Chen's Women's Health Lectures Flashcards
Contraindications of Estrogen
- undiagnosed abnormal vaginal bleeding
- DVT or PE
- Active history of STOKRE or MI
- Breast cancer
- Hypercoaguable disorder
- pregnancy
Therapeutic Uses of Estrogen
- Breast cancer palliation (aka ok to use estrogen in breast cancer if tumor is not estrogen based)
- Uremic Bleeding
- Prevent postmenopasual osteoporosis
- Menopause (vasomotor sx)
- Vulvar and vaginal atrophy
- female hypogonadism
- Ovarian failure
- abnormal uterine bleeding
- contraception
Therapeutic Uses of Progestin
- long term prevention of pregnancy
- treatment of heavy menstrual bleeding
- emergency contraception
- amenorrhea
- endometriosis
Menopause:
no period for _____ months and will have elevated _____ levels
12; FSH
Premature menopause occurs before age _____
40
Things that can cause premature menopause
- hysterectomy
- radiation therapy
- chemotherapy
Worst symptoms of menopause occur during the first ____ years
1 -2
How does smoking affect Menopause
smoking decreases estrogen levels —- can cause early menopause
What are menopausal symptoms
- Vasomotor Sx
- Irregular Menses
- Episodic Amennorrhea
- Sleep disturbances
- Mood changes
- Genitourinary Syndrome of menopause
Long Term Consequences of Menopause
- CV disease
- Bone loss
- Osteoarthritis
- Body composition
- Skin changes
- Balance
3 Main Kinds of MHT (Menopausal Hormonal Therapy)
- Estrogen only
- Estrogen and progestin
- SERM (estrogen and selective-estrogen receptor modulator)
3 ways to treat Menopausal Symptoms
Non-pharmacologic
Hormonal Replacement
Non-Hormonal
3 ways to treat Menopausal Symptoms
Non-pharmacologic
Hormonal Replacement
Non-Hormonal
what are the indications for menopausal hormone therapy
- vasomotor symptoms
- Vulvovaginal atrophy
- Osteoporosis prevention
what are absolute contraindications for menopausal hormone therapy
- unexplained vaginal bleeding
- pregnancy
- estrogen-dependent malignancies (endometrial or breast cancer)
- Stroke
- Active thromboembolic disorders
- Active liver disease
What type of women CAN use estrogen monotherapy
women without a uterus
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Premarin
ORAL
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Estrace
oral
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Estrogel
topical gel
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Divigel
topical gel
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Elestrin
topical gel
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Estring
ring
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Femring
ring…
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Vagifem
Vaginal Tablet
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Menostar
transdermal
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Alora
Transdermal
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Climara
transdermal
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Minivelle
transdermal
What type of product is it?
(oral, topical gel, ring, vaginal tablet, transdermal, or topical spray)
Vivelle-Dot
transdermal
If a woman is experiencing vulvovaginal atrophy - what product is appropiate
topical vaginal products
Non-pharmacologic things to do for menopause
- stop smoking
- avoid hot drinks, tea, soup
- avoid alcohol
- dress in layers to keep cool
Explain the Womens Health initiative study
- compared estrogen vs estrogen and progesterone vs placebo - made it look like the hormone caused more issues long term —-but more data analysis showed that if therapy initiated within 10 years of menopause start
Recommended Treatment Duration for Estrogen/Progestin therapy (for menoapause)
3 - 5 years
Recommended Treatment Duration for Estrogen therapy (for menoapause)
up to 7 years
What drug class(es) can be used for Hot flashes in menopause
SSRIs/SNRIs
What are alternative options for Vasomotor Symptoms
- Phytoestrogens (plant estrogen)
- Black Cohosh (not recommended)
- Dong Quai (not recommended)
- Gabapentin/Pregabalin
- Clonidine
Treatment Algorithm of Menopause: Combines _________ and _________
- 10 year CVD risk scores
- years since menopause onset
Women in menopause have low or high levels of FSH? and WHY
HIGH! because no estrogen being produced leads to the hypothalamus trying to make more — leads to more FSH being produced
what critical factors were used to evaluate the Womens Health Initiative that lead to them discovering that there can be reduced risk for CHD
- age of initiation
- time since menopause
Current Recommendations for Menopausal Hormone Therapy:
Treatment should start and be limited to women that are under age _______ OR within the last _____ years of the last period
60; 10
What are the 4 types of methods of administration of combined estrogen and progesterone for menopause treatment?
