

Yes - follow backup contraception instructions for the new method just as if you had not used the quick start method (~7 days)

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106
Q

How long after taking ulepristal acetate for emergency contraception should you wait before starting a new method of birth control?

A

ideally, do not start a new hormonal method any sooner than 5 days after taking ulepristal acetate because of concern that it may decrease its efficacy; abstinence or condoms are recommended

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107
Q

Categories 1-4 from the CDC on eligibility for a contraceptive method

A

Category 1 = no restriction on use
Category 2 = advantages of using the method generally outweigh the theoretical or proven risks
Category 3 = The theoretical or proven risks generally outweigh the advantages (relative contraindication - refer to OB/GYN physician)
Category 4 = unacceptable risk (absolute contraindication)

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108
Q

How long is the copper-releasing IUD effective for?

A

10 years

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109
Q

How long are the (4) types of hormonal IUDs effective for?

A 
Skyla = 3 years
Liletta = 5 years
Kyleena = 5 years
Mirena = 5 years
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110
Q

MOA copper-releasing IUD

A

Inhibits sperm capacitation, alters tubal and uterine transport of the ovum, has an enzymatic influence on the endometrium

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111
Q

MOA LNG-IUDs

A

thickens cervical mucus, produces an atrophic endometrium unfavorable to implantation, slows ovum transport through the tube, inhibits sperm motility and function

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112
Q

Effectiveness of the IUDs, typical use

A

Copper - 0.8%

LNG - 0.2%

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113
Q

IUD in the postpartum period?

A

Can be used during lactation and placed immediately postpartum. Specifically, place within 48 hours of delivery or wait 4 weeks postpartum because placement after 48 hours and before 4 weeks is associated with increased risk for uterine perforation

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114
Q

copper-releasing IUD can increase _______ and _______ during menses

A

blood loss, dysmenorrhea (pain)

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115
Q

What is likely to happen to bleeding and dysmenorrhea with LNG-IUDs

A

irregular bleeding and spotting for the first 3-6 months of use followed by absence or decrease in bleeding and decrease in dysmenorrhea

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116
Q

The risk of PID is increased for the first _______ after IUD insertion

A

20 days

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117
Q

Category 4 (Absolute Contraindications) for IUD initiation

A
  • known or suspected pregnancy
  • postpartum or post-abortion sepsis
  • unexplained vaginal bleeding
  • cervical cancer awaiting treatment
  • breast cancer within previous 5 years (except for copper)
  • uterine anatomic abnormalities that may distort the cavity
  • current PID, G/C, or purulent cervicitis
  • endometrial cancer
  • rare: pelvic TB or gestational trophoblastic disease
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118
Q

Category 3 (Relative Contraindications) for IUD initiation

A
  • ischemic heart disease (except for copper)
  • h/o breast cancer >5 years ago (except for copper)
  • high risk for GC STIs
  • HIV-AIDS unless clinically well on ART
  • liver disease
  • lupus (except for copper)
  • rare: solid organ transplant with complications, pelvic TB
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119
Q

How long should the uterus sound for best placement of the IUDs

A

6-9cm

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120
Q

How short should you trim the IUD threads after insertion

A

3-4cm

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121
Q

What type of follow-up is required after placement of an IUD

A

Advise to return an time to discuss side effects, problems, desire to change method – otherwise, no routine follow-up is required until it is time to remove or replace method

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122
Q

Do you need back-up protection after placement of an IUD?

A

LNG - yes, 7 days

Copper - no

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123
Q

Severe cramping or pain after IUD placement, rule out…. (3)

A

perforation, infection, pregnancy

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124
Q

Rate of IUD expulsion in first year

A

2-10%

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125
Q

Management of IUD expulsion

A

remove, rule out pregnancy or infection, replace if desired, and rx doxycycline for 5-7 days

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126
Q

How common is uterine perforation after IUD placement

A

1 in 1,000 insertions

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127
Q

What do you need to do if someone gets PID with an IUD in place

A

Treat PID with appropriate antibiotics. There is no evidence to support preventive antibiotics with IUD placement. Also, there is no need to remove the IUD after PID diagnosed unless they have no clinical improvement within 48-72 hours of antibiotic initiation

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128
Q

How long does the progestin-only implant (Nexplanon) work for

A

3 years

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129
Q

What type of progesterone is in the IUD and in the arm plant

A

IUD = levonorgestrel

arm implant = etonogestrel

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130
Q

MOA of Nexplanon / progestin arm implant

A

suppresses LH and thus ovulation in almost all users, produces an atrophic endometrium, and thickens cervical mucus

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131
Q

Effectiveness of the Nexplanon arm implant, perfect AND typical use

A

0.05%

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132
Q

Does obesity reduce the efficacy of Nexplanon?

A

“cumulative evidence supports that obesity does not reduce efficacy”

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133
Q

Most users of Nexplanon arm implant ovulate within ____ of removal

A

6 weeks

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134
Q

Nexplanon arm implant in the postpartum period?

A

Can be used during lactation and immediately postpartum

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135
Q

Expected bleeding and dysmenorrhea patterns after Nexplanon arm implant insertion

A

Overall, reduced pain and dysmenorrhea. Pain and bruising is common at the insertion site. Bleeding patterns are likely to become irregular, prolonged, and more frequent in the first few months of use although may become amenorrheic eventually

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136
Q

Category 4 (Absolute Contraindication) for Nexplanon arm implant use

A

breast cancer within past 5 years

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137
Q

Category 3 (Relative Contraindications) for Nexplanon arm implant use

A 
ischemic heart disease or stroke
unexplained vaginal bleeding
h/o breast cancer >5 years ago
liver disease
lupus
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138
Q

What follow-up is needed after insertion of Nexplanon arm implant?

A

Advise can return at any time to discuss side effects or problems - otherwise, no routine follow-up is required until removal or replacement in 3 years

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139
Q

Do you need back-up contraception after placement of the Nexplanon arm implant?

A

Not if inserted on days 1-5 of menses; otherwise, use back-up for 7 days

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140
Q

What is the MOA of the estrogen component of oral contraceptive pills?

A

inhibits ovulation through the suppression of FSH, stabilizes the endometrium for less unscheduled bleeding and spotting

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141
Q

What is the most common type of synthetic estrogen used in OCPs?

A

ethinyl estradiol

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142
Q

What is the MOA of the progesterone component of oral contraceptive pills?

A

the progesterone provides most of the contraceptive effect – inhibits ovulation through inhibition of the LH surge, inhibits sperm penetration by thickening cervical mucus

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143
Q

Characteristics of first generation progesterones (3) and common example (1)

A

norethindrone

  • lowest potency
  • shortest half-life
  • lower doses are more likely to have unscheduled bleeding and spotting
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144
Q

Characteristics of second generation progesterones (4) and common examples (2)

A

norgestrel, levonorgestrel

  • more potent
  • longer half-life
  • less unscheduled bleeding and spotting (d/t longer half life)
  • more androgen-related side effects
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145
Q

Characteristics of third generation progesterone (1) and common example (1)

A

norgestimate

- maintains the potency of second gen with less androgenic side effects

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146
Q

Characteristics of fourth generation progesterones (1) and common example (1)

A

drospirenone

- antiandrogenic properties

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147
Q

Effectiveness of OCPs, perfect and typical use

A 
perfect = 0.3%
typical = 9%
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148
Q

OCPs reduce lifetime risk of (3) cancers

A

ovarian, endometrial, colorectal

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149
Q

Antibiotics and OCP use - counseling

A

Most broad-spectrum antibiotics do NOT lower hormone levels or affect efficacy (ampicillin, metronidazole, doxycycline, fluconazole). There are a few that do induce CYP450 and thus MAY decrease COC effectiveness (rifampin, griseofulvin)

