Exam 3 Flashcards
Most common cause of UTI
E. Coli
Staph Saprophyticus 5-20%
Uncomplicated UTI
Pre-menopausal, sexually active, non-pregnant women
Complicated UTI
Men, postmenopausal, pregnant women, urinary structural defects, neurologic lesions, catheter use, symptoms >7 days
How many days of UTI treatment
1-3 days of antibiotics usually enough
Urinary analgesics
Methenamine, phenazopyridine, flavoxate
Treats urgency, burning, frequency, discomfort; acts as local anesthetic of urinary tract; discolors urine
Should not be used for more than 2 days
First line antibiotics for UTI
Bactrim
Nitrofurantoin (7 day course for uncomplicated UTI only)
Fofomycin (one time drug)
Fluoroquinolones (given for pyelonephritis, not uncomplicated UTI)
Second line antibiotics for UTI
Fluoroquinolones and fosfomycin for recurrent cystitis
-Reserved for complicated UTI and pyelonephritis
Antibiotics for UTI safe for pregnancy
amoxicillin, cephalexin, nitrofurantoin (1st and 2nd trimesters only)
Geriatrics treatment for UTI
Nitrofurantoin CI after 65
Educate about precipitating factors
Treat for 7-10 days in women and 10-14 days in men
Prophylactic UTI treatment
For patients with 3+ UTI’s
Lifestyle changes
CAM for UTI
Cranberry acidifies the urine
Probiotics
Categories of prostatitis
1: acute bacterial prostatitis
2: chronic bacterial prostatitis
3: chronic nonbacterial prostatitis and pelvic pain syndrome
4: asymptomatic inflammatory prostatitis
Main organisms for acute bacterial prostatitis
E Coli and pseudomonas
S/S prostatitis
Pain in lower abdomen, difficulty with bladder emptying, small stream, nocturia, fever, painful ejaculation, pain in rectal or perineal area
Antibiotics for prostatitis
Coverage of G-
Usually treat for 4-6 weeks or up to 12 weeks
Fluoroquinolones have best tissue penetration
Bactrim has less penetration and high resistance
Must monitor creatinine clearance
2nd line therapy for prostatitis
Doxycycline, azithromycin, clarithromycin for 4-6 weeks
BPH may be due to
Higher amounts of estrogen within the gland which increases activity of substances that promotes cell growth
Increased smooth muscle tone in lower urinary tract due to stimulation of cell receptors–increased urethral resistance and outlet obstruction
Main classes of drugs for BPH
Alpha 1 blockers, 5 alpha reductase inhibitors, PDE type 5 inhibitor
alpha 1 blockers for BPH
-Zosin
relaxes smooth muscle of prostate and bladder neck without interfering with bladder contractility
Relaxes sympathetic tone
May take months for effects
SE: hypotension, fluid retention, fatigue
Take at night
Tamsulosin highly selective with less side effects
5 alpha reductase inhibitors
Fibasteride + Dutasteride
Decreases levels of intracellular DHT without reducing testosterone levels
Decreases size of prostate
SE: decreased libido, impotence, gynecomastia, may falsify levels of PSA
Category X (can’t even touch)
1st line for BPH
Watchful waiting if low questionnaire, limit fluids, avoid decongestants, massage prostate, void frequently
2nd line for BPH
Alpha blocker if score >7
5 alpha reductase inhibitor
If history of hypertension, use alpha blocker
3rd line for BPH
Combination of alpha blocker and 5 alpha reductase inhibitor
CAM for BPH
Saw Palmetto, pygeum, Zinc
Primary treatment for BPH
Surgery
Treatment initiated when symptoms become problematic
Sequence for erection to occur
Nerve impulses in the brain, spinal column and area around the penis + response in muscles, fibrous tissues, veins, arteries near corpora cavernosa
Release of NO following PANS essential for erection–> smooth muscle relaxation that promotes inflow of blood
Drugs that can affect erectile dysfunction
Alcohol, analgesics, anticholinergics, anticonvulsants, antidepressants, antihistamines, antihypertensives, corticosteroids, diuretics, nicotine, tranquilizers
phosphodiesterase 5 inhibitors
Sildenafil, tadalafil, vardenafil
30-120 minutes for response
