Chapter 7: Genito-Urinary System Flashcards
Ben, a 7-year-old went swimming with his friends from school as part of physical Education activities . His teacher realizes that Ben’s records show that he takes Desmopressin regularly. Which of the following advice should the teacher give Ben. Choose most relevant option below.
A. Ben should be warned he could vomit whilst swimming due to his current medication .
B. Ben could feel thirsty as a result of the drug he is taking.
D. Ben should avoid swimming altogether.
E. Ben should be isolated and asked to swim in a separate pool.
C. Ben should not drink water from the pool whilst swimming. (moderate water intake, too much water, reduces concentration of sodium causing hyponeatrima possibly leading to convulsions/seizures)
NOCTURNAL ENURESIS (bedwetting) IN CHILDREN
AGE - 1yrs–5yrs
▪ use Natural and non-drug treatment first (fluid control: closer to bedtime limit amount of fluids, enuresis alarm: set an alarm/take them to restroom at set times, reward system)
do not put under the age of 5 or under on medication, definitely over 5yrs (can start giving medication), as young as 6, ideally from 7yrs
➢ Desmopressin (diabetes insipedus: nephrogenic type, used to diagnose, action: anti-diuretic hormone helps retain water, desmopressin and sodium: if sodium goes down, absorbs more desmopressin, leads to convulsion, drugs that increases hyponatreamia: excessive water, low sodium diet, SSRI, loop diuretics, carbamazepine, TCAs)
➢ Oxybutinin (antimuscarinic side effects: water retention, side effects used to treat incontinence, dry mouth, blurry vision, drowsiness, oxybutinin and clozapine: constipation=>intestinal obstruction=>fatal consequences, antihistamines: antimuscarinic side effects, can be due to taking alongside oxybutinin, stop antihistamine as not clinically important)
➢ Imipramine (TCA, off license use, also used in noctual enuresis apart from mental health)
URINARY FREQUENCY, incontinence
➢ Antimuscarinics: first line, antimuscarinics–oxybutynin, solifenacin
➢TCA - unlicensed, imipramine (2nd line)
➢Mirabegron – can cause increase in BP, monitor/check BP, use of contraception women of childbearing as can cause issues.
3 TYPES
>Don’t give duloxetine in women with stress incontinence as first line.
> tamsulosin (flomax, POM and P): can get on PGD, 45-75yrs
URINARY RETENTION (unable to pass urine)
Causes: in men (benign prostatic hyperplasia: enlargement of prostate gland)
Acute – catheterization (fitting the catheter/removal of can cause infection)
Alpha blockers (relax vessels to allow urine through): alfuzosin, prazosin, tamsulosin, doxazosin
Finasteride (can only be taken by men, not be taken by women, can cause breast cancer in men, increase risk of suicide/notice any changes in behavior/mood, use gloves and tweezers when handling (methotrexate)
Stella, a young lady , is a new dispenser who is about to make dossette
boxes for the first time . She is instructed to wear gloves and use
tweezers when handling certain drugs. Which of these drugs do NOT require Stella to use gloves or tweezers when handling?
A. Dusteride (same family as finasteride)
B. Methotrexate (cytotoxic)
C. Chlorpromazine (1st gen antipsychotic, causes contact sensitisation: skin will peel off)
D. Finasteride
E. None of the above
E. None of the above
HRT
> HRT IS THE REPLACEMENT OF HORMONES SUCH AS OESTROGEN AND PROGESTERONE THAT WOMEN LOSE DUE TO MENOPAUSE. (early menopause before 50 no period 2 yrs, late menopause after 50 no period 1 yr)
Gina eligibility: not for patients with early menopause, must be 50+ and not have period for 1 yr
MENOPAUSE SYMPTOMS: vaginal atrophy, mood swings, sweating, hot flushes, irritable, dryness, poor concentration (imagine having HRT scarcity for menopausal women)
HRT PRODUCTS ARE AVAILABLE AS PATCHES , TABLETS , GELS ETC
PATIENTS CAN CHOOSE WHICH FORM THEY PREFER.
Menopausal but still SEEING PERIODS- GIVE CYCLICAL HRT (CONTAINS BOTH HORMONES)
STOPPED PERIOD OVER A YEAR – GIVE CONTINOUS HRT HAVE A REVIEW EVERY YEAR.
HRT
> FOR PATIENTS WHO HAVE HAD A HYSTERECTOMY (womb removal) – DON’T NEED PROGESTERONE (protects womb lining). GIVE OESTROGEN ONLY HRT!!!