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150
Q

Which (2) antibiotics are most implicated in reducing OCP efficacy

A

rifampin, griseofulvin

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151
Q

Which (4) anti-convulsants do NOT affect OCP efficacy

A

gabapentin, pregabalin (Lyrica), clonazepam, valproic acid

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152
Q

Estrogenic side effects of OCPs

A

nausea, breast tenderness, chloasma, telangiectasias, cervical ectropion, increased BP, blood clots, migraine headache, increased triglycerides & cholesterol concentration in gallbladder bile, hepatocellular adenoma

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153
Q

Progestogenic side effects of OCPs

A

breast tenderness, fatigue, depressive symptoms, increased insulin resistance, constipation, bloating, gall stones, cyclic weight gain

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154
Q

Androgenic side effects of OCPs

A

weight gain, hirsutism, acne, increased LDL cholesterol

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155
Q

Category 4 (Absolute Contraindications) to combined OCPs

A
  • > 35yo and heavy cigarette smoker (>15 cigs/day)
  • multiple risk factors for CVD
  • ischemic heart disease, h/o stroke, valvular heart dz
  • uncontrolled hypertension
  • acute DVT or PE
  • major surgery with prolonged immobilization
  • clotting disorder
  • migraine with aura
  • breast cancer within last 5 years
  • diabetes >20 years duration or with complications
  • liver disease
  • SLE lupus
  • solid organ transplant with complications
  • peripartum cardiomyopathy ( severe or <6 months pp)
  • <21 days postpartum
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156
Q

combination OCPs in the postpartum period?

A

absolutely contraindicated within 21 days postpartum or with peripartum cardiomyopathy. Otherwise, relative contraindications for …

  • 21-42 days pp with other VTE risk factors
  • 21-30 days pp and breastfeeding without known VTE risk factors
  • 30-42 days pp and breastfeeding WITH VTE risk factors
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157
Q

Category 3 (Relative Contraindications) for combined OCPs

A
  • > 35yo and light cigarette smoking (<15 cigs/day)
  • h/o hypertension that is adequately-controlled or less than 160/100
  • HLD
  • h/o breast cancer NED >5 years
  • symptomatic gallbladder disease
  • mild liver cirrhosis
  • h/o bariatric surgery (malabsorptive)
  • h/o DVT or PE with no risk factors for recurrence (provoked)
  • moderate to severe IBD with associated risk for clot
  • within 21 - 42 days postpartum with any risk factors for VTE and/or breast feeding
  • peripartum cardiomyopathy (>6 months or non-severe)
158
Q

What type of follow-up is required after initiating OCPs?

A

Advise to return an time to discuss side effects, problems, desire to change method – otherwise, no routine follow-up is required

159
Q

Is a physical or pelvic exam required prior to starting OCPs?

A

No (as long as BP is known)

160
Q

OCPs and St Johns Wort

A

St Johns Wort is a CYP450 inducer and may increase hepatic metabolism of OCPs, lessening their effectiveness

161
Q

Weight loss medications and OCPs

A

Orlistat blocks fat absorption - may reduce intestinal absorption of OCPs as well as induce diarrhea

162
Q

Drug interactions with OCPs, Patch, and Ring that may reduce OCP efficacy, generally (5)

A
  • anticonvulsants
  • antibiotics
  • antiretrovirals
  • Orlistat
  • St Johns Wort
163
Q

Drug interactions with OCPs, Patch, and Ring whereby the OCP may potentiate the effect of these drugs, generally (3)

A
  • benzodiazepines
  • TCAs
  • theophylline
164
Q

OCPs that contain ________ progesterone, specifically, may cause hyperkalemia in combination with these drugs (5) - monitor potassium after first cycle of OCP

A

drospirenone

  • ACEs/ARBs
  • potassium-sparing diuretic
  • heparin
  • aldosterone antagonist
  • NSAIDs (chronic daily use)
165
Q

Unscheduled bleeding/spotting with OCP initiation – initial counseling (2)

A

reassurance (common side effect in first 3 months, should decrease over time), reinforce taking pills at the same time of day

166
Q

Pt experiences spotting/bleeding before they finish their active OCPs - what pharmacological strategy may be helpful?

A

increase the progestin content for more endometrial support

167
Q

Pt experiences continued spotting/bleeding after their OCP placebos are finished - what pharmacological strategy may be helpful?

A

increase estrogen content of first pills in the pack OR decrease progestin content of first pills for more estrogen to proliferate endometrium

168
Q

Pt is taking OCPs continuously and experiences unscheduled bleeding/spotting - what pharmacological strategy may be helpful?

A

Take at least 21 active pills, then 3-4 days off for withdrawal bleed to start, then restart the active pills

169
Q

Pt has been taking OCPs for several years and this year has stopped getting a withdrawal bleed. Pregnancy is ruled out and reassurance is provided. However, they would prefer to keep a monthly period. What pharmacological strategy may be helpful?

A

If on 20mcg estrogen formulation, may increase to 30 or 35mcg. Or try a triphasic formulation with lower progestin levels in the early pill

170
Q

Pt starts OCPs today, her LMP was >5 days ago, do they need to use back-up method?

A

Yes, back-up protection for 7 days

171
Q

Pt starts OCPs today, first few days of her menstrual period. Do they need to use back-up method?

A

No

172
Q

Pt experiences nausea when taking OCPs, what initial recommendation?

A

Take pills with meals or at bedtime

173
Q

Warning signs with OCPs use - ACHES mnemonic

A 
Abdominal pain (sever)
Chest pain
Headache
Eye problems (blurry vision, scotoma)
Severe leg pain (thigh or calf - DVT)
174
Q

Pt is taking OCPs for contraception. They call the office reporting they missed one pill - they take it every morning at 7am and it is now 7pm of the same day. They just had unprotected sex and is concerned about pregnancy risk.

A

Take the late pill now/ASAP. Continue taking the remaining pills at the usual time. No back-up contraception is needed. Emergency contraception is not usually needed but may consider if have missed any other pills this cycle or in the last week of their previous cycle

175
Q

Pt is taking OCPs for contraception. They called the office reporting they missed yesterday’s pill - they take it every morning at 7am and it is now 7am of the following day, and they are wondering what to do. They had unprotected sex last night and are concerned about pregnancy risk

A

Take the late pill now/ASAP, even if it means taking two pills today (this morning’s and yesterday’s). No back-up contraception is needed. Emergency contraception is not usually needed but may consider if have missed any other pills this cycle or in the last week of their previous cycle

176
Q

Pt is taking OCPs for contraception. They called the office reporting that they missed 2 pills - they take it every morning at at 7am, today is Wednesday and they missed their morning dose on Monday and Tuesday. They had unprotected sex last night and are concerned about pregnancy risk

A

Take the most recent missed pill (yesterday’s) as soon as possible and the remaining pills on schedule (so 2 doses today - yesterdays’ pill and today’s pill). Discard the other missed pill (Monday’s). Use back-up protection or avoid intercourse until hormonal pills have been taken for 7 consecutive days. If they are in their last week of pills and do not have 7 consecutive left this cycle, then omit the hormone-free placebo week and start a new pack. Emergency contraception should be considered, especially if hormonal pills that were missed were in the first week of that pill pack.

177
Q

Pt is taking OCPs for contraception. They called the office reporting that they missed 4 pills - they take it every morning at 7am, today is Friday and they missed doses on Monday-Thursday. They had unprotected sex last night and are concerned about pregnancy risk

A

Take the most recent missed pill (yesterday’s) as soon as possible and the remaining pills on schedule (so 2 doses today - yesterdays’ pill and today’s pill). Discard the other missed pills (Mondays, Tuesdays, Wednesdays). Use back-up protection or avoid intercourse until hormonal pills have been taken for 7 consecutive days. If they are in their last week of pills and do not have 7 consecutive left this cycle, then omit the hormone-free placebo week and start a new pack. Emergency contraception should be considered, especially if hormonal pills that were missed were in the first week of that pill pack.