- continuous cyclic
- continuous long cycle
- continuous combined
- intermittent combined
How does Continuous Cyclic Therapy of Estrogen/Progesterone work? (Used in Menopause treatment)
Estrogen DAILY
Progesterone given for ~ 12 - 14 days per a 28 day cycle
- just like a period… draw side is that its like a period - have the withdrawal bleeding
What is the associated risk continuous cyclic therapy that was pointed out?
2 fold increase risk in endometrial cancer after 6 - 10 years
How does Continuous LONG CYCLE Therapy of Estrogen/Progesterone work? (Used in Menopause treatment)
Estrogen DAILY
Progesterone give w/ estrogen ~ 12 - 14 days EVERY OTHER MONTH!
(Causes periods for only 6 months per year)
How does Continuous Combined Therapy of Estrogen/Progesterone work? (Used in Menopause treatment)
Estrogen and Progesterone DAILY
Estrogen and Progesterone Therapy in Menopause:
- which type of administration results in ENDOMETRIAL ATROPHY and ABSCENCE of VAGINAL BLEEDING
Estrogen/Progesterone TOGETHER EVERYDAY aka continuous combined
Estrogen and Progesterone Therapy in Menopause:
- which type of administration has a decreased risk for endometrial cancer
Estrogen/Progesterone TOGETHER EVERYDAY aka continuous combined
What are the 3 oral options for Estrogen and Progesterone drug therapy for menopause
- Prempro
- Angeliq
- Activella
What are the 2 transdermal options for Estrogen and Progesterone drug therapy for menopause
- Climarapro
- Combipatch
What is the idea behind using intermittent combined therapy for menopause
estrogen for 3 days then estrogen and progesterone for 3 days
(Do this so that the progesterone receptors are NOT DOWNREGULATED)
what drug is used for intermittent combined therapy for menopause
prefest
what drug is a estrogen and SERM combo?
Duavee
What is the SERM component name in the drug Duavee?
bazedoxifene
SERM agents are NON-HORMONAL and have agonist activity at the _____
bone
SERM agents are NON-HORMONAL and have antagonist activity at the _____ and _____
breast; uterus
SERM agents decrease or increase the risk for endometrial cancer
DECREASE!
First line treatment for Genitourinary Syndrome in Menopause
- NON HORMONAL (Lubricants/ vaginal Mositurizers)
Second line treatment for Genitourinary Syndrome in Menopause
Estrogen based prodcuts (topical or low dose oral contraceptives)
What topical estrogen products can be used for Genitourinary Syndrome in Menopause
Ring, Cream, Tablet
Estrogen products that are given vaginally - do they need a progesterone “counterpart” for offering endometrial protection
Nope! - low dose and not a lot of systemic exposure means that progestin is not needed
what is Ospemifene (osphena)? and it is used to treat what?
it is a SERM product used for treating moderate to sever Dyspareunia
3 main questions you should ask yourself when creating a treatment plan for managing menopausal symptoms?
- Location of symptoms (vasomotor or genitourinary)
- Any contraindications?
- Does the pt have an intact uterus
Types of Primary Osteoporosis
Type 1,2, and 3
what is type 1 primary osteoporosis
postmenopausal
what is type 2 primary osteoporosis
age-related
what is type 3 primary osteoporosis
idopathic, juvenille, adult
What are some medical conditions that cause secondary osteoporosis
alcoholism, cushing’s syndrome, eating disorders, GI disorders, Hyperparathyroidis, skeletal cancer
What are the medications that can cause osteoporosis
- Glucocorticoids
- anticonvulsants
- medroxyprogesterone
- proton-pump inhibitors
- aromatase inhibitors
- gonadotropin releasing hormone agonists
- immunosupressants
- warfarin
- lithium
- heparin
- thyroid supplements
- vitamin A supplements
- Thiazolidinedione
- SSRIs
- cytotoxic drugs
- Canagliflozin
How to be diagnosed with Osteoporosis
- Atraumatic fracture of spine, femur, or distal radius
- WHO bone mineral density interperation by Dual-Energy X-Ray
how many stages of labor
3
what is stage 1 of labor
going towards full cervical dilation
what is stage 2 of labor
time from full dilation to deliver
what is stage 3 of labor
time from delivery of infant to delivery of placenta
Oxytocin is used in labor what in what stages?