SIDE-EFFECTS – headaches, breast tenderness, mood changes, nausea, spotting (may need to be referred).
Consider changing doses or forms if patients complain of ongoing side- effects after 6 to 8 weeks.
HRT PROTECTS BONES FROM OESTEOPOROSIS (oestrogen in important for the maintenance of bones in woman)
RISKS OF HRT
> Risk of breast cancer
Risk of endometrial cancer
Risk of ovarian cancer
Risk of venous thromboembolism Risk of stroke
Risk of coronary heart disease
**yes there is a risk of these conditions, however the risk is very small, long-term HRT is an increased risk of getting these conditions
Surgery
>Major surgery under general anaesthesia, including orthopaedic and vascular leg surgery, is a predisposing factor for venous thromboembolism and it may be prudent to stop HRT 4–6 weeks before surgery
COC: stop 4 weeks before planned surgery
Warfarin: 5 days
HRT: 4-6 weeks
Insulin: dose adjustment (long-acting insulin: reduce to 80% day before)
WHEN TO STOP HRT
> Hormone replacement therapy should be stopped (pending investigation and treatment), if any of the following occur:
*sudden severe chest pain (even if not radiating to left arm);
*sudden breathlessness (or cough with blood-stained sputum, can cause pulmonary embolism:clots in lungs);
*unexplained swelling or severe pain in calf of one leg;
*severe stomach pain;
*serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body;
*hepatitis, jaundice, liver enlargement;
*blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
*prolonged immobility after surgery or leg injury;
*detection of a risk factor which contra-indicates treatment.
Refer patient to urgent medical attention=>A/E
Contraceptives
There are various types of contraceptives
1. Barrier method (condoms, diaphragms)
2. I.U.D (copper, etc)
3. Patches
4. Injections eg depo provera (progesterone)
5. Vaginal rings
6. Oral – COC (oestrogen and progesterone) or progesterone only . (Yazmin, microgynon)
Examples?? Learn Brand names
Miss. Zara, a 23-year-old woman would like to discuss contraceptives options with her doctor. During the discussion, her
doctor mentions that an IUD is less suitable for her. What is the
most accurate reason for the doctor’s response?
A. Increased risk of infertility
B. Increased risk of Ovarian cancer
C. Increased risk of P.I.D.
D. Increased risk of multiple pregnancies
E. Increased risk of breast cancer
C. Increased risk of P.I.D. (female less than 25yrs are at risk of PID)
COC
> Take for 21 days with 7 day break
Not for women over 50 yrs
Monophasic COC: same amount of progesterone/oestrogen in all tablets (more effective for women with regular cycles)
Phasic COC: change of strengths through tablets (more effective for irregular periods)
Everyday preparation (so patients dont forget, taken everyday even though 7 days are placebo/inactive tablets)
Avoid if 2 or more Symptoms are present- Smoking, over 35yrs , BMI 30 or more, Family history of blood clots/DVT, immobilization, etc
when should COC be stopped before major elective surgery??? 4 weeks
Long Journeys/traveling?? Advice: wear compression stockings, increase mobility
COC reduces risk of endometrial and ovarian cancer but increases risk of breast cancer and cervical cancer.
COC – Reasons to stop
> Stroke
Breathlessness: pulmonary embolism
VTE
High Blood pressure ……160/ 95
Liver dysfunction
Prolonged immobility after surgery or injury
Detection of a risk factor eg smoking, over 40, BMI over 35 , diabetes
PROGESTERONE ONLY CONTRACEPTIVES
❑ Take one tablet at the same time every day (keep concentration in blood consistent)
❑ If started after day 5 of cycle additional protection is needed. (period ends, best day to take it is right at the beginning of the cycle, the next day, day 1 is best time to take it)
❑ Increases risk of breast cancer.
❑ Used in Emergency contraception. Eg Levonell one-step
>morning after: Levonell (16+, PGD for under 16, 72 hrs after activity, the earlier to take it the better, the longer you wait the less effective, possible to get pregnant on the morning after pill, if vomit within 2 hrs needs another medication, refer patients on enzyme inducers: carbamazepine, phenytoin, rifampicin, phenobarbitol
❑ If patient has BMI of ..26kg/M2 or more >70kg, give 2 tablets of levonorgestrel (unlicensed, not allowed to sell 2 OTC, must refer for 2) or just sell ELLA-ONE
o Pinky, an 18-year-old who have never taken contraceptives before . Starts a new pack of microgynon but missed a dose within the first 7 days and UPSI occurred during that same period. What advice would you give this patient.
o Sharon , A 25-year-old woman who has been taking Rigevidon regularly for the past 6 months. Reports that she missed a tablet yesterday- within the first 7 days of a new pack and unprotected sexual intercourse occurred last night. What advice would you give this patient.
o Mrs. Happy a 35-year-old woman takes Microgynon regularly, starts Micrigynon on day one of her cycle. She had unprotected sex yesterday(day 6 of cycle ) . She has not missed a pill but worries and would like to know what to do .