178
Q

What types of estrogen and progesterone are in the transdermal contraceptive patch?

A

norelgestromin, ethinyl estradiol

179
Q

What is the schedule for use of the transdermal contraceptive patch?

A

Apply a new patch every week x 3 weeks, followed by 1 week withdrawal bleed (or continuous). Alternate patch placement sites

180
Q

MOA of the transdermal contraceptive patch

A

same as combined OCPs

181
Q

Perfect and typical use failure rates for the transdermal contraceptive patch

A

Perfect use - 0.3%

Typical - 9%

182
Q

Contraindications to transdermal contraceptive patch

A

same as for combined OCPs with the exception of bariatric surgery is not relevant

183
Q

Which contraceptive option is known to be less effective for folks who weigh >198lbs

A

transdermal patch

184
Q

Where can the transdermal contraceptive patch be applied

A

buttocks, abdomen, upper torso front or back (excluding breasts), upper outer arm. Alternate patch placement sites

185
Q

Do you need back-up contraception after starting the contraceptive transdermal patch?

A

If in first 5 days of period - no
If >5 days since LMP - yes, for 7 days
(same as the combined OCPs)

186
Q

What type of estrogen and progesterone is in the NuvaRing (contraceptive vaginal ring)

A

etonogestrel, ethinyl estradiol

187
Q

What is the schedule for use of the NuvaRing (contraceptive vaginal ring)

A

worn in the vagina x3 weeks, take out for 1 week withdrawal bleed (or continuous - then replace 4 weeks)

188
Q

Perfect and typical use failure rates for the NuvaRing (contraceptive vaginal ring)

A

Perfect use - 0.3%

Typical use - 9%

189
Q

Contraindications to NuvaRing & Annovera (contraceptive vaginal rings)

A

same as for combined OCPs with the exception of bariatric surgery is not relevant

190
Q

Do you need back-up contraception after starting the NuvaRing & Annovera (contraceptive vaginal rings)?

A

If in first 5 days of period - no
If >5 days since LMP - yes, for 7 days
(same as the combined OCPs)

191
Q

Pt is using NuvaRing for contraception. They accidentally left the ring in for 6 weeks without remembering to change it. They had unprotected intercourse yesterday and are concerned about risk for pregnancy

A

If ring is left in vagina for longer than 4 weeks, it may not protect from pregnancy; use a back-up method until the new ring has been in place for 7 days. Consider emergency contraception

192
Q

Pt is using transdermal patch for contraception. The patch fell off <48 hours ago and they are wondering what they need to do

A

Apply a new patch as soon as possible, if <24 hours may try either a new patch or the old one to reapply. Maintain the same patch-replace schedule. No back-up contraception is needed. Emergency contraception is generally not needed but may be considered if detachment occurred earlier in the cycle or in the last week of the previous cycle

193
Q

Back-up protection is not needed if less than ______ combined OCP pills are missed

A

less than 2

194
Q

Back-up protection is not needed if the contraceptive patch falls off and is replaced within ____________

A

48 hours

195
Q

Back-up protection is not needed if reinsertion of the NuvaRing occurs within _________

A

48 hours

196
Q

Pt is using transdermal patch for contraception. The patch fell off and they have only just noticed 3 days later. They are wondering about pregnancy risk and what to do

A

Apply a new patch as soon as possible. Since it was longer than >48 hours without a patch on, use back-up contraception until a new patch has been worn for at least 7 consecutive days. If the delayed application happened in the third week of patch use (before scheduled withdrawal bleed), omit the hormone-free week by finishing the third week patch use and starting a new patch immediately, again using back-up protection until a new patch has been applied for at least 7 days. Emergency contraception should be considered if delayed application occurred within the first week of patch use and unprotected intercourse happened in the last 5 days, or at other times of the cycle as appropriate.

197
Q

Pt is using NuvaRing for contraception. They took the ring out for intercourse and forgot to replace it afterwards, which was now 24 hours ago. They are wondering about pregnancy risk and what to do

A

Insert the ring as soon as possible. Since the ring was only left out for <48 hours, no back-up contraception is needed. Emergency contraception is not usually needed but could be considered if this delayed reinsertion occurred earlier in the cycle. (*** WEBSITE SAYS BACK UP NEEDED FOR 7 DAYS IF OUT >3 HOURS)

198
Q

Pt is using NuvaRing for contraception. They took the ring out for intercourse and forgot to replace it afterwards, which was now 3 days ago. They are wondering about pregnancy risk and what to do

A

Insert the ring as soon as possible. Since the ring was out >48 hours, back-up contraception is needed until the new ring has been in for 7 consecutive days. If delayed reinsertion occurred in the third week of the cycle, skip withdrawal bleed and replace with a new ring; otherwise will continue to need back-up contraception until a ring has been in place for 7 consecutive days. Emergency contraception should be considered if the delayed insertion occurred within the first week of the cycle and unprotected intercourse happened in the last 5 days, or at other times as appropriate. (*** WEBSITE SAYS BACK UP NEEDED FOR 7 DAYS IF OUT >3 HOURS)

199
Q

(2) contraceptive vaginal ring options

A

NuvaRing, Annovera

200
Q

What is the difference between NuvaRing and Annovera

A

Annovera is newer - same diameter as NuvaRing but twice as thick. Different type of progestin is used and one Annovera ring is used for a full year (13 28-day cycles)

201
Q

What type of estrogen and progesterone is in Annovera (vaginal contraceptive ring)

A

segesterone acetate, ethinyl estradiol

202
Q

What is the schedule of use for Annovera (vaginal contraceptive ring)

A

One ring is used for 13 28-day cycles. Insert the ring, leave in place for 21 days, then remove for 7 days to have a withdrawal bleed. Then, reinsert the same ring No continuous cycling option

203
Q

Failure rate of Annovera in terms of perfect and typical use

A

perfect use - 3.0%

typical use - not available

204
Q

MOA of NuvaRing and Annovera (vaginal contraceptive rings)

A

same as combined OCPs

205
Q

Care and keeping of the re-useable Annovera vaginal contraceptive ring

A

Clean with mild soap and water, pat dry, and place in provided case during the 1 week dose-free interval

206
Q

MOA for progestin-only OCPs

A

thickens cervical mucus, produces an atrophic endometrium, inconsistently/variably inhibits ovulation

207
Q

Failure rates for progestin-only OCPs in terms of perfect and typical use

A

perfect use - 0.3%

typical use - 9%

208
Q

Progestin-only OCPs postpartum?

A

Can be used immediately postpartum and during lactation/breastfeeding

209
Q

Why is it SO important to take the progestin-only OCPs at the same time every day?

A

Serum progesterone levels peak shortly after taking the pill, then decline to nearly undetectable levels 24 hours later. Each pill only provides 24 hours of protection

210
Q

Side effects of progestin-only OCPs

A

increased ovarian cysts, menstrual cycle irregularities, mastalgia, depression

211
Q

Category 4 (Absolute Contraindications) for use of progestin-only OCPs (1)

A

breast cancer within the last 5 years

212
Q

Category 3 (Relative Contraindications) for use of progestin-only OCPs (6)

A
  • h/o breast cancer NED >5 years
  • liver disease
  • bariatric surgery with malabsorptive procedure
  • ischemic heart disease or a stroke WHILE taking a progestin-only pill
  • SLE lupus
  • concomitant use of some medications: ART therapy, some anticonvulsants, rifampin antibiotic
213
Q

Schedule of use for progestin-only OCPs

A

take one pill at the same time each day, every day - no placebo or off-week

214
Q

What are the progesterone-only contraceptive options?