2 and 3!
3 categories of Labor Dystocia
- power (contractions not good, mom having hard time pushing)
- passenger (size of position of fetus)
- passage (bone or tissue in the way of the baby)
what kind of labor dystocia is it ok to use oxytocin
power issue (get them contractions going)
options for Labor dystocia
- C-section
- IV oxytocin
how to be diagnoes with labor dystocia
below or minimal normal rate of change or descent in labor
what are the contraindications for inducing labor
- placenta previa (placenta covering cervix)
- sideway positioned fetus
- previous c -section
- prior uterine incision
- umbilical cord prolapse (cord hanging out of cervix)
- prior uterine rupture
Oxytocin is given IV with ____ or ____
NS or LR
Oxytocin can cause (hypo or hyper) tension and uterine (hypo or hyper) stimulation
HYPOtension; HYPER stimulation
max dose of oxytocin -
40 milliunits/min
Adverse effects of oxytocin
- too many contractions (> 5 contractions in 10 minutes) this is called TACHYSYSTOLE
- hyponatremia (why best to give with NS)
- Hypotension
- Hyperbillirubinemia (in infants)
Oxytocin is the first line agent for uterine atony to prevent _______
excessive blood loss (aka postpartum hemorrhage)
If the fetus dies inside the mother and oxytocin is needed for medical termination… is the dose higher or lower than oxytocin used in labor
the dose is higher
Hallmark symptoms of Diabetes Insipidus
- polyuria (pee a lot)
- polydipsia (super thirsty)
- Dehyradtion
Diabetes Insipidus is characterized by excretion of abnormally large volumes of ______ urine
dilute;
Diabetes Insipidus is characterized by more than \_\_\_\_ L/m^2 of urine per 24 hours OR > \_\_\_\_ mL/kg per 24 hours (adults)
2; 40
what are the different types of Diabetes Insipidus
- Central
- Nephrogenic
- Primary Polydipsia
What is the explanation behind central diabetes insipidus
deficiency of vasopressin secretion; (hypothalamus neurons or destroyed or degenerated)
What is the explanation behind nephrogenic diabetes insipidus
renal resistance to vasopressin action
body still makes vasopressin but kidney doesn’t know what to do with it
What are different causes of nephrogenic diabetes insipidus
- LITHIUM
- Hypercalcemia
- hypokalemia
- pregnancy
What is the explanation behind primary polydipsia
excessive fluid intake will suppress vasopression secretion (no hormone or receptor defect is present)
Different ways to diagnose Diabetes insipidus
- 24 hour urine volume
- Lab tests (electrolytes, kidney, plasma or urine osmolality)
- water deprivation test
- aquaporin2 abnormalities
Osmolality Changes in Diabetes Insipidus:
PLASMA Osmolality: would be _______ mOSM
> 300 ( v concentrated plasma bc water is being lost)
Osmolality Changes in Diabetes Insipidus:
URINE Osmolality: would be _______ mOSM
< 200 (v small because urine is so dilute..)
Osmolality Changes in Diabetes Insipidus:
Urine specific gravity will (decrease or increase)
decrease - because means v dilute
what is normal plasma osmolality levels
280 - 295 mOSM
Non-Pharm treatments for Diabetes Insipidus
- Remove underlying cause
- LOW SOLUTE DIET (low protein and sodium)
Non-Pharm treatments for Diabetes Insipidus:
limit sodium to < ____ g/day
2.3
Non-Pharm treatments for Diabetes Insipidus
limit protein to < ___ g/kg/day
1
What drugs can be used for Central Diabetes Insipidus
- Chlorpropamide
- Carbamazepine
- (Hydro)Chlorothiazide
- Indomethacin
- Desmopressin
what are the ADEs of Desmopressin
Dose Related - Nausea; HA, Flushing
- Hypertension/hypotension, tachycardia, palpitations
- Hyponatremia/Seizure
Pharmacologic Treatment for Nephrogenic Diabetes Insipidus
- correct undelrying cause (like drug related)
- salt restriction - and thiazide diuretic
- indomethacin
- Amiloride ( a potassium sparing diuretic and hydrochlorothiazide)
Infertility: inability to become pregnant after _____ months
12
what are some factors that can lead to female infertility
- cervical factors
- uterine factors
- tubal/peritoneal factors
- ovulatory factors
what are some non-pharmacologic ways to help with infertility
- weight adjustment (if BMI to low probably are not ovulating, or too high of BMI causes issues (insulin resistance)
- avoid smoking, alcohol, caffeine, illicit drugs
- Reduce stress
- “expectant management”
Expectant Management ideas: Want to confirm evidence of ovulation when infertile - good to increase chances of pregnancy - \_\_\_\_\_\_\_\_\_ kits - timed \_\_\_\_\_\_ - change in \_\_\_\_\_\_\_\_
urine ovulation predictor; intercourse; cervical mucus
