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2021 BNF > Chapter 7: Genito-urinary system > Flashcards

Chapter 7: Genito-urinary system Flashcards

1
Q

What are the two hormones in combined hormonal contraceptives? What three forms can they come in, can you think of the brand name of any of these?

A

Oestrogen and Progestogen COC pill
e.g. Microgynon (Ethinylestradiol + Levonorgestrel) Cilest (Ethinylestradiol + Norgestimate)
Combined transdermal patch (Evra)
Combined vaginal ring (NuvaRing)

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2
Q

What guidelines should be followed when providing contraception to under 16’s?

A

Fraser Guidelines

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3
Q

IUD’s are less appropriate for women with increased risk of _____?

A

Pelvic Inflammatory Disease (an infection of the upper part of the female reproductive system- uterus, fallopian tubes, and ovaries, and inside of the pelvis) - Not for <25yrs

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4
Q

COC’s reduce the risk of what conditions?

A

PIDOvarian + endometrial cancers (the progestogen reduces endometrial)benign breast disease

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5
Q

What is the difference between monophasic and phasic COC’s?

A

Monophasic contain the same amount of oestrogen and progestogen in each tablet. Most commonly used. Phasic contain different amounts in each tablet- i.e. some of the tablets in the strip may contain 30 mcg of ethinylestradiol and some may contain 40 mcg. These are usually used for those that do not have a withdrawal bleed or have breakthrough bleeds on monophasic.

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6
Q

What oestrogen do the majority of COC’s contain?

A

Ethinylestradiol

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7
Q

COC’s and surgery?

A

Discontinue 4 weeks before major surgery/ leg surgery/ immobilisation Re-start at next period at least 2 weeks after re-mobilised

POP’s aren’t an issue- can keep these going through surgery as no risk of clots with oestrogen-free

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8
Q

Above what BP should the COC be avoided in ?

A

Over 160/ 95 mmHg

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9
Q

What is the mechanism of action of COC’s?

A

Stop follicles (containing an egg) developing in the ovary and prevent ovulation (release of an egg from the follicle to travel down the fallopian tube to the uterus) through suppression of Luteinising hormone and Follicle stimulating hormone.

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10
Q

What is the mechanism of action of POP’s?

A

Alter cervical mucus to prevent sperm penetration (creates a hostile environment)

Some (desogestrel) inhibit ovulation- this has become a much more common MofA rather than just altering mucus

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11
Q

What kind of contraceptive is the contraceptive Injection? What do women need to be warned of with these?

A

Long- acting Progestogen only
Last around 3 months (12 weeks) at a time

Menstrual disturbance- troublesome bleeding reported

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12
Q

How long does the subdermal implant provide contraceptive cover for?

A

up to 3 years Implant should be removed within 3 years of insertion

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13
Q

Two types of Intrauterine devices?

A 
Copper- toxic to sperm
Progestogen only (levonorgestrel releasing- called Intrauterine system)
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14
Q

In terms of cancers, which may the COC protect against, and which may it increase the risk of?

A

Protect against: Ovary and endometrial cancer

Progestogen reduces risk of endometrial

Small increased risk of: Breast and cervical cancer; risk diminishes after 10 years of stopping.

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15
Q

What are some of the side effects of the COC?

A 
Abdominal cramps
Leg cramps
Nausea
breastchanges
depression
hypertension
Headaches
irregular bleeding (NB: does not appear to cause weight gain!)
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16
Q

Other than contraceptive purposes, what can COC’s/ POP’s be used for?

A

Reducing menstrual pain and bleeding- medical terms?ACNE

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17
Q

If a woman has one of the risk factors for VTE/ CV disease (over 35, obese, FH, migraine with aura, heavy smoker) caution is advised. IF a COC is going to be used, what strength?What about if they had 2 or more risk factors?

A

One risk factor- exercise caution, go for lower strength Oestrogen (ethinylestradiol 20 mcg. Usual strength= 30- 35 mcg)2 or more: avoid use of a COC

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18
Q

What is the criteria used to assess whether a woman with pre-existing medical conditions would be suitable for a COC?