Inhibits breakdown of one of messengers required for erection
CI: nitrates, unstable angina, systolic BP<90, uncontrolled HTN, recent stroke, arrhythmias, cardiac impairment, renal disease, alpha blockers, recent MI
SE: headache, flushing, nasal congestion, dyspesia
Avoid with high fat meals
1st line tx for ED
Lifestyle changes
PDE5 inhibitor
If no response, refer to urologist
Follow up after 6 months
CAM for ED
Yohimbine
Overactive bladder
Ach mediated activation of muscarinic receptors is predominant mediator in detrusor contraction–primarily M3 receptor
Behavioral therapy
Bladder training, pelvic floor muscle exercises, weight loss
Anticholinergics for OAB
Oxybutynin, tolterodine, trospium, solifenacin, fesoterodine
Blockade of muscarinic actions–inhibits action of ACh on bladder smooth muscle
Increases bladder capacity, decreases intensity/frequency of bladder contractions, delay initial urge to void
Can cross BBB
Time frame of response 2 weeks
CI: urinary retention, narrow angle glaucoma, severe renal impairment
SE: constipation, urinary retention, xerostomia
Estrogen for OAB
Improves tone and elasticity of female urogenital anatomy by increasing secretion of cervical mucosa, thickening of vaginal mucosa and proliferation of endometrium
Beta adrenoreceptor agonist for OAB
Mirabegron
Selective B3 agonist
Increases bladder capacity and decreases frequency of urination without impacting urine pressure or residual volume
B3->NE–>Increased cAMP–>smooth muscle relaxation–> increased storage
Botox for OAB
Reserved for patients who have failed other treatments
Injected into detrusor muscle
Inhibits Ca dependent release of ACh, ATP and substance P; desensitizes motor neurons, decreases M1, M2 and M3
UTI common SE
SNRI for OAB
Venlafaxine + Duloxetine
Antidiuretic drugs for OAB
Desmopressin
Can inhibit diuresis without impacting blood pressure
CI: hyponatremia, renal impairment
SE: Water retention
1st line tx for OAB
Anticholinergic Oxybutynin + behavioral modifications
Mirabegron can be considered
2nd line tx for OAB
Try different anticholinergic
Duloxetine
Estrogen
3rd line tx for OAB
Botox or surgery
CAM for OAB
Saw palmetto extract
Beta adrenoreceptor agonist for OAB
Mirabegron
Selective B3 agonist
Increases bladder capacity and decreases frequency of urination without impacting urine pressure or residual volume
B3->NE–>Increased cAMP–>smooth muscle relaxation–> increased storage
Botox for OAB
Reserved for patients who have failed other treatments
Injected into detrusor muscle
Inhibits Ca dependent release of ACh, ATP and substance P; desensitizes motor neurons, decreases M1, M2 and M3
UTI common SE
SNRI for OAB
Venlafaxine + Duloxetine
Antidiuretic drugs for OAB
Desmopressin
Can inhibit diuresis without impacting blood pressure
CI: hyponatremia, renal impairment
SE: Water retention
1st line tx for OAB
Anticholinergic Oxybutynin + behavioral modifications
Mirabegron can be considered
2nd line tx for OAB
Try different anticholinergic
Duloxetine
Estrogen
3rd line tx for OAB
Botox or surgery
CAM for OAB
Saw palmetto extract
Drugs that worsen OAB
Sedatives and hypnotics, phenothiazines, alpha blockers, caffeine
Most prevalent STI in the US
Chlamydia
S/S chlamydia
Vaginal discharge, mucopurulent cervicitis with edema and friability, urethritis, PID, ectopic pregnancy, infertility, endometriosis
1st line therapy for chlamydia
Azithromycin 1 dose DOC
Doxycycline–less expensive
Fluoroquinolone–Ofloxacin
2nd line tx for OA
NSAIDs
Ointment for newborns in eyes
Erythromycin opthalmic ointment
1st line tx for syphilis
Penicillin G IM 1 dose
if allergic, desensitize patient
Can try doxycyline if CI penicillin
Most common pathogens for PID
N. Gonorrhoeae and C. trachomatis
Tx for PID
Same as chlamydia/gonorrhea (Azithromycin + Ceftriaxone)
Drug therapy for genital warts
Podofilox + Podophyllin Resin (self applied gel, apply weekly, wash after 1-4 hours)
Imiquimod (self applied cream, apply 3x a week, leave for 6-10 hours)