Timed Intercourse “facts”
- sperm lives for _____ days after ejaculation
- egg lifespan is _____ hours after ovulation
1 -2 (up to 5)
12 - 24
Expectant Management:
Change in cervical mucus
Normal mucus acts as _______ but during ovulation the is ________ so that sperm can pass through
a protective barrier; clear/slippery/stretchy
Pharmacologic Treatment Options for infertility:
- Controlled _________
- _________ w/ or w/o IUI
- Assisted Reproductive Techniques
- ovarian hyperstimulation
- Gonadotropins
Types of assisted Reproductive techniques
- IUI
- IVF
- ICSI
Drugs that are used for controlled ovarian hyperstimulaiton
- Clomid
- Aromatase inhibitors
what aromatase inhibitor drugs are used for controlled ovarian hypertstimulaton
letrozole
anastrozole
Drug therapy for infertility:
what is used to develop multiple follicles by increasing FSH
Gonadotropins (FSH and LH or either alone)
Drug therapy for infertility:
what is used to trigger ovulation
hCG
hCG is typically used in infertility after use of ___________
gonadotropins, aromatase inhibitors, or clomiphene
the TIMING of what drug in infertility treatment is very important
hCG
Complications of infertility treatment
- OHSS (ovarian hyperstimulation syndrome)
- Risk of female cancers
- Multiple births
Symptoms of PCOS
- hyperandrogenism (acne, hirsutism, alopecia)
- Menstrual disturbances (no period or irregular period)
- (possibly) Obesity
What are the 3 possible mechanisms for PCOS
- inappropriate gonadotropin secretion
- insulin resistance w/ hyperinsulinemia
- excessive androgen production
PCOS Mechanism:
If there is an increase in GnRH :
a ________ never develops because it causes a pulse frequency of _____ too soon
dominant follicle; LH
PCOS Mechanism:
Too much GnRH - which phase never occurs? Follicular or Luteal
Luteal
PCOS - at higher risk of _________ cancer because ________
endometrial; no shedding of lining
Hyper________ is a major contributor to hyper_________ in PCOS
insulinemia; androgenism;
PCOS:
If insulin resistance is in fat or muscle - the body compensates this by making more insulin (because the body thinks it needs it)
- the ovary reacts to extra insulin how?
ovary has increased insulin senstivity in the ovarian andrgoenic pathway and will make more androgens! (aka hyperandrogenism)
How does insulin resistance affect the liver ?
in the LIVER:
Insulin will inhibit SHBG (sex hormone binding globulin) SHBG normally binds testosterone therefore more insulin = LESS TESTOSTERONE bound to SHBG = MORE FREE TESTOSTERONE
PCOS Diagnosis Criteria
Need 2 out of the 3
- Chronic Anovulation
- Polycystic ovaries
- Hyperandrogenism
PCOS Cause:
Hypersecretion of ______ and ______ will increase androgen production
LH; insulin
PCOS Complications:
- INFERTILITY (bc no ovulation)
- CV disease/ T2DM/HTN/Dyslipidemia
- endometrial hyperplasia and cancer
- depression/anxiety
- obstructive sleep apnea
- pregnancy complications
Treatment goals for PCOS
- maintain normal endometrium
- block actions of androgens on target tissues
- reduce insulin resistance and hyperinsulinemia
- reduce weight
- prevent long-term complications
- ovulation induction
What are the 3 things that need to be thought about for PCOS treatment decisions
- patient priorities
- efficacy vs risks of treatment
- desire to become pregnant
Non-Pharmacological treatments for PCOS
- Weight loss (can decrease free testosterone and reduces miscarriage)
- Exercise can prevent the development of metabolic syndrome
Pharmacologic Treatment for PCOS:
what is 1st line treatment for menstrual irregularity
COC (combined oral contraceptive)
Pharmacologic Treatment for PCOS: what is 1st line for hirsutism
COC (combined oral contraceptive)
Pharmacologic Treatment for PCOS: what is first line for acne
COC (combined oral contraceptive)
Pharmacologic Treatment for PCOS:
why is estrogen in COC helpful
estrogen levels will suppress LH –> decrease ovarian andgroen production
Pharmacologic Treatment for PCOS:
What are the two options for Anti-Androgen Therapy
- Spironolactone
- 5a-reductase inhibitors (finasteride, dutasteride)
Pharmacologic Treatment for PCOS
Spironolactone blocks _______ effects at the follicle
androgenic
Pharmacologic Treatment for PCOS:
Monitor for _____ when pt takes sprionolactone
K+
Pharmacologic Treatment for PCOS:
what are the adverse effects of spironolactone
- vaginal bleeding
- breast tenderness
- HA
- dizziness
Pharmacologic Treatment for PCOS
Spironolactone and Pregnancy - safe or not safe?