A

UKMEC scoring(Medical Eligibility criteria for contraceptive use) Risk benefit analysis for prescribing guidance

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19
Q

What assessments are needed prior to starting a COC/ POP?

A

Relevant HistoryBPBMIFor COC’s- reassess BP after 3 months, then yearly after that

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20
Q

What are the instructions for initiating the COC?

A

Can start it on any day of the cycle

Day 1 = first day of period If starting on day 6 or later- contraceptive precautions needed for 7 days

Same applies if switching from a POP to a COC- use contraceptive precautions for 7 days

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21
Q

Name some Progestogens? Which can be used as Long acting progestogens?

A

Ulipristalacetate

Levonorgestrel

Desogestrel

Norethisterone

LARC’s: Norethisterone Levonorgestrel Medroxyprogesterone Etonogestrel

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22
Q

In terms of cancer risk, what can progestogen only contraceptives do?

A

Small increased risk of breast cancers as with COC’s, diminished after 10 years of use.

Breast cancer is a contra-indication

Small increased risk of cervical cancer with Injectable progestogen use.

Progestogen protects against endometrial cancer

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23
Q

Side effects of POPs?

A

Oral use:NauseaDepressionHeadachesBreast discomfortAppetite disturbanceMenstrual irregularities

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24
Q

What are the instructions for initiating the POP?

A

Start on day 1 of cycle (first day of period), no extra protection needed, as cannot start on any day of cycle like COC’s.

Take continuously- no pill-free interval with POP’s! A new blister is started directly the day after the previous one. Should get no withdrawal bleeds- however women who experience some irregular bleeding should possibly switch to a different method (bleeding irregularity has been reported in up to 50% of women using Cerazette)

After a couple of months of treatment, bleedings tend to become less frequent.

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25
Q

After how many years should copper IUD’s usually be replaced?

A

5 years

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26
Q

What are the different types of Long acting reversible contraception?

A

Intrauterine contraceptive device (IUCD- copper releasing, non-hormonal)

Intrauterine system (IUS Mirena- Levornogestrol releasing)

Injectable Progestogen- oily based, released slowly over 12 weeks (IM injection) or 13 weeks (SC injection)

Sub-dermal progestogenic implant

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27
Q

Which progestogen injection has been associated with a reduction in bone mineral density and therefore increased osteoporosis risk?

A

Medroxyprogesterone

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28
Q

What is the only implant licensed in the UK?

A

Etonogestrel (nexplanon)

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29
Q

What is the main undesirable SE associated with Progestogen only contraceptive use (both POP’s and long acting)?

A

Undesirable/ irregular vaginal bleeding patterns

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30
Q

How is erectile dysfunction treated?

A

With drugs improving the flow of blood to penis Phosphodiesterase type- 5 inhibitors usually used (sildenafil, avanafil, tadalafil)

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31
Q

What drug, used for erectile dysfunction, may result in priapism (prolonged painful erection?)

A

Alprostadil

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32
Q

If men are to get certain erectile dysfunction meds such as sildenafil and tadalafil, on an NHS prescription, because they meet certain criteria, what must be endorsed?

A

SLS

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33
Q

Which erectile dysfunction drugs can also be prescribed for pulmonary arterial hypertension?

A

TadalafilSildenafilThese relax muscles in the blood vessel walls in the lungs, dilating them and reducing BPShould be used under specialist supervision

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34
Q

What are the common side effects of the Phosphodiesterase type- 5 inhibitors (sildenadil, tadalafil, avanafil) used in erectile dysfunction??

A

FlushingBack pain Dyspepsia (heart burn)migraineBlocked noseVISUAL disturbance

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35
Q

What are the risk factors for erectile dysfunction?

A

Similar to those for CV disease:ObesitySedentary lifestyle (blood isn’t flowing much)SmokingHigh cholesterol

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36
Q

What is the new drug used for premature ejaculation?

A

Dapoxetine

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37
Q

What drug can be used to induce labour?

A

Oxytocin

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38
Q

What are Gemeprost, misoprostol and mifepristone used for?