Trichloroacetic acid + Bichloroacetic acid (applied by professional, left to air dry)
Joints commonly affected by OA
Knees, hips, cervical/lumbar spine, distal interphalangeal joints and carpometacarpal joint
1st line tx for OA
Acetaminophen
2nd line tx for OA
NSAIDs
Diflunisal
Non-acetylates salicylates
Beneficial in patients sensitive to GI irritation caused by aspirin use
Can be used for OA
Capsalcin
Topical agent
Decreases substance P (usually responsible for pain transmission)
Can be used for OA
Steroids for OA
Indicated if 1-2 joint involvement and has not responded to 1st or 2nd line treatment
Tramadol
Mu opioid receptor agonist similar to other opioids such as morphine; ascending pain pathways are inhibited
Do not exceed 400mg a day
Response in 1-2 hours
CI: opioid dependency, acute intoxication of alcohol, hypnotics, psychotropics
SE: nausea, dizziness, sweating, drowsiness, constipation, respiratory depression
Xanthine oxidase inhibitors
Allopurinol + Febuxostat
Decreases uric acid levels by selectively inhibiting xanthine oxidase–primarily responsible for converting xanthine into uric acid
Probenecid
Increases excretion of serum uric acid by inhibiting reabsorption of uric acid at proximal tubule
Used if XOI is CI or not tolerated
Pegloticase
Last line therapy for gout
Very expensive IV drug
Acute gout treatment
Rest joint, ice, short course of NSAIDs, steroids or colchicine
Colchicine
Inhibits activation, degranulation and migration of neutrophils to area of gout attack
Take within 24 hours of attack
MOA of acetaminophen
Inhibits central COX, which results in decreased prostaglandin synthesis; has analgesic and antipyretic effects but not anti-inflammatory effects
Take around the clock for OA pain management; maximum of 4000mg per day
Pain relief within 1 week
SE: dizziness, rash, hepatic failure
Interactions: warfarin, isoniazid
NSAIDs
Indicated for OA, RA, mild to moderate pain
Inhibits COX
Anti-inflammatory–inhibits production of prostaglandins, prostacyclin and thromboxane in both CNS and PNS (Blocks COX enzyme)
Analgesic + antiplatelet (reduces production of TXA)
Do not take with aspirin or ACEI
SE: increased mucosal damage, less vasodilation, decreased blood flow to kidneys
Biologic disease modifying antirheumatic drugs
Tumor necrosis factor inhibitors Etanercept, -mab Bind the circulating TNF alpha and render it inactive, which decreases the chemotactic effect All are injectables Rapid response CI: infections, activation of latent TB Do not use with abatacept
Diclofenac MOA
Same as NSAID
Has less side effects due to being topical
Do not apply to damaged or non-intact skin
SE: rash, dry skin, itching, exfoliation
Sulfasalazine for RA
Anti-inflammatory effect
CI: sulfa allergy, pregnancy and lactation
SE: nausea, diarrhea, dizziness, intestinal and urinary obstruction, orange yellow skin, HA, depression, bone marrow suppression
S/S RA
Morning stiffness in involved joints persisting for at least 1 hour and subsides with activity; painful, swollen joints
NSAID for RA
Continued from initial diagnosis to initiation of DMARD
Steroids for RA
Higher doses are beneficial in acute flares to regain control of inflammation of pain
DMARDs
Methotrexate, sulfasalazine, hydroxychloroquine, Leflunomide
Should be initiated within 3 months of symptoms
1st line therapy for RA
Methotrexate or leflunomide monotherapy
Sulfasalazine for poor prognostic factors
Hydroxychloroquine
TNF alpha inhibitors + methotrexate for high disease activity
Biologic disease modifying antirheumatic drugs
Tumor necrosis factor inhibitors
Etanercept, -mab
Bind the circulating TNF alpha and render it inactive, which decreases the chemotactic effect
COX2 inhibitors
Celebrex
Can be used if patient is a risk factor for GI complications
Less likely to cause ulcers and bleeding
Sulfasalazine
Anti-inflammatory effect
CI: sulfa allergy, pregnancy and lactation