A

LNG-IUDs, injection (depo provera), progestin-only pills

215
Q

Route of administration: DMPA

A

IM - deltoid or gluteal muscle

SQ - anterior thigh or abdominal wall

216
Q

Schedule of dosing for DMPA contraceptive injection

A

Q3 months

217
Q

MOA of DMPA contraceptive injection

A

inhibits ovulation through the suppression of LH/FSH, produces an atrophic endometrium, thickens cervical mucus

218
Q

Which of the birth control options inhibit ovulation

A 
DMPA: yes
Combined OCPs: yes
Patch: yes
Ring: yes
Arm Implant: yes - in almost all users

Copper IUD: no
LNG-IUDs: no, possibly variably
Progestin-only pills: possibly variably

219
Q

Failure rates for DMPA contraceptive injection in terms of perfect and typical use

A

perfect use - 0.2%

typical use - 6%

220
Q

Drug interactions with DMPA contraceptive injection

A

minimal! the only known interaction is aminoglutheimide, a drug to treat Cushing’s disease

221
Q

% of folks who lose their period on DMPA

A

50% by 1 year, 70% by end of 2nd year

222
Q

DMPA and postpartum?

A

Can be used immediately postpartum and during lactation and breastfeeding

223
Q

Benefits of DMPA is that it may reduce risk of (5)

A
  • intravascular sickling in sickle cell disease
  • incidence of seizures in folks with seizure disorder
  • pain from endometriosis (SC formulation)
  • risk for PID
  • risk of endometrial cancer
224
Q

Side effects & disadvantages of DMPA

A
  • WEIGHT GAIN (av. 5 lbs in 1 year, 14 lbs after 4 years)
  • amenorrhea (50% in 1 year, 70% in 2)
  • irregular bleeding
  • mastalgia
  • depression
  • decreased bone density with long term use (>5 years)
  • increase in LDL and total cholesterol, decrease in HDL
  • delayed return to fertility
225
Q

Expected weight gain with DMPA use

A

5lbs in year one, 14lbs after 4 years of use

226
Q

How long is DMPA use recommended for and what is the limiting factor?

A

Up to 5 years of use given its propensity for decreasing bone density with >5 years of use (returns to normal after discontinuation)

227
Q

Expected return to fertility after DMPA use

A

3 months, in some individuals 6-12 months

228
Q

Category 4 (Absolute Contraindications) for DMPA use (1)

A

breast cancer within the last 5 years

229
Q

Category 3 (Relative Contraindications) for DMPA use

A
  • multiple risk factors for CVD
  • uncontrolled HTN and/or vascular disease
  • H/o ischemic heart disease or stroke
  • H/o breast cancer NED >5 years
  • unexplained vaginal bleeding
  • diabetes >20 years in duration and/or with complications
  • liver disease
  • SLE lupus
  • Rheumatoid arthritis or long-term corticosteroid therapy due to risk for fractures/bone loss
230
Q

Do you need back-up protection when initiating DMPA birth control?

A

within 5 days since LMP - no

>5 days since LMP - yes, back-up for 7 days

231
Q

DMPA injection can be given up to ______ late from last injection without needing additional back-up protection

A

2 weeks late (up to 15 weeks from last injection)

232
Q

Pt is using DMPA injection for birth control. She was on vacation and so the earliest she could come for her next appointment was 16 weeks since last injection. She is wondering what to do and if she is at risk for pregnancy

A

Since she is more than 2 weeks late (>15 weeks since last injection), give the next injection ASAP if reasonably certain she is not pregnant and use back-up method for protection until 7 days after next injection is given. Consider use of emergency contraception as appropriate

233
Q

(4) emergency contraceptive options

A

levonorgestrel pill (Plan B), ulipristal acetate pill (UPA, Ella), combined OCPs (ethinyl estradiol and norgestrel or levonorgestrel), copper IUD

234
Q

MOA of emergency contraceptive pills

A

inhibits or delays ovulation, however will not disrupt an established pregnancy

235
Q

MOA of copper IUD for emergency contraception

A

prevents fertilization and interferes with implantation

236
Q

Efficacy of the emergency contraceptive pills

A

Variable, depending on a number of factors such as baseline fertility, timing of intercourse during cycle, timing of taking the pill. May be less effective for overweight and obese individuals.

Overall, studies demonstrate that the risk of pregnancy after a single act of unprotected intercourse is 5.5-8% which is reduced to 1-2.2% after taking emergency contraceptive pills

237
Q

How long after unprotected intercourse will the emergency contraceptive pills be effective?

A

Overall, 3-5 days.

ulipristal acetate (UPA) pill has no decrease in effectiveness up to 120 hours (5 days) after intercourse. The levonorgestrel pill (Plan B) and COCs should be taken as soon as possible, may be less effective if delayed beyond 72 hours (3 days), with only moderate effectiveness between 72-120 hours (3-5 days).

238
Q

How effective is the copper IUD as emergency contraceptive?

A

reduces risk of pregnancy by more than 99%

239
Q

Side effects of emergency contraceptive pills

A

nausea and vomiting are the most common. This is less common with the levonorgestrel (Plan B) or ulipristal acetate (UPA) pills than with the COCs. May also cause a change in bleeding pattern for the next cycle

240
Q

Is any follow-up visit required after prescription for emergency contraceptive?

A

No

241
Q

Instructions for use of oral combined contraceptive pills as emergency contraception

A

Make sure to take within 3-5 days for optimal effectiveness. Take 2 pills that day, each one 12 hours apart. Consider taking anti-nausea medication 1 hour before first dose. If vomits within 2 hours of taking a pill, may need a repeat dose. Wait until the next day to resume OCPs or start a new method of ongoing birth control. Abstain from intercourse or use back-up for 7 days.

242
Q

Instructions for use of ulipristal acetate (UPA) pill as emergency contraception

A

Make sure to take within 3-5 days for optimal effectiveness. Take UPA. Do not start another method of hormonal birth control until 5 days after UPA, as this may reduce the effectiveness of its emergency contraception. Use a back-up method until have been on a method for 7 days.

243
Q

Do you need to take a pregnancy test after taking emergency contraceptive pills?

A

Advise patient to have a pregnancy test if they do not experience a withdrawal bleed within 3 weeks of taking

244
Q

The copper IUD can be inserted up to _______ after unprotected intercourse to be effective as emergency contraception

A

5 days

245
Q

MOA of vaginal spermicides for contraception

A

nonoxynol-9 is the active ingredient. Destroys the sperm membrane

246
Q

Failure rate of vaginal spermicides for contraception

A

Perfect use - 18%

Typical use - 28%

247
Q

Vaginal spermicides are not recommended for individuals at high risk for, or diagnosed with, this condition

A

HIV/AIDS

248
Q

Instructions on use of vaginal spermicides as contraception

A

Use with each act of intercourse. Place deep inside the vagina and allow adequate time for the spermicide to dissolve if using the film, tablet, or suppository. The instructions will designate how long before intercourse can be used. Leave spermicide in place for at least 6 hours after intercourse. Use with condoms to increase effectiveness

249
Q

Failure rate of male condoms for contraception

A

Perfect use - 2%

Typical use - 18%

250
Q

What type of male condom should be recommended for folks with a latex allergy

A

polyurethane condom

251
Q

What type of male condoms may not protect against STIs and HIV

A

natural membrane (made from lamb’s cecum/intestine)

252
Q

What type of lubricants are okay to use with latex condoms

A

water-soluble lubricants are preferable (KY jelly, astroglide, egg whites). Oil-based lubricants should be avoided (i.e., baby oil, vegetable or mineral oils, petroleum jelly)

253
Q

Failure rate of female condom

A

Perfect use - 5%

Typical use - 21%

254
Q

What is the female condom made of

A

nitrile sheath, alternative to latex (contraindicated with nitrile allergy)

255
Q

Instructions for use of female condom

A

Insert inner ring deep into the vagina. Outer ring should rest outside the vulva. Do not use male condom with using the female condom as these may adhere together and cause dislodgement

256
Q

Which diaphragm has essentially replaced all earlier dome-shaped diaphragm contraceptives in the US

A

Caya diaphragm

257
Q

Failure rate for Caya diaphragm

A

perfect use - 14%

typical use - 17%

258
Q

How long can you use a Caya diaphragm or FemCap cervical cal for

A

1-2 years

259
Q

Folks at high risk for these (2) conditions, diaphragm (Caya), cervical cap (FemCap), and contraceptive sponge are not advised for contraception

A

HIV (because of the spermicide you are supposed to use with it) and h/o toxic shock syndrome (diaphragm can cause)

260
Q

Caya diaphragm, FemCap cervical cap, or sponge for contraception in the postpartum period?