A

Induction of ABORTIONMifepristone can be used to facilitate the process: sensitises the uterus to administration of the abortion drugs Gemeprost and Misoprostol.

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39
Q

What is the treatment for bacterial vaginosis?

A

Metronidazole gelClindamycin cream

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40
Q

We know that clotrimazole cream can be used for fungal vaginal infection (thrush). What is the strength of each formulation used?

A

Internal vaginal cream: Clotrimazole 10% (Canesten internal cream)- insert one applicatorful into the vagina at night- can repeat dose once if needed.External cream, to be applied to ano-genital area 2-3 times a day: Clotrimazole 1% creamCanesten 2% thrush cream

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41
Q

What are the instructions for use of clotrimazole vaginal pessaries for thrush?

A

200mg pessary insert at night for 3 nights (use at night as minimal movement)Recurrent thrush:500mg pessary weekly for 6 months after using clotrimazole cream for 10-14 days

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42
Q

Bar clotrimazole (Canesten), what other topical Imidazole cream can be used for thrush?

A

Ketoconazole cream (Nizoral)Also used for dandruff/ seborrhoiec dermatitis/ Fungal skin condition called pityriasis versicolor as Nizoral shampoo

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43
Q

What class of medications is usually used for treating Urinary frequency/ Urinary Urgency?

A

Antimuscarinics (Anti-cholinergic’s): one of their side effects is urinary retention!Examples:FesoterodineOXYBUTININDarifenacinSOLIFENACIN TolterodineTrospium

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44
Q

What is Beningn prostate Hyperplasia?

A

An enlarged prostate gland. The prostate gland surrounds the urethra, the tube that carries urine from the bladder out of the body. As the prostate gets bigger, it may squeeze or partly block the urethra. This often causes problems with urinating- trouble to start weeingtrouble to stop weeing (dribbling)Weak streamOften feeling you need a wee- gets you up at night

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45
Q

What are the alpha blockers used in BPH, and what do they do?

A

Relax smooth muscle and therefore increase urine flowExamples:DoxazosinAlfuzosinIndoramin Tamsulosin (can get OTC- Flomax)Prazosin

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46
Q

What are Finasteride and Dutasteride used for? What are the associated warnings?

A

Also used for BPH (these are not alpha blockers)WOMEN of child bearing age should not handle crushed or broken tablets.These are excreted in semen therefore used of a condom recommended Cases of Male Breast Cancer reported: males to report any changes in breast tissue: lumps, pain, nipple discharge

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47
Q

What is the extra precaution needed before inserting an intra-uterine device into some women?

A

Risk of infection due to pre-existing STI’s:for women under 25 years, over 25 years with a new partner- perform an STI check before fitting the device Risk of infection occurs in first 20 days after insertion- if woman has sustained pain attend emergency department ASAP as this could indicate Pelvic inflammatory disease

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48
Q

What is the first dose effect associated with the alpha blockers used for BPH?

A

Patients should be advised that their first dose may cause hypotension therefore there is risk of falling. They should take their first dose in bed- lie down if symptoms of sweating and dizziness develop and stay lying down.

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49
Q

What conditions and cancers does HRT increase the risk of?

A

Clots- Venous Thromboembolism (DVT and PE)StrokeBreast cancer- risk disappears within 5 years of stoppingOvarian cancer Endometrial cancerSame as COC’s as it is oestrogen that causes these.HRT containing progestogen (for women with a uterus)provide some protection against endometrial cancer [but still increased risk of breast cancer].

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50
Q

What is the menopause?

A

Where a womans periods cease as her oestrogen levels decline. Results in hot flushes, night sweats, low mood (caused by vasomotor instability). Usually happens 44-55 years of age.Treatment of symptoms usually involves HRT- small doses of oestrogen to soften the blow of the oestrogen decline. Also given progestogens if still has a uterus. Tibolone: a drug that has oestrogenic, progestogenic and weak adrenergic activity used in HRT.

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51
Q

What condition can HRT be used to prevent?