SE: nausea, diarrhea, dizziness, intestinal and urinary obstruction, orange yellow skin, HA, depression, bone marrow suppression
Antimalarials for RA
Hydroxychloroquine
Low risk of SE, does not lower progression of RA
Inhibits antigen processing by elevating cellular pH
CI: pre-existing retinal field changes
SE: nausea, diarrhea, abdominal discomfort, photosensitivity, skin pigment changes, damage to retina
Interactions: beta blockers, cyclosporine, digoxin
Pregnancy category C
Lelfunomide
Anti inflammatory and anti proliferative, retarding erosions and joint space narrowing
Decreases B cell and T cell proliferation
Similar to methotrexate
CI: pregnancy (Wait 2 yearS), hepatotoxicity, alcoholism, liver disease
SE: elevated LFT, GI symptoms, weight loss, alopecia, bone marrow suppression
May increase warfarin
Abatacept
Decrease activation of T cells; Given IV, infusion or subcu
SE: COPD exacerbations
Interactions: live vaccines and TNF inhibitors
Tocilizumab
Blocks IL6, decreases B cell and T cell activity
Given IV
SE: increased LDL and liver enzymes
Interactions: live vaccines, leflunomide, TNF alpha inhibitors
1st line therapy for RA
Methotrexate or leflunomide monotherapy
Sulfasalazine for poor prognostic factors
Hydroxychloroquine
TNF alpha inhibitors + methotrexate for high disease activity
Only DMARDs ok to use during pregnancy
Antimalarials, sulfasalazine, azathioprine, cyclosporine
Indicators of reduced disease activity
Decreased ESR and C reactive protein, absence of joint erosions on US or MRI of the joint
Medications for fibromyalgia
TCAs, SSRI, new generation anticonvulsant, cyclobenazprine, NSAID
Lab monitoring for sulfasalazine
CBC, LFT, UA, renal function
Lab monitoring for methotrexate
CBC, creatinine, LFT, alkaline phosphatase, chest x ray, hepatitis B + C
Tension headache prophylaxis
Antidepressants (tca), fluoxetine, venalaxafine
Elderly patient teeatment for long term management of moderate to severe OA
COX 2 inhibitor–celebrex
39 year old female with primary dysmenorrhea
NSAID for 2-3 days
57 year old with DM and HTN
Aspirin
Dx for fibromyalgia
Pain on palpation in at least 11/18 tender points
Medications for fibromyalgia
TCAs, SSRI, new generation anticonvulsant, cyclobenazprine, NSAID
Tension headaches
Dull quality, pain radiates bilaterally from forehead to the occiput in band like fashion; radiates down neck and sometimes into trapezius muscle
Important not to overtreat
Drugs for tension headache
Acetaminophen, aspirin, NSAID, antiemetics, excedrine
Tension headache prophylaxis
Antidepressants (tca)
1st line for tension headache
Acetaminophen, aspirin
2nd line for tension headache
NSAIDs and excedrine
Prophylaxis for migraines
1st line: beta blockers, calcium channel blockers, TCAs
2nd line: SSRI, anticonvulsants
Antiemetics
Promethazine + Prochlorperazine
Can increase pain relieving properties of analgesics by decreasing gastric emptying and increasing analgesic absorption
Migraine
Neurologic syndrome causes throbbing head pain and nausea, appetite change, phototobia, phenophobia
1st line agent for migraines
NSAIDs and aspirin
5-HT1 receptor agonists for migraines
-triptans
Causes cerebral vasoconstriction and can treat both pain and nausea of migraine
Ergot derivatives for migraines
Constriction of peripheral and cranial vessels
Used to treat infrequent, long standing migraines in patients who have had multiple relapses with triptans
Not used usually due to unpredictable patient responses and increased SE
Opioids for migraines
Used as rescue medication for severe migraines that do not respond to other medications
Do not use routinely
Steroids for migraines
Can be used as rescue medication until patient free for 24 hours
2nd line therapy
OTC caffeine containing compounds
Ergot derivative + antiemetic
Floricet
Butalbital-Acetaminophen-Caffeine
Do not use more than 3 days; sedating; potentially habit forming
1st line therapy for absence seizures
Ethosuximide, valproic acid, lamotrigine