WB Questions
MISSED PILL
> COC – missed pill is 24 hours or more.
Qlaira is 12hrs or more
P Only Contraceptive – 3 hours or more
Desogestrel is 12 hours
COC 1 missed – take next as normal, even 2 at once
COC 2 missed – Take next dose and use protection. Consider EHC=>take pill for today, morning after pill if had unprotected sex, use condom for 7 days (Zoey/QLAIRA=9 days)
P only contraceptive- 1 missed – take missed pill Asap plus condoms for 2 days
P only contraceptive- 2 missed – take 1 dose, morning after/EHC if had unprotected sexual intercourse, plus condoms 2 days
missed pill: 24 from point of first missed pill into 2nd one
first 7 tablets in a pack are most important for new/returning patients as body is building up enough protection, if miss a pill during this time can potentially become pregnant, must start all over, use EHC if had unprotected sex and use condoms for 7 days
Emergency contraception
> levonelle- Within 72 hours, take another if vomit within 2 hrs, refer patients on enzyme induces or specific health conditions, breastfeeding women wait 8hrs between taking drug and feeding child. 16+ can take
ELLA ONE - Within 120 hours, breastfed mother must wait 7 days to feed (will need to bottle feed), can reduce oral contraceptive up to 5 days, no minimum age/childbearing age can take
**Copper IUD is the most effective ?>PATIENT’S REP: interview patient taking the medication (over the phone, in person)
ADVANCE SUPPLY: when patient travels where there isn’t easy access
Age of patient
Can affect menstrual cycle – LEVONELLE MORE LIKELY THAN ELLA-ONE (earlier, later, longer shorter)
Report signs of abuse- See safeguarding (under 16, report to child protection officer)
Take EHC as soon as possible.
TRANSGENDER PATIENT: transgender male without surgery/hormonal changes, then supply. If they have had hormonal/surgical changes, no need to supply.
must signpost to another pharmacy if not wanting to engage in this service/decline to supply
Signpost for religious/ Ethical reasons.
menstrual cycle disruption if taken morning after more than once in a cycle
DRUG INTERACTIONS
Enzyme inducers
1. Carbamazepine
2. Phenytoin
3. Rifampicin=>TB for 6 months (initial (2 months)+2nd phase (4months)). Taking Yasmin (COC)=>needs adequate contraceptive protection by putting patient on IUD or giving them depo provera injection (every 3 months), be on it during the 6 months treatment and another 4 weeks once completed as rifampicin can still remain in the system=>can start first 7 days of COC
4. Phenorbabital
5. St. John’s wort
>Rx: Regular contraceptive plus progesterone only injection or copper IUD.
For how long? 4 additional weeks once treatment is completed
A female patient comes into your pharmacy on a Saturday morning. She is 35 years old and takes desogestrel regularly at 12 noon every day. She tells you that she forgot to take her tablet on Friday and had unprotected sex on Friday night. She would like you to give her appropriate advice based on what she has explained to you. Which option below is the most appropriate.
A. Tell the patient that she should take a tablet straight away and that should be sufficient.
B. Tell the patient that she needs to take two desogestrel tablets today to make up for the missed pill and that should be sufficient.
C. Tell her to get emergency pill, continue with her desogestrel as normal and use condoms for next 7 days
D. Tell her to get emergency pill, continue with her desogestrel as normal and use condoms for next 2 days
E. Tell her to see her GP for advise
Ms. G is on rifampicin for 6 months for TB treatment and was administered an IUD. She decided to stop taking her microgynon pill as a result. If she re-starts her Microgynon tablets , when will she get full contraceptive protection from it.
A. 4 weeks after stopping rifampicin
B. 5 weeks after stopping rifampicin
C. 6 weeks after stopping rifampicin
D. 8 weeks after stopping rifampicin
E. 12 weeks after stopping rifampicin
Stella is about to take ulipristal acetate 30mg because she missed her pill for some days . Stella is a regular patient in your pharmacy and takes desogestrel. She asks when she can re-start her regular pill. What’s the best advice you can give her?