A

OSTEOPOROSIS

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52
Q

How many days are the progestogen tablets used in HRT taken for each cycle? What about the oestrogen tablets? What is the prescription charge for the HRT packs containing oestrogen and progestogen tablets?

A

Progestogen tablets: for 12- 14 days of each cycle for women with a UTERUSOestrogen tablets: taken continuouslyUsually a separate prescription charge for each of the tablets in the pack: e.g. Prempak- C renders 2 prescription charges.

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53
Q

Does HRT provide contraceptive cover, considering it comprises oestrogens and progestogens?

A

NOA woman is still considered fertile for 2 years after her last menstrual period (if under 50- for 1 year if over 50 years). If any potentially fertile women are on HRT, non-hormonal contraceptive measures are advised such as Condoms.

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54
Q

What are the side effects of the alpha blockers used in BPH?

A

Dizziness (Most common) Postural HypotensionBack painBlurred visionDry mouth

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55
Q

How many weeks can Tamsulosin OTC be given for treatment of BPH before clinical assessment by a doctor?

A

Max 6 weeks treatment OTC

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56
Q

What is the treatment for Chlamydia, OTC?

A

Azithromycin1g STAT (2 x 500mg tablets)Need to have tested positive for chlamydiaPartner does not need to be tested to receive dose

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57
Q

What should patients report with treatment with Tamoxifen, a hormone used in treating Breast cancer?

A

Risk of VTE- report to hospital if there is any redness, swelling or pain in the leg.Endometrial changes- report any abnormal vaginal bleeding, vaginal discharge and pelvic pain due to risk of cancer/ polyps

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58
Q

Which oral contraceptives offer everyday dosing- i.e. you don’t need to take a pill free break as there are 7 inactive pills in there so can help with compliance as people don’t have to remember to start a new pack?

A

Zoely: Estradiol and Nomogestrol (oestrogen + progestogen)These are monophasic pills (i.e. the active pills contain the same amount of actives in each tablet)

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59
Q

Which oral contraceptive is a monophonic preparation i.e. each tablet contains a different amount of active so the patient has different levels of hormones throughout the month?

A

Qlaira (estradiol and dienogest)pack also contains 2 inactive pills

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60
Q

How do you manage acute urinary retention?

A

Catheterisation (alpha blocker such as tamsulosin, doxazosin should be given at least 2 days beforehand)

61
Q

What is the pharmacological management of chronic urinary retention in men?

A

An alpha-adrenoceptor blocker (alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride or terazosin). Treatment should initially be reviewed after 4–6 weeks and then every 6–12 months.

62
Q

What is the pharmacological treatment for benign prostate hyperplasia and raised PSA and high risk of progression eg elderly?

A

5a-reductase inhibitor - finasteride, dutasterideThis can be combined with an alpha blocker if symptoms remain an issue

63
Q

What can be used for the pharmacological management of urinary incontinence?

A

OxybutininTolterodineFesoterodineSolifenacin succinateMirabegron - only if antimuscarinics ineffective/not suitable

64
Q

What is the suggested duration of treatment for an uncomplicated lower UTI in men and women?

A

7 days for men3 for women

65
Q

What 3 antibiotics can be used for long term low dose lower UTI prophylaxis?

A

TrimethoprimNitrofurantoinCefalexin

66
Q

What antibiotics should be used for management of upper UTIs (acute pyelonephritis)?How long should the treatment be?

A

IV Broad spectrum antibiotic e.g. cephalosporin, quinoloneOr IV gent if severely ill10-14 days

67
Q

What would be the most appropriate antibiotic classes for a pregnant lady with a UTI?

A

Penicillins or cephalosporins

68
Q

If non drug treatment is unsuccessful (e.g. using an alarm, fluid intake) in children who have nocturnal enuresis, what would be the pharmacological management?

A

Oral desmopressin if > 5 years For children under 5 years, this should resolve spontaneously

69
Q

When starting alpha blockers for urinary retention/benign prostate hyperplasia, when should the first dose be taken and why?

A

At bedtime ideally as can cause hypotension and possibly a collapse

70
Q

What is the MHRA warning regarding the use of finasteride?