A

Wait until 6 weeks postpartum or until uterine involution is complete. Same for after a second-trimester abortion, wait 6 weeks

261
Q

Instructions for use of Caya diaphragm for contraception

A

Insert just prior to intercourse or up to 2 hours prior. Place 1 tsp of spermicidal gel into each fold of the diaphragm and a small amount around the rim. Insert it such that the cervix is completely covered and it is positioned behind the symphysis pubis. If repeated intercourse, you can leave the diaphragm in place but reinsert spermicide. Make sure the leave the diaphragm in place for at least 6 hours following intercourse but do not leave in place for >24 hours. Wash with plain soap and water after each use. Replace at least every 2 years. Assess for holes or breakdown periodically by filling with water and inspecting for leaks. Consider emergency contraception if it is dislodged <6 hours after sex.

262
Q

Warning signs of toxic shock syndrome from contraceptive diaphragm

A

fever, nausea, vomiting, diarrhea, syncope, weakness, arthralgias, myalgias, rash

263
Q

What is the contraceptive cervical cap (FemCap) made out of

A

silicone

264
Q

Cervical cap and sponge is LESS effective for __________ women

A

parous (have given birth before)

265
Q

Failure rate for cervical cap (FemCap)

A

perfect use: 10-20%

typical use: 20-40%

266
Q

FemCap cervical cap, Caya diaphragm, and sponge should not be used during…..

A

menses

267
Q

Instructions for use of FemCap cervical cap for contraception

A

Insert at least 15 minutes prior to intercourse to create suction. Fill 1/3 of the cap with spermicide, compress the rim to insert, and advance into vagina until it slides over cervix. Check to ensure the cap covers the cervix. Not necessary to reinsert spermicide with repeated intercourse. Make sure to leave in place for at least 6 hours after intercourse but for no more than 48 hours.

268
Q

What is the contraceptive sponge and what is it made of?

A

Small, pillow-shaped polyurethane sponge that contains 1g of nonoxynol-9 spermicide. Only comes in one size.

269
Q

Failure rate for contraceptive sponge

A

perfect use: 10-20%

typical use: 20-25%

270
Q

Instructions for use of contraceptive sponge

A

Moisten the sponge with tap water before use. Insert deep into vagina with concave side fitting over the cervix. Check to ensure cervix is covered by the sponge. Leave in place for at least 6 hours after intercourse; repeated spermicide is not required for repeated intercourse. Do not wear the sponge longer than 24-30 hours. Discard after use.

271
Q

How do fertility awareness-based methods work? (FABMs)

A

Method of contraception using abstinence during estimated fertility period based on: Menstrual cycle pattern (calendar), basal body temperature, evaluation of cervical mucus, cervical position. Based on the understanding that the ovum remains fertile for 24 hours, sperm for 72 hours.

272
Q

Most pregnancies occur when intercourse occurs [BEFORE vs. AFTER] ovulation

A

before!

273
Q

Failure rate for fertility awareness based methods

A

typical use for all methods - 24%

274
Q

“Standard days method” of fertility awareness-based contraceptive method assumes fertile period between days…..

A

8-19 of cycle

275
Q

Fertility awareness-based methods are less effective for folks who have irregular cycles, such as (3)

A

recent menarche, perimenopausal, recently postpartum

276
Q

Instructions for the use of the calendar method (FABMs) for birth control

A

Keep a record of your menstrual cycles for several months. From the shortest cycle length, subtract 18 days (first fertile day). From the longest cycle length, subtract 11 days (last fertile day). Use these numbers to determine days of abstinence for every cycle.

277
Q

Instructions for the use of BBT (FABMs) for birth control

A

Take temperature every morning before rising. Record on a BBT chart. Temperature will increase by 0.4 degrees F or more at ovulation. You can assume ovulation has occurred when the temperature remains elevated for 3 or more days - abstain for at least 3 of these days. (You are most fertile 2 days before the increase)

278
Q

What (3) conditions must be true for lactational amenorrhea to be effective

A
  1. within 6 months postpartum
  2. has not had return of period
  3. breastfeeding around-the-clock without supplementation (i.e., once baby is sleeping through the night, may not be often enough to afford protection)
279
Q

MOA of lactational amenorrhea

A

elevated prolactin leads to inhibited GnRH pulsatile release, LH is low, meaning there is no ovarian follicular development and anovulation occurs

280
Q

Which app is an FDA-approved FABM method?

A

Natural Cycles

281
Q

Failure rate for lactational amenorrhea

A

perfect use - 0.5 to 1.5%

typical use - data is not available

282
Q

Does milk expression by hand or pumping afford the same fertility-inhibiting effect in lactational amenorrhea as breast feeding?

A

No

283
Q

Failure rate for withdrawal method

A

perfect use - 4%

typical use - 22%

284
Q

What type of procedures are used for female sterilization, or fallopian tube occlusion contraception?

A

Outpatient surgical procedure, or postpartum prior to discharge. The fallopian tubes are obstructed to prevent union of sperm and egg, can be done transabdominally or laparoscopically via….

  • surgical ligation (Pomeroy procedure)
  • surgical ligation and attachment to uterine body (Irving procedure)
  • electrocauterization
  • excision of a section of the tube (Pritchard procedure, fimbriectomy)
  • Occluded with a compressive silastic bang (Falope Ring) or clip (Filshie)
285
Q

Failure rate for fallopian tube occlusion sterilization

A

perfect & typical: 0.5%

286
Q

Risks of fallopian tube occlusion sterilization

A

reversal is difficult, expensive, and often unsuccessful. procedure can come with operative complications such as injury to the bladder, uterus, or intestines. Wound infection. Higher risk that the pregnancy would be ectopic if pregnancy occurs. Anesthesia complications such as death (rare)

287
Q

Follow-up required after fallopian tube occlusion sterilization

A

1-2 weeks after procedure, assess for healing and s/s infection

288
Q

Instructions for use of fallopian tube occlusion sterilization

A

Nothing by mouth 8 hours before procedure. Will need transportation home. Rest for 24 hours after procedure. Abstain from exercise or intercourse for 1 week. Notify for s/s infection

289
Q

What type of procedures are used for male sterilization, or vas deferens surgery contraception?

A

Occlusion of vas deferens prevents transmission of sperm through semen; the ejaculate will be without sperm. Can be done with only local anesthesia and via no-scalpel, no-sutures method. Most commonly the vas deferens is ligated with sutures and a section is excised. Other methods include electrosurgical or thermal cautery, application of clips, or a combination of methods.

290
Q

Failure rate of male sterilization

A

0.10-0.15%

291
Q

Risks of male sterilization procedure (vasectomy)

A

should be considered irreversible. would infection is possible. Extensive research has identified no significant long-term physical or mental health effects with vas surgery.