A. Start immediately; there is no need to use a barrier method of contraception
B. Start after 3 days, a barrier method of contraception will be needed for the first 7 days
C. Start after 5 days, a barrier method of contraception will be needed for the first 12 days
D. Start after 7 days, a barrier method of contraception will be needed for the first 7 days
E. Start after 7 days, a barrier method of contraception will be needed for the first 5 days
Why is ulipristal acetate not recommended for use in women who have severe asthma treated by oral corticosteroid?
a. Hypertensive crisis
b. Hyperkalaemia
c. Hypokalaemia
d. Anti-Glucocorticoid effect of ulipristal acetate
e. Anti - Mineralocorticoid effect of steroids
Jennifer is a 35 year old female patient. She weighs 14 stone and 7lbs. Her height is 165cm. She stopped smoking 5 years ago. Based on this information, do you think she can be prescribed CILEST tablets today at her GP surgery?
a. BMI is ………………./ yes but use with caution
b. BMI is ………………./ No Avoid because ……………………
c. BMI is …………………/ yes .totally fine to use. No issues at all
d. BMI is …………………./ No. Avoid she has more than 3 risk factors
e. BMI is ………………../ Yes but suggest desogetrel instead.
You are in the consultation room with stella who wants to buy ELLA ONE (ULIPRISTAL ACETATE). During your conversation, Stella mentions that she has already taken ELLA ONE previously during this current menstrual cycle. She also tells you that she plans to go out tonight with her friends to a party. Which of the following is correct?
a. Refuse sale and refer Stella to her GP.
b. It is known that alcohol definitely interacts with ELLA
ONE, so Stella cannot drink whilst she is out partying.
c. Ulipristal acetate is also used to treat polycystic ovary sydrome
d. Ofloxacin will affect effectiveness of Ella One if taken concomitantly
e. Ulipristal acetate is also used to treat uterine fibroids
Jesnaira is 17yrs old and would like to speak to privately. She has not had unprotected sex yet but is planning on going on holiday with her girlfriends to Ibiza. She tells you that she would like to buy the ‘’morning after pill’’ as she doesn’t want any surprises whilst she is out there. What do you think is the most appropriate thing to do? She takes lymecycline regularly for acne.
a. Refuse sale because you can’t sell levonelle in advance
b. Refuse sale and consel her on safe sex practice
c. Refuse sale and refer to Gp
d. Sale her levonelle one step
e. Sale levonelle . But she should be told lymecycline
interacts with levonelle, so she should not take lymecycline on the same day.
Consider the prescription for Jackie
Miss. Jackie 15years old 20/09/2019
Desogestrel 75mg tablets Mitte 168
Take one tablet at the same time daily for 21 days with 7 -day tablet free days.
From the information above, is anything of concern to you?
A. The date on the prescription
B. The age of the patient
C. The dosage instruction of the drug
D. The quantity on the prescription
E. Nothing is wrong with the prescription
A 15-year-old girl comes to your pharmacy on a Saturday morning. She requests to buy the morning after pill. The PGD in your pharmacy allows patients from 13yrs to access the EHC service. Whilst, asking her some questions in the consultation room about LEVONELLE, you noticed some red marks and bruises on her face and neck which she said she’d rather not talk about.
What is the most appropriate thing to do based on the scenario above?
a. Supply Levonelle to the patient. Then try persuading her to talk to you in confidence about the marks and bruises if okay with her. If she refuses, then leave it at that.
b. Do not supply Levonelle to the patient. Contact her parents and talk to them about your observation as she is only 15 years old.
c. Supply levonelle to the patient. Report your observation straight to the Police after the consultation.
d. Supply levonelle to the patient and let her go without further questioning. It is none of your business.
e. Do not supply Levonelle. Refer her to her GP or a sexual health clinic.
Mary who is on HRT tablets is scheduled to have hip replacement therapy in 3 months’ time. She asks you if she needs to stop taking her HRT medicine. What is the most appropriate response to give Mary?
a. Mary should stop taking her HRT medicines immediately and her GP should prescribe low molecular weight heparin as soon as possible.
b. Mary does not need to stop taking her HRT medicines for any reason.
c. Mary should stop taking her HRT tablets 10 weeks before surgery.
d. Mary should continue taking her HRT medicines until two days before surgery when she will be prescribed a low molecular weight heparin.
e. Mary should stop taking her HRT tablets 4 to 6 weeks before surgery.
o Pinky , An 18-year-old who have never taken contraceptives before . Starts a new pack of microgynon but missed a dose within the first 7 days and UPSI occurred during that same period. What advice would you give this patient.