A

Rare reports of depression and suicidal thoughts

71
Q

What is used for the alkalinisation of urine?

A

Potassium citrateSodium bicarbonate

72
Q

If a patient requires major elective surgery and is on an oestrogen-containing contraceptive, how is this managed?

A

Should be stopped 4 weeks before if it means the surgery will result in prolonged immobilisation of lower limbsShould be restarted at the first menses occurring at least 2 weeks after full mobilisation A progesterone only contraceptive may be provided as an alternative

73
Q

Before surgery, if an oestrogen-containing contraceptive cannot be stopped beforehand, what is recommended?

A

Thromboprophylaxis

74
Q

What would be the reasons to immediately stop combined hormonal contraceptives or HRT?

A
  • Sudden severe chest pain (even if not radiating to left arm)- Sudden breathlessness (or cough with blood-stained sputum)-Unexplained swelling or severe pain in calf of one leg;severe stomach pain- Serious neurological effects including unusual severe, prolonged headache- Hepatitis, jaundice, liver enlargement- Blood pressure above systolic 160 mmHg or diastolic 95 mmHg; (in adolescents stop if blood pressure very high)- Prolonged immobility after surgery or leg injury
75
Q

What is an associated risk of the IUD in women under 25 years?

A

Increased risk of pelvic inflammatory diseaseCopper has higher risk over the progesterone only IUD

76
Q

Other than patient choice, in what groups of patients would you consider the progesterone only pill over the combined hormonal contraceptive?

A

When oestrogens are contra-indicated (including those with history of VTE, heavy smokers, those with hypertension above systolic 160 mmHg or diastolic 95 mmHg, valvular heart disease, diabetes mellitus with complications, and migraine with aura)

77
Q

Intravesical is administration into where?

A

Bladder

78
Q

Combined oral contraceptives reduce the risk of what types of cancer?

A

Ovarian and endometrial cancer

79
Q

It is recommended that combined oral contraceptives are not continued beyond what age?

A

50 years as there are more suitable alternatives

80
Q

Low strength preparations of combined contraceptive pill contain how much ethinylestradiol?When would you use this?

A

20 micrograms If risk factors for circulatory disease are present

81
Q

Standard strength preparations of combined contraceptive pill contain how much ethinylestradiol?

A

30 or 35 micrograms

82
Q

Phased preparations of the combined contraceptive pill is appropriate for what individuals?

A

Who either do not have withdrawal bleeding or who have breakthrough bleeding with monophasic products

83
Q

Can progesterone only contraceptives be used during surgery?

A

Yes

84
Q

Women taking oral contraceptives are at an increased risk of deep vein thrombosis during long periods of travel over how many hours?

A

Over 3 hours

85
Q

At what part of the cycle can you start combined oral contraceptive?When would you need to have additional barrier method and for how long for?

A

If reasonably certain woman is not pregnant, first course can be started on any day of cycleIf starting on day 6 of cycle or later, additional precautions (barrier methods) necessary during first 7 days.

86
Q

If a patient is on combined oral contraception and is changing to another combined oral contraception containing a different progesterone, how is this done?

A

If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start the first active tablet of new brand immediatelyMay need additional precautions but depends on specific preparations

87
Q

If a patient is on a progesterone only tablet and is changing to a combined oral contraception, how is this does and are additional precautions needed?

A

If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start new brand immediately, additional precautions (barrier methods) necessary for first 7 days.

88
Q

If a patient wishes to start combined oral contraception after childbirth (not breastfeeding), how is this done?When would additional precautions be needed?

A

Start 3 weeks after birth (increased risk of thrombosis if started earlier); later than 3 weeks postpartum additional precautions (barrier methods) necessary for first 7 days (9 days for Qlaira®).

89
Q

What is the risk of starting combined oral contraception before the recommended 3 weeks postpartum?

A

Increased risk of thrombosis

90
Q

If a patient has had an abortion or miscarriage, when can they start combined oral contraception if they want to?

A

Start same day

91
Q

What is the advice surrounding a patient being started on combined oral contraception if breastfeeding?

A

Avoid until weaning Or Avoid for 6 months after birth (adverse effects on lactation).