Steroids for headaches
Controls or prevents inflammation by controlling rate of protein synthesis
Used for severe or persistent headaches
Pregnancy classes for headache medications
B: Cyproheptadine
C: triptans
X: ergotamines
Prophylaxis for headaches in children
Amitryptilline, topiramate, divalproex, propranolol
CAM for headaches
feverfew, butterbur, magnesium, CoQ10
1st line therapy for partial seizures
Carbamazepine, phenytoin, fosphenytoin, valproic acid, lamotrigine, lacosamide, topiramate, oxcarbazepine
1st line therapy for generalized tonic clonic seizures
Carbamazepine, lacosamide, phenytoin, valproic acid, fosphenytoin
1st line therapy for absence seizures
Ethosuximide, valproic acid, lamotrigine
Hydriantoins
phenytoin + fosphenytoin
Blocks post tetanic potentiation by stabilizing neuronal membranes; decreased seizure by increasing efflux and decreasing influx of Na; alters Ca uptake in presynpatic terminals
SE: gingival hyperplasia, hirsutism, rash, nystagmus, confusion, peripheral neuropathy, vitamin D deficiency, anemia, thrombocytopenia
Carbamazepine
limits influx of Na ions across cell membrane
CI: allergy to TCA, bone marrow suppression, use of MAOI
Oxycarbazepine
Blocks Na channels
Valproic Acid
Works by affecting GABA
CI: severe hepatic disease
Anti-epileptics and birth control pills
Decreases effectiveness
Barbiturates
Broad spectrum antiepileptic activity
Sedating with long term cognitive, memory and behavioral effects
Binds to GABA A
Status epilepticus tx
Benzodiazepines first line
IV preferred, but IM, rectal or intranasal options
When can you think about d/c seizure medications
If patient has been seizure free >2 years
Monitoring for anti-seizure medications
Therapeutic range annually, hepatic enzymes annually
Prevention of febrile seizures in children
Phenobarbital
Anti-epileptics for pregnancy
All are category X
Anti-epileptics and birth control pulls
Decreases effectiveness
Pathophysiology of ADHD
Decreased volume and functionality in prefrontal cortex, caudate and cerebellum
Regulated by dopamine and NE
1st line therapy for ADHD
Stimulants
2nd line therapy for ADHD
Non stimulants
3rd line therapy for ADHD
Bupropion
Stimulants for ADHD
Methylphenidate + Amphetamine
Inhibit reuptake of dopamine and NE
Amphetamines also directly stimulate release of dopamine and NE
Usually see response in 1-2 days
SE: sleep disturbance, decreased appetite, weight loss, agitation, nervousness
Nonstimulants for ADHD
Atomexetin, guanfacine, clonidine, bupropion
Used only if patients have CI to stimulant
Memantine
NMDA antagonist for AD
Treatment of cognitive symptoms
Focuses on glutamatergic symptoms rather than ACh
Blocks excitotoxicity effects associated with abnormal transmission of glutamate
Inhibits neuronal degeneration due to increased glutamate
Antipsychotics for AD
For non-cognitive symptoms–psychosis, anxiety, depression, sleep disorders
Atypical antipsychotics preferred
Haloperidol has fewest SE
Benzodiazepines for AD
Lorazepam + Alprazolam
For treatment of behavioral problems
Reserved for treatment of anxiety or episodic agitation
Long term use not recommended–may worsen AD symptoms
Stimulant with best efficacy for ADHD
Methylphenidate
long acting increases compliance
CAM for ADHD
Gingko biloba and glutamine–can improve concentration and alertness
Alzheimer Disease
ACh levels are decreased + excessive stimulation of glutamate
Memory loss and cognitive impairment is associated with decreased levels of ACh
Cholinesterase inhibitors for AD
Donepezil, Rivastigmine, Galantamine
Treatment of cognitive symptoms
No longer recommended if patient is in severe stage
SE: N/V, diarrhea, bradycardia, increased GI acid, increased secretions
Memantine
NMDA antagonist for AD
Treatment of cognitive symptoms
Focuses on glutamatergic symptoms rather than ACh
Inhibits neuronal degeneration due to increased glutamate
Antipsychotics for AD
For non-cognitive symptoms–psychosis, anxiety, depression, sleep disorders