NOT SAFE! category c for pregnancy - MUST USE RELIABLE FOR OF CONTRACEPTION
Pharmacologic Treatment for PCOS:
what should be used if COC and spironolactone are not helping with hirsutism?
finasteride
dutasteride
Side effects of 5areductase inhibitors
orthostasis; HA
Pharmacologic Treatment for PCOS
Taking a 5a reductase inhibitor - safe with pregnancy or nah?
No! - must use reliable form of contraception
Pharmacologic Treatment for PCOS
Insulin Sensitizer - what is the drug option?
metformin
When is metformin seen as 1st line treatment?
if PCOS pt has glucose abnormalities too and failed lifestyle modifications
metformin: may take up to _______ to see an effect for fixing menstrual irregularity
6months
when is metformin seen as second line treatment
for menstrual irregularity
For Treating Insulin Resistance in PCOS:
what is first and second line treatment
1st- lifestyle modification
2nd- metformin
For Treating Mesntrual Irregularity in PCOS:
what is first and second line treatment
1st- COC
2nd - Metformin
For Treating Hyperandrogenism in PCOS:
what is 1st, 2nd, 3rd, and last line treatment
1 - COC
2 - Antiandrogens (spironolactone, dutasteride, finasteride)
3 - topical Vaniqa (for facial hair only)
4 - cosmetic procedures (bleach, plucking, waxing, shaving, laser)
Clomid for PCOS - how does it work/what is it used for
it is used for Anovulation/infertility in PCOS; it works by telling the body it is low on estrogen (when it is not) therefore more GnRH –> more LH, FSH occurs - this will cause ovulation
Do NOT use Clomid for more than _______ (how long…)
6 months
Start Clomid for Anovulation infertility when? (in relation to cycle)
Fay 2 - 5 after menses
Max dose for Clomid
100 mg/day
Monitor Parameters for Clomid
- OHSS (ovarian hyperstimluation syndrome)
Risks: Kidney failure, thrombosis; stroke
Signs and Symptoms for OHSS (ovarian hyperstimulation syndrome)
- enlarged ovaries
- ascites
- abdominal pain
- hydrothorax
- decreased urine output
- HYPERCOAGULABILITY (clot risk)
What aromatase inhibitor is a possibility for treating PCOS/Anovulation Infertility
- letrozole
how does letrozole work to help with anovulation infertility
it will inhibit estrogen from being made –> hypothalamus is like “woah lets make LH and FSH” will cause ovulation
currently is clomid or letrozole “better”
- which one has less side effects/potenitally better outcomes
Letrozole
how long can someone use letrozole for anovulation infertility
up to 5 cycles
1st/2nd/3rd line treatment for (PCOS induced) Anovulation?
1 - Clomiphene; Letrozole
2 - Clomiphene + metformin OR low dose gonadotropin therapy OR laparoscopic ovarian drilling
3 - IVF
WHO DEXA Diagnostic Criteria for Osteoporosis:
t score for a NORMAL diagnosis
> 0 -> -1 SD
WHO DEXA Diagnostic Criteria for Osteoporosis:
t score for osteopenia
-1.1 -> - 2.4 SD
WHO DEXA Diagnostic Criteria for Osteoporosis:
t score for Osteoporosis
< - 2.5 SD
WHO DEXA Diagnostic Criteria for Osteoporosis:
t score and criteria for SEVERE osteoporosis
< - 2.5 SD AND more than 1 fragility fracture