92
Q

What are the 6 risk factors for VTE for combined oral contraception?How many risk factors would deem the patient unsuitable for combined oral contraception?

A
  1. Family history of venous thromboembolism in first-degree relative aged under 45 years 2. Obesity; body mass index ≥ 30 kg/m2 (avoid if body mass index ≥ 35 kg/m2 unless no suitable alternative)3. Long-term immobilisation e.g. in a wheelchair, leg in plaster 4. History of superficial thrombophlebitis5. Age over 35 years (avoid if over 50 years)6. Smoking.Use with caution if any of following factors present but avoid if two or more factors present
93
Q

What are the 7 risk factors for arterial disease for combined oral contraception?How many risk factors would deem the patient unsuitable for combined oral contraception?

A
  1. Family history of arterial disease in first degree relative aged under 45 years2. Diabetes mellitus (avoid if diabetes complications present)3. Hypertension4. Smoking (avoid if smoking 40 or more cigarettes daily)5. Age over 35 years (avoid if over 50 years)6. Obesity (avoid if body mass index ≥ 35 kg/m2 unless no suitable alternative)7. Migraine without aura - avoid if with aura
94
Q

At what blood pressure would you avoid initiating combined oral contraceptives in?

A

Above systolic 160 mmHg or diastolic 95 mmHg

95
Q

You would avoid initiating combined oral contraceptives in patients smoking how many cigarettes a day?

A

40

96
Q

What is the patient advice surrounding combined oral contraceptives and headaches?

A

Women should report any increase in headache frequency or onset of focal symptoms (discontinue immediately)

97
Q

Combined oral contraceptives increase the risk of what types of cancer?

A

Breast and cervical

98
Q

What is the patient advice surrounding combined oral contraceptives and vomiting/diarrhoea?When is it advised to take additional precautions?

A

If vomiting occurs within 2 hours of taking a combined oral contraceptive another pill should be taken as soon as possibleIn cases of persistent vomiting or severe diarrhoea lasting more than 24 hours, additional precautions should be used during and for 7 days after recovery

99
Q

Patient taking combined oral contraceptives:If vomiting and diarrhoea occurs during the last 7 tablets, what is the advice?

A

The next pill-free interval should be omitted (in the case of ED tablets the inactive ones should be omitted).

100
Q

Combined oral contraception:A missed pill is one that is more than how many hours late?

A

24 hours

101
Q

If a woman forgets to take one dose of her combined oral contraceptive pill, what is the advice?

A

If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at the normal time (even if this means taking 2 pills together).

102
Q

If a woman misses 2 or more oral combined contraceptive pills, what is the advice?

A

If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking. In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or, in the case of everyday (ED) pills, omitting the 7 inactive tablets).

103
Q

In patients taking oral combined contraceptives, when would EHC be recommended?

A

Emergency contraception is recommended if 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a packet and unprotected intercourse has occurred since finishing the last packet.

104
Q

What is the MHRA warning with IUD contraception?

A

Uterine perforation most often occurs during insertion, but might not be detected until sometime laterSigns and symptoms include:- Severe pelvic pain after insertion (worse than period cramps)- Pain or increased bleeding after insertion which continues for more than a few weeks- Sudden changes in periods;pain during intercourse-Unable to feel the threads

105
Q

The main risk of infection with copper IUD occurs within the first how many days after insertion?

A

Within 20 daysBut believed to be linked with STIs

106
Q

What does the BNF say about the progesterone only pill and risk of breast cancer?

A

The risk of breast cancer in users of POCs is possibly of similar magnitude as that associated with COCs, however the evidence is less conclusive.

107
Q

What antidepressant can be used for moderate to severe stress incontinence in women?

A

Duloxetine

108
Q

What is a common electrolyte disturbance side effect of desmopressin?

A

Hyponatraemia (and associated convulsions)

109
Q

What is the patient advice for desmopressin if taking for primary nocturnal enuresis?