oSharon , A 25-year-old woman who has been taking Rigevidon regularly for the past 6 months. Reports that she missed a tablet yesterday- within the first 7 days of a new pack and unprotected sexual intercourse occurred last night. What advice would you give this patient.
oMrs. Happy a 35-year-old woman takes Microgynon regularly, starts Micrigynon on day one of her cycle. She had unprotected sex yesterday(day 6 of cycle ) . She has not missed a pill but worries and would like to know what to do .
oA 46-year-old patient wants the morning after pill (levonelle) . She had unprotected sexual intercourse yesterday. She tells you she also takes salbutamol, carbimazole and allopurinol. What advice would you give this patient.
oA 16-year-old patient who wants the morning after pill and informs you that they were sexually abused by their partner two days ago . What advice would you give this patient.
oA 15-year-old patient who wants Ella one for EHC. Which guidelines would you use to ascertain her mental capacity before suppling the medication ? …………………………
A transgender man visits your pharmacy for advice following an episode of unprotected sexual intercourse with their male partner 4 days ago. They tell you that they are worried that they will become pregnant. The man also feels very embarrassed about this situation and does not wish to see another healthcare professional.
What is the most appropriate further action in this situation?
A.) Refer to a sexual health clinic for a IUD device as it is the most effective emergency contraception.
B.) Supply Ella one
C.) Supply levonelle
D.) Explain to the man that it is impossible for them to get pregnant and that they should not worry about getting pregnant.
E.) Refer to the GP
A 36-year-old woman comes into your pharmacy for the ‘morning after pill’ following sexual intercourse two days ago. You take her into the consultation room and she tells you that she is currently breastfeeding and has a 6-month-old child who only accepts breastmilk. Also, she mentions that she is worried about getting pregnant again after having four children. What would be the most appropriate advice to give her?
A. Take one Levonelle tablet immediately and avoid breastfeeding for a week
B. Take one ellaOne tablet immediately and avoid breastfeeding for a week
C. Take one Levonelle tablet immediately after feeding and avoid breastfeeding for at least 8 hours.
D. Take one ellaOne tablet immediately after feeding and avoid breastfeeding for at least 5 days.
E. Emergency contraception is not required for this patient.
Maria a 50-year-old woman comes to the pharmacy requesting Gina 10 micrograms (estradiol) vaginal tablets OTC. She is experiencing vaginal atrophy and has heard these tablets might help with her symptoms. Upon questioning, she states that she has had a hysterectomy and her periods stopped around 2 years ago. She reports no significant medical history and takes no other medication.
Which of the following would be the most appropriate action for the pharmacist to take?
A. Advise that her symptoms are normal and will get better with time
B. Refer to her GP as Gina tablets are not suitable for her.
C. Refer to her GP for a blood test before selling OTC
D. Refuse the sale as Gina vaginal tablets are not indicated for vaginal atrophy
E. Sell her a pack of Gina over the counter
Mr. Ramsey , a 51-year-old man who suffered a stroke 5 years ago, comes into the pharmacy asking to speak to the pharmacist regarding the purchase of Viagra Connect® (sildenafil 50mg tabs). You speak to the patient in the consultation room and ask questions to determine whether you can make a supply. After questioning, you decide to refer Mr. Ramsey to his GP as you are unable to supply the medicine.
Which of the following is the most likely reason that would make the supply for Mr. Ramsey inappropriate?
A. He drinks alcohol
B. He suffered a stroke 5 years ago
C. He is currently taking Erythromycin
D. He is currently taking solifenacin
E. He is a smoker
Mrs D has recently been prescribed hormone replacement therapy (HRT). She is concerned about the side effects of HRT and would like you to give her more information. During your discussion, you mention side effects that may occur, in which she should stop her HRT immediately.
Which of the following is NOT a reason to stop treatment with HRT?
A. sudden severe chest pain
B. sudden breathlessness
C. unexplained swelling or severe pain in calf of one leg
D. Hyperhidrosis
E. Jaundice
You work in a community pharmacy . A 51-year-old lady would like to buy GINA for vagina atrophy. Her symptoms include hot flushes, sweating, vaginal dryness and vaginal burning. She is otherwise healthy and had her las period 6 months ago.
What would be your next line of action ?
A. ReferhertoAandE
B. She qualifies for OTC GINA., 6 months’ supply
C. Refer her to another pharmacy as you do not have any stock of GINA currently.
D. Refer her to her GP.
E. Supply for 3 months only