292
Q

What follow-up is required after male sterilization procedure?

A

3 months after procedure, confirm success with semen analysis

293
Q

Instructions for use of male sterilization procedure (vasectomy)

A

Use scrotal support (i.e., brief-style underwear) for at least 2 days to reduce pain. Apply an ice pack to scrotum for a minimum of 4 hours after procedure. Notify for s/s infection. Avoid ejaculation for 1 week. Avoid exercise or heavy lifting for 1 week. Continue a back-up method for 3 months until can confirm with semen analysis

294
Q

How long after procedure for male vs. female sterilization must use back-up or abstain?

A

female - 1 week

male - 3 months

295
Q

On average, the first ovulation occurs ______ days post partum in non-lactating folks. But may occur as early as ….

A

average = 45 days (1.5 months)

early as = 25 days (1 month)

296
Q

VTE risk is increased for the first few weeks postpartum, generally declining to baseline level after _____

A

42 days (1.5 months)

297
Q

Combined hormonal contraceptives in the postpartum period, timeline for NON-LACTATING women

A

0-21 days = absolute contraindication
21-42 days w/ addl VTE risk = relative contraindication
21-42 days w/o addl VTE risk = likely okay
>42 days = best

298
Q

Combined hormonal contraceptives in the postpartum period, timeline for LACTATING women

A

0-21 days = absolute contraindication
21-30 days = relative contraindication
30-42 days w/ addl VTE risk = relative contraindication
30-42 days w/o addl VTE risk = likely okay
>42 days = best

299
Q

Progestin-only hormonal contraceptives in the postpartum period, timeline for LACTATING women

A

0-21 days = likely okay
21-30 days = likely okay
>30 days = best

300
Q

Progestin-only hormonal contraceptives in the postpartum period, timeline for NON-LACTATING women

A

okay immediately

301
Q

IUDs in postpartum period, timeline (regardless of lactation status or method of delivery)

A

0-10 minutes = likely okay for LNG, best for copper
10 minutes to 4 weeks = likely okay
>4 weeks = best

302
Q

Combined hormonal contraceptives come in these routes/methods (3)

A

pills, patch, ring

303
Q

Combined hormonal contraceptives in the peri-menopausal years?

A

Safe option if non-smoking, non-obese, healthy. May be especially attractive for relief of vasomotor symptoms and menstrual regulation. May even reduce risk of endometrial hyperplasia and cancer associated with anovulatory cycles during perimenopause

304
Q

Progestin-only contraceptive methods in the peri-menopausal years?

A

There are no age-related contraindications. They may provide some relief from vasomotor symptoms. They may reduce the risk of endometrial hyperplasia and cancer. DMPA specifically may reduce bone density (however, these folks then don’t tend to undergo the typical rapid loss of bone density following menopause)

305
Q

IUDs in the peri-menopausal years?

A

Safe. Long-acting and as effective as sterilization. May also be therapeutic for perimenopausal folks with heavy bleeding

306
Q

When should a peri-menopausal patient d/c their hormonal contraceptive method?

A

There are no definitive answers for when to d/c.

  • CHC - continue to age 50-55 years. If you are going to measure hormone levels, must be off of the method for >14 days to eliminate it’s effect on FSH and estradiol
  • POP, IUD - can continue to age 55. If you are going to measure hormone levels, check FSH on 2 occasions between ages 50-54 at least 1-2 months apart and if both are >30, then continue the method one more year before stopping
  • Copper IUD - continue use until amenorrheic for 1 year (post-menopausal). If less than 50 yo, continue until amenorrheic for 2 years OR 1 year but with hormone confirmation (two FSH levels >30 at least 1 -2 months apart)
307
Q

Can gender-affirming hormone therapy with testosterone and GnRH analogues be counted on for birth control in trans folks?

A

No - they suppress ovarian function, but cannot be relied on for contraceptive protection (or is this because we don’t have good enough data/studies??)

308
Q

Warning regarding testosterone in trans folks with reproductive capacity

A

testosterone is a teratogen that is contraindicated in pregnancy

309
Q

Selecting a birth control method for trans folks on masculinizing hormone therapy with reproductive capacity

A

the estrogen components of combined hormonal methods may counteract the masculinizing effects of testosterone.

The Copper IUD and progestin-only methods (POPs, arm implant, LNG IUDs) will not interfere with testosterone effects. :)

310
Q

Approximately ____% of pregnancies in the US are unintended

A

50%

311
Q

Medication abortions are FDA-approved up to _____ days from LMP

A

70 days (10 weeks, ~2.5 months)

312
Q

What (2) medications are used in a medical abortion, first line

A

mifepristone (200mg PO) + misoprostol (800mcg)

313
Q

MOA of mifepristone as a medical abortion agent

A

19-norsteoid, progesterone antagonist

  • blocks the action of progesterone needed to establish and maintain the placental attachment
  • softens the cervix
  • stimulates prostaglandin synthesis by cells of the early decidua
314
Q

MOA of misoprostol as a medical abortion agent

A

prostaglandin analog

  • softens cervix
  • stimulates uterine contractions
315
Q

Common short-term side effects of misoprostol as a medical abortion agent

A

nausea, vomiting, diarrhea, temporary elevation of body temperature. Importantly, prenatal exposure to misoprostol is associated with major congenital abnormalities (although absolute risk is low, about 1%)

316
Q

What is the dosing/regimen/fup of medication abortion with mifepristone and misoprostol

A

mifepristone 200mg PO (in clinic, at initial visit - also give Rh immunization depending on Rh status) followed by misoprostol 800 mcg (vaginal, buccal, or sublingual at home 24-48 hours later). Follow-up in clinic 1-2 weeks later to assess for complete abortion. May repeat the misoprostol or provide aspiration if it is not complete by 1-2 weeks, by 2-3 weeks after would require aspiration abortion.

[MISPROSTOL - VAGINAL: 6-48 hours later; BUCCAL: 24-48 hours later; SUBLINGUAL: 24-48 hours later].

317
Q

Effectiveness of mifepristone + misoprostol medical abortion therapy

A

96-98% through 9 weeks EGA

318
Q

Contraindications to medication abortion

A

known or suspected ectopic pregnancy, IUD in place (remove before giving medication), hemorrhagic disorder, anticoagulant therapy, chronic kidney disease, long-term use of systemic corticosteroids, inherited porphyrias

319
Q

Second line medication abortion options (2), less commonly used

A

methotrexate + misoprotol

320
Q

MOA of methotrexate in medication abortion

A

folic acid analogue. Inhibits the enzyme necessary for DNA synthesis and acts on the rapidly dividing cells of the placenta.

321
Q

How effective is methotrexate + misoprostol for medication abortion?

A

92-96% effective up to 7 weeks (49 days) EGA

322
Q

Patient counseling/warnings with use of methotrexate plus misoprostol for medication abortion

A

It may take up to 1 month for expulsion of the gestational sac. It is a known teratogen. Discontinue breastfeeding for 72 hours after taking it. Avoid use of folic acid for 1 week after the procedure, as it may inhibit the action of methotrexate.

323
Q

Contraindications for methotrexate + misoprostol medication abortion regimen

A

known or suspected ectopic pregnancy, IUD in place (remove before giving medication), hemorrhagic disorder, anticoagulant therapy, chronic kidney disease, long-term use of systemic corticosteroids, inherited porphyrias, acute inflammatory bowel disease, uncontrolled seizure disorder

324
Q

What is the dosing/regimen/fup of medication abortion with methotrexate and misoprostol

A

Methrotrexate IM injection or orally at initial visit (also give Rh immunization, depending on Rh status), followed by the misoprostol per vagina at home 3-7 days later. Follow-up in clinic 1-2 weeks later to assess for complete abortion. May repeat the misoprostol or provide aspiration if it is not complete by 1-2 weeks, by 2-3 weeks after would require aspiration abortion.