A

To reduce the risk of Hyponatraemia (and associated convulsions):Should be warned to avoid fluid overload (including during swimming) and to stop taking desmopressin during an episode of vomiting or diarrhoea (until fluid balance normal).Should not have anything to drink for 1 hour before they take desmopressin, and then for 8 hours after they have taken it.

110
Q

What is the patient advice needed with tamsulosin?

A

May affect performance of skilled tasks e.g. driving.

111
Q

What is the patient counselling with finasteride?

A

Rare cases of male breast cancer- report any lumps, nipple discharge

112
Q

What is the contraception advice with finasteride?

A

Use condoms as it is excreted in semenWomen of child-bearing potential should avoid handling crushed tablets

113
Q

The combined contraceptive pill is not for women above what age?

A

50

114
Q

At what point of the menstrual cycle should you start the progesterone only pill? If this is not possible, how many days of additional precaution do you need?

A

Start on Day 1If started after day 5, additional precaution is needed for 2 days

115
Q

After how many hours is classed as a missed pill for progesterone only?What is the exception?How many days will you will you need additional precaution?

A

3 hours Desogestrel - 12 hours 2 days of additional precaution needed

116
Q

When would you need EHC if taking the progesterone only pill?

A

If you miss a dose and unprotected sex occurs before 2 pills are taken correctly

117
Q

What is the advice around the progesterone only pill ad vomiting?

A

If you vomit within 2 hours of taking the pill, take another one ASAPIf you have been unable to take the pill within 3 hours of normal time (12 hours for desogestrel) then additional protection is needed until 2 days after

118
Q

True or false:It is not advised to remove an IUD mid cycle

A

TRUE

119
Q

What is the MHRA advice with contraceptive implants?

A

Implants may reach the lung via the pulmonary artery

120
Q

What is the pharmacological management of benign prostate hyperplasia?

A

Alpha blocker eg tamsulosin

121
Q

What is doxazosin used for?

A

Hypertension or benign prostate hyperplasia

122
Q

What are drugs that can induce hepatic enzyme activity? CENOPPPRSTRR

A

CarbamazepineEslicarbazepineNevirapineOxcarbazepinePhenytoinPhenobarbital PrimidoneRitonavir St John’s WortTopiramateRifabutinRifampacin (possibly also griseofulvin)

123
Q

Women using combined hormonal contraceptive patches, vaginal rings or oral tablets who require enzyme-inducing drugs or griseofulvin should be advised to change to a reliable contraceptive method that is not affected by enzyme-inducers such as:

A
  1. Parenteral progestogen-only contraceptives (medroxyprogesterone acetate and norethisterone) 2. Intra-uterine devices (levonorgestrel).
124
Q

Women using combined hormonal contraceptive patches, vaginal rings or oral tablets who require enzyme-inducing drugs or griseofulvin should be advised to change to a reliable contraceptive method that is unaffected by enzyme-inducers, such as some parenteral progestogen-only contraceptives (medroxyprogesterone acetate and norethisterone) or intra-uterine devices (levonorgestrel; see also Contraceptives, non-hormonal). This should be continued for how long?

A

The duration of treatment and for four weeks after stopping.

125
Q

What are the parenteral progestogen-only contraceptives which are not impacted by enzyme-inducers?

A

Medroxyprogesterone acetate and norethisterone.

126
Q

For a short course (2 months or less) of an enyme-inducing drug, contraception can be managed how?

A

Continuing the combined hormonal contraceptive method may be appropriate if used in combination with consistent and careful use of condoms for the duration of treatment and for four weeks after stopping the enzyme-inducing drug.

127
Q

For long-term course (over 2 months) of an enzyme-inducing drug (except rifampicin or rifabutin) or a course of griseofulvin, how should contraception be managed?

A
  1. Use of monophasic combined oral contraceptive at a dose of ethinylestradiol 50micrograms or more daily [unlicensed use] and use either an extended or a ‘tricycling’ regimen (taking three packets of monophasic tablets without a break followed by a shortened tablet-free interval of four days [unlicensed use]; continue for the duration of treatment with the interacting drug and for four weeks after stopping.
128
Q

What is the minimum dose of ethinylestradiol recommended for contraceptives in patients taking enzyme-inducing drugs?