325
Q

Surgical options for elective abortion (2)

A

vacuum aspiration, dilation & evacuation (D&E)

326
Q

Through how many weeks EGA is vacuum aspiration an option for surgical abortion

A

first trimester (13-14 weeks)

327
Q

Through how many weeks EGA is D&E an option for surgical abortion

A

up to 20 weeks

328
Q

Laboratory/diagnostic tests the WHNP should complete prior to referral for surgical abortion

A
  • Pregnancy dating by LMP and/or TVUS
  • urine pregnancy test (beta HCG)
  • Hgb/hct
  • Blood type and Rh status
  • STI evaluation
329
Q

Warning signs for patients to call clinic to report after medical or surgical abortion

A

fever, persistent or increasing lower abdominal pain, prolonged or excessive vaginal bleeding, purulent vaginal discharge, no return of menses within 6 weeks

330
Q

Average age of menopause in the US

A

52yo

331
Q

Definition of menopause

A

12 months without a period

332
Q

Definition of premature menopause

A

cessation of ovulation and menses before age 40yo, whether spontaneous or induced

333
Q

STRAW (Stages of Reproductive Aging Workshop) - what changes define the menopausal transition?

A 
Principal criteria = menstrual cycle changes
Other characteristics = 
- vasomotor symptoms
- symptoms of urogenital atrophy
Supportive characteristics = endocrine changes
- AMH (low)
- FSH (high) 
- LH (high)
- estradiol (low)
- inhibin B (low)
- antral follicle count (via US - low)
334
Q

What is the relationship of AMH to menopause

A

AMH is produced exclusively by granulosa cells of the ovarian follicles; as such, it is a marker of ovarian reserve. AMH begins to decrease as early as a female’s 20s, and will be undetectable about 5 years after menopause

335
Q

What is the relationship of inhibin B to menopause

A

inhibin B is an ovarian peptide that works in a negative feedback loop with FSH. As the number of ovarian follicles declines towards menopause, inhibin B levels will fall as FSH rises

336
Q

What laboratory findings for FSH, LH, and E2 are indicative of menopause

A

FSH >40 mIU/mL
LH >3x elevation (20-100 mIU/mL)
E2 <20 pg/mL

337
Q

What is the relationship between menopause and weight gain

A

There is no data to support that menopause hormonal changes are responsible for weight gain, it is more likely the result of aging and lifestyle. There is some evidence that hormonal changes of menopause may be related to changes in fat composition and fat distribution from subcutaneous stores to visceral abdominal fat

338
Q

Menopausal transition - effects on the skin

A

The skin has a significant number of estrogen receptors. As estrogen declines, there are corresponding declines in skin collagen and thickness. Scalp, pubic, and axillary hair becomes thinner and drier.

339
Q

Menopausal transition - effects on bone

A

There is increased bone loss associated with the decrease in estrogen, greatest loss occurs in the first few years after menopause and then slows (but continues)

340
Q

Menopausal transition - effects on labia

A

The labia decrease in subcutaneous fat and tissue elasticity

341
Q

Menopausal transition - effects on vagina

A

The vaginal microbiome changes in response to decreasing estrogen with increases in vaginal pH from acidic to alkaline (pH >5.0). Additionally, the vaginal epithelium develops a higher proportion of parabasal cells than mature superficial cells, leading to a thinner, less vascular, and less elastic epithelium. The vaginal walls may appear more thin, smooth, and pale and may have small petechiae and be friable to touch.

342
Q

Menopausal transition - effects on cervix

A

Decreases in size, os may become flush with the vaginal walls and may also become stenotic

343
Q

Menopausal transition - effects on ovaries

A

Ovaries decrease in size, usually not palpable

344
Q

Menopausal transition - effects on urethra and bladder

A

The urethra and trigone of the bladder have high concentrations of estrogen receptors thus may experience atrophic changes. The urethral meatus may become more prominent as the labia minora thins and the introitus retracts, additionally urethral caruncles are common

345
Q

Effects of HRT on cognitive function?

A

It is unclear how estrogen or estrogen+progesterone affects cognitive function with younger menopausal individuals. However, the Women’s Health Initiative Memory Study (WHIMS) found the risk of dementia was increased in healthy women aged 65-79yo who were using estrogen+progesterone therapy

346
Q

Menopausal transition - effects on cardiovascular system

A
  • Increases in LDL, VLDL-C, triglycerides, and possibly a decrease in HDL
  • Increase in certain fibrinolytic and pro-coagulation factors that regulate clotting processes
  • the extent of the impact of estrogen levels of CVD is not definitively established
347
Q

Height loss greater than 1.5 inches in older folks may be associated with…..

A

vertebral compression fractures and osteoporosis

348
Q

Post-menopause - pelvic exams needed?

A

pelvic exam can be conducted if a pap test is needed or otherwise symptomatically indicated. Otherwise, routine pelvic exams should be a shared, informed decision between patient and provider

349
Q

Post-menopause - CBE needed?

A

ACOG recommends annually for folks 40yo and older. ACS and USPSTF does not recommend for average-risk females at any age

350
Q

Colorectal cancer screening should begin at age…

A

45yo

351
Q

Screen once for Hepatitis C if the patient was born between ______

A

1945 to 1965

352
Q

When and how often does the American Diabetes Association (ADA) recommend diabetes screening

A

Q3 years starting at age 45yo

353
Q

When/how can you stop cervical cancer screenings in someone with no history of abnormals, or only low-grade changes?

A

Stop screening at age 65yo if adequate prior screening which is defined as three consecutive negative cytology results OR two consecutive negative co-testing results within the last 10 years, the most recent of which was within the past 5 years

354
Q

When/how can you stop cervical cancer screenings in someone with h/o CIN2 or higher?

A

If history of cervical intraepithelial neoplasia 2 (CIN2) or higher, continue screening for 20 years after spontaneous regression or appropriate management

355
Q

Your 70yo pt presents for an annual. They stopped cervical cancer screening at age 65yo with adequate prior screening. They report this year having a new sexual partner, and they are wondering if they ought to receive another pap test?

A

Once screening has stopped, do not resume even if individual reports a new sexual partner

356
Q

When/how should you stop mammogram screening?

A

No definitive age to discontinue screening. Per ACS, ACOG base on an individual’s health and whether they would be a candidate for treatment of breast cancer. Per USPSTF, stop after age 74yo

357
Q

Schedule for bone mineral density screening

A

start at age 65yo unless risk factors; no definitive specific recommendations on frequency of screening or when to discontinue

358
Q

What are the vasomotor symptoms of menopause

A

Recurrent, transient episodes of flushing accompanied by sensation of warmth to intense heat on the upper body and face. May include profuse sweating and heart palpitations. May awaken during the night, leading to insomnia, sleep disturbance, cognitive (memory) and affective (anxiety) disruptions with loss of REM sleep

359
Q

% of folks who experience vasomotor symptoms during perimenopause

A

75%

360
Q

Expected timing and duration of vasomotor symptoms of menopause

A

usually begins in the late menopause transition, with the greatest frequency and severity within the first 2 years after the final menstrual period. They typically last 5-7 years but may continue for some folks 10+ years

361
Q

Non-pharm options for management of vasomotor symptoms of menopause

A

Likely to be useful:
CBT, hypnosis

May be useful, needs more study:
weight loss, mindfulness-based stress reduction, derivatives of soy isoflavones (phytoestrogens)

Unlikely to be useful:
exercise, yoga, acupuncture, paced respiration, black cohosh, dong quai, evening primrose oil

362
Q

What is the main purpose of including progesterone in menopausal hormone therapy formulations

A

to reduce the risk of endometrial cancer in folks with a uterus associated with unopposed estrogen

363
Q

How is conjugated equine estrogen made

A

mixture of estrogens isolated from urine of pregnant mares (horses)

364
Q

What is the only human estrogen available in an FDA-approved, single-estrogen formulation

A

17 beta-estradiol

365
Q

Which progesterone is “bioidentical” and what is the difference between this and progestins

A

micronized progesterone, which is a compound identical to endogenous steroid hormone produced by the ovaries.

This is in contrast to progestins, which are a synthetic product that have progesterone-like activity but are not identical to endogenous progesterone

366
Q

Hormonal pharmacotherapeutic options for vasomotor symptoms of menopause (classes - 2)

A
  • hormone therapy (estrogen or estrogen + progesterone)

- selective estrogen receptor modulators (SERM; bazedoxifene)

367
Q

Bazedoxifene

A

SERM with estrogen antagonist effect on the endometrial and breast tissue, with estrogen agonist effects on the bone.

368
Q

Counseling on bioidentical hormone therapies that are specifically compounded for an individual

A

Custom-compounded bioidentical hormone products are not FDA approved, there is no evidence that they are safer than conventional HT, and the same contraindications apply to their use. There is no evidence that saliva testing is effective for customizing hormone therapy dosing regimens

369
Q

Contraindications to the use of hormone therapies for menopausal symptoms

A
  • undiagnosed abnormal vaginal bleeding
  • known, suspected, or history of breast cancer
  • known or suspected estrogen-dependent cancer
  • active or history of DVT or PE
  • active or history of arterial thromboembolic disease, like a stroke or an MI
  • liver disease
  • clotting disorder (protein C, protein S, or antithrombin deficiency)
  • pregnancy
370
Q

Breast cancer survivors and vaginal estrogen?

A

For survivors of beast cancer with bothersome genitourinary syndrome of menopause not relieved by non-hormonal therapies, low-dose vaginal estrogen with minimal systemic absorption may be considered in consultation with oncologist

371
Q

(4) potential risks of menopausal hormone therapy, generally

A

endometrial hyperplasia/cancer (estrogen alone), breast cancer, thromboembolic disorders (CAD, stroke, blood clot), dementia

372
Q

Counseling on risk of breast cancer with menopausal hormone therapy use

A

Relationship is inconclusive - possible small but significant increase of breast cancer with long-term use (~>5 years)

373
Q

Counseling on risk of thromboembolic event with menopausal hormone therapy use

A

Relationship is inconclusive - folks who start HT closer to menopause have less risk than those starting several years after menopause. Generally, transdermal formulations have less risk than oral routes. No hormone therapies should be used for the prevention of cardiovascular disease or stroke and it should be avoided in individuals at high risk for stroke

374
Q

Counseling on risk of dementia with menopausal hormone therapy use

A

Relationship is inconclusive - possible small but significant increase in risk if estrogen-progesterone therapy is initiated at >65yo

375
Q

How to discontinue menopausal hormone therapy use

A

There is no data available regarding the choice of abrupt cessation vs. tapering. Approximately 50% of folks will experience a recurrence of symptoms with discontinuation no matter age or length of time hormones were used

376
Q

Effects of oral estrogen-progesterone or estrogen-only menopausal hormone therapies on cholesterol levels

A

POSITIVE: increases HDL, lowers LDL
NEGATIVE: increases triglycerides, increases CRP

377
Q

Differences between Femring and Estring

A

Femring is vaginal estrogen ring approved for the treatment of vasomotor symptoms of menopause and vulvovaginal atrophy. It has a 99-day duration and systemic absorption, thus MUST SUPPLEMENT WITH PROGESTERONE IF HAS INTACT UTERUS

Estring is a vaginal estrogen ring with only local effect, given little to no systemic absorption. It will treat vulvovaginal atrophy but does not provide relief from vasomotor symptoms of menopause. Do not need to supplement with progesterone for folks with intact uterus

378
Q

Side effects of menopausal hormone therapy (5) and tips on managing them

A
  • breast tenderness (usually subsides after first few weeks; can be caused by both E and P components)
  • nausea (from E component - take with meal or at bedtime)
  • skin irritation with transdermal patch
  • fluid retention and bloating (both E and P components)
  • mood alterations (likely P component)

May try lowering the dose, changing the route, or changing to a different formulation

379
Q

Bleeding and continuous-combined menopausal hormone therapy?

A

Erratic spotting and light bleeding of 1-5 days duration may occur in the first year o fuse; need an endometrial evaluation if the bleeding is heaver or longer than usual, or if it resumes after several months of amenorrhea

380
Q

Non-hormonal pharmacotherapeutic options for vasomotor symptoms of menopause, classes (3)

A

SSRIs, SNRIs, gabapentin (anticonvulsant)

381
Q

Which is the only non-hormonal prescription medication approved by the FDA for vasomotor symptoms of menopause

A

paroxetine 7.5mg QHS at bedtime (SSRI; Paxil)

382
Q

Symptoms of genitourinary syndrome of menopause

A
  • genital dryness, burning, and irritation
  • lack of lubrication, dyspareunia, sexual dysfunction
  • urinary frequency, nocturia, urgency, dysuria, and recurrent UTIs
383
Q

% of folks who experience genitourinary syndrome of menopause symptoms

A

50%

384
Q

Menopausal transition – effect on the vaginal flora

A

Decreased estrogen leads to decreased vaginal lactobacilli which increases the vaginal pH (more alkaline/basic)

385
Q

Nonhormonal therapies for treatment of genitourinary syndrome of menopause (4)

A
  • vaginal lubricants
  • vaginal moisturizers
  • regular sexual activity with a partner
  • regular sexual activity that is non-coital (i.e., masturbation)
386
Q

Why are vaginal moisturizers helpful for genitourinary syndrome of menopause

A

Applied several times weekly, they can provider longer-term relief of vaginal dryness than lubricants and they help maintain vaginal moisture and a lower vaginal pH (more acidic)

387
Q

(3) types of vaginal lubricants

A

water, silicone, or oil-based

388
Q

Why is regular sexual activity helpful for genitourinary syndrome of menopause

A

promotes blood flow to the genital area

389
Q

(3) types of hormonal therapies that can be used for genitourinary syndrome of menopause

A
  • vaginal estrogen
  • ospemifene (Osphena; SERM)
  • prasterone (Intrarosa; steroid pro-hormone)
390
Q

Counseling about ospemifene (Osphena) for genitourinary syndrome of menopause

A

A SERM approved for the treatment of moderate to severe dyspareunia related to vulvovaginal atrophy. Has estrogen agonist effects on the vaginal tissue (thickens and makes less fragile, decreases vaginal pH to more acidic), with weak estrogen agonist effects on the uterus and breasts (thus, same contraindications for use as with systemic estrogen). It may take several weeks for full relief of symptoms.

Administration = daily oral pill.
Common side effects = hot flashes, vaginal discharge, muscle spasms, increased sweating

No FDA indication for improving bone health. Has not been evaluated in combination with progesterone for those with intact uterus. Should not be used with another estrogen or another SERM.

391
Q

Counseling about prasterone (Intrarosa) for genitourinary syndrome of menopause

A

Approved for the treatment of moderate to severe dyspareunia related to vulvovaginal atrophy. It is an inactive endogenous steroid prohormone that is converted into active androgen and estrogen locally in the vaginal cells to improve vaginal epithelium maturation index and to lower the vaginal pH.

Administration = once daily vaginal dose at bedtime
Most common side effect - vaginal discharge

Contraindicated with abnormal genital bleeding of unknown cause.

Has not been studied for use in those with a h/o breast cancer.

NCC Board Prep (10 decks)

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