A

At least 50microgram ethinylestradiol daily.

129
Q

What is ‘tricycling’?

A

Taking three packets of monophasic tablets without a break followed by a shortened tablet-free interval of four days (unlicensed).

130
Q

For how long after treatment cessation of an enzyme-inducing drug should extra precautions be used?

A

four weeks.

131
Q

If breakthrough bleeding occurs with use of ethinylestradiol (minimum 50mcg) daily and an enzyme-inducing drug, what is recommeneded?

A

The dose of ethinylestradiol should be increased by increments of 10micrograms up to a maximum of 70micrograms daily on specialist advice, or to use additional precautions, or to change to a method unaffected by the interacting drugs.

132
Q

What are the two most potent enzyme-inducing drugs, for which an alternative method of contraception (such as an IUD) is always recommended?

A

Rifampicin and rifabutin. Rifampacin: TB, leprosy and legionnaire’s disease. Rifabutin: TB, prevent and treat Mycobacterium avium complex. Alternative to rifampicin in people with HIV/AIDs on antiretrovirals.

133
Q

Is the effectiveness of the etonorgestrel-releasing implant impacted by enzyme-inducing drugs?

A

Yes

134
Q

What options are there for EHC in people taking enzyme-inducing drugs?

A

Effectiveness of levonorgestrel and ulipristal acetate is reduced in women taking enzyme-inducing drugs or griseofulvin.A copper intra-uterine device can be offered instead. If copper intra-uterine device is declined or unsuitable, the dose of levonorgestrel should be increased.

135
Q

Regular hormonal contraception should not be newly initiated in a patient until how many days after administration of ulipristal acetate as emergency hormonal contraception?

A

At least 5 days, can cause reduced effectivness of ulipristal acetate.

136
Q

Which type of EHC can be used more than once in the same cycle?For the one that cant, why is this?

A

Ulipristal acetate can be used as EHC more than once. The manufacturer advises that the use of levonorgestrel as EHC more than once in the same cycle is not advisable due to increased risk of side-effects.

137
Q

Levonorgestrel should not be used as emergency hormonal contraceptive within how many days of administration of Ulipristal acetate (as emergency hormonal contraception), the contraceptive effect of ulipristal acetate may be reduced by progestogens.

A

5

138
Q

Ulpristal acetate is not recommended for use in women who have severe asthma treated with what?Why?

A

Ulipristal acetate is not recommend for use in women who have severe asthma treated by oral corticosteroids, due to the antiglucocorticoid effect of ulipristal acetate.

139
Q

Which SNRI is licensed for moderate to severe stress urinary incontinence?

A

Duloxetine

140
Q

What are darifenacin and solifenacin?

A

some of the newer antimuscarinic drugs licensed for urinary frequency, urgency and incontinence

141
Q

What is oxybutinin?

A

antimuscarinic drug that also has a relaxant effect on smooth muscle. Has many antimuscarinic side effects that limit use and consequently newer ones are taking over

142
Q

A lot of the drugs used for urinary problems are antimuscarinic. what are the antimuscarinic side effects?

A

Constipationdry mouthskin drynessurinary retentionskin flushing pupil dilation

143
Q

What is tolerodine?

A

Another antimuscarinic used in this condition

144
Q

What are Flavoxate and Trospium

A

More antimuscarinics- some of the newer ones

145
Q

Is there any bloody drugs in this condition that aren’t antimuscarinic?!

A

Mirabegron!A selective beta 3 agonist

146
Q

What is first line treatment for nocturnal eneuresis (bed wetting) in children?

A

An enuresis alarm- an alarm that goes off as soon as the child wets the bed as it detects moisture- the child gradually learns to wake before the alarm and gets to toilet on time.Desmopressin is used if the alarm fails for child over 5 years!!

147
Q

what is Fesoteradine

A

another antimuscarinic used in this for frequency/ urgency/ incontinence

148
Q

What do we need to warn drivers taking Tamsulosin?

A

may effect driving and performance of skilled tasks- extra warning label

2021 BNF (19 decks)

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