Atypical antipsychotics preferred
Benzodiazepines for AD
Lorazepam + Alprazolam
For treatment of behavioral problems
Reserved for treatment of anxiety or episodic agitation
Long term use not recommended–may worsen AD symptoms
Antidepressants for AD
Sertraline + Citalopram first line
1st line therapy for AD
Cholinesterase inhibitors–Donepezil particularly
Memantine + cholinesterase inhibitors for severe AD
Medications that can protect against AD
NSAIDs, COX inhibitors, estrogen replacement
Statins in AD
Linked to preserving cognitive function
Anticholinergics for PD
Trihexyphenidyl + Benztropine
Useful for treatment of drooling and tremor
May cause impaired memory, hallucinations, blurry vision, dry mouth, urinary retention, constipation
What medications can induce PD symptoms
Atypical antipsychotics and neuroleptic drugs
Parkinson Disease
Symptoms due to decreased dopamine; leads to breakdown of communication to motor regulators in the brain
Hallmark signs of parkinson disease
Bradykinesia, resting tremor, cogwheel rigidity, difficulty maintaining balance
Mild potency drugs for PD
Anticholinergics, amantadine, MAO-B inhibitors
Moderate potency drugs for PD
Dopamine agonists
Pathophysiology of menstrual cycle
FSH stimulates conversion of androgens to estrogen–> development of dominant follicle that further produces estrogen–> stimulates development of glandular epithelium of uterus–>increases cervical mucus–> decreases viscosity of mucus–> increases vaginal pH
Anticholinergics for PD
Trihexyphenidyl + Benztropine
Useful for treatment of drooling and tremor
May cause impaired memory, hallucinations, blurry vision, dry mouth, urinary retention, constipation
Amantadine for PD
May inhibit NMDA receptor
Used for patients experiencing dyskinesia
MAO-B inhibitors for PD
Selegiline + Rasagiline
Modest improvement in motor symptoms
Inhibits metabolism of dopamine
Dopamine agonists for PD
Less effective than levodopa but causes dyskinesia and motor fluctuations less frequently
Preferred choice–Pramipexole, Ropinirole, Rotigotine
Stimulation of D2 receptors results in improved dopaminergic transmission in motor area of basal ganglia
SE: fatigue, nausea, constipation, hypotension, hallucinations
Levodopa
Most effective for tx of symptomatic relief of PD
Fastest onset of action
May experience wearing off after few hours
Can cross BBB to be converted to dopamine
Administered with carbidopa to limit peripheral breakdown
Catechol-o-methyltransferase Inhibitors
Entacapone + Tolcapone
Used in combination with levodopa to decrease wearing off but they can increase risk of dyskinesia
Inhibits breakdown of levodopa in periphery
Used in adjunct with carbidopa + levodopa
Combined OC decreases risks of
Endometriosis, ovulatory pain, ovarian cysts, benign breast disease, PMS, premenstrual dysphoric disorder, ovarian, endometrial cancer
Estrogen–suppression of FSH
Progestin–Suppression of LH
Lifespan of egg
1-3 days
Nuvaring
15mcg ethinyl estradiol + 120mcg etonogestrel
Removed for 4th week
Periodic abstinence for birth control
4th day of sticky, wet mucus
Combined birth control pill
Estrogen (ethinyl estradiol) + Progestin (desogestrel, ethynodiol diacetate, levonorgestrel, norethindrone, norgestimate, norgestrel)
Works by preventing ovulation by suppressing FSH + LH
IUD
Causes sterile inflammatory reaction within uterus that interferes with sperm transport,
Thickens cervical mucus, suppresses ovarian function, thins uterine lining
Can decrease bleeding
Combined OC decreases risks of
Endometriosis, ovulatory pain, ovarian cysts, benign breast disease, PMS, premenstrual dysphoric disorder, ovarian, endometrial cancer
Emergency contraception
High dose progestin
Used for prevention of pregnancy up to 5 days after intercourse
MOA: delays ovulation, alteration of endometrium, interference of fertilized egg, interference with tubal transport of sperm/egg
SE: N/V, fatigue, breast tenderness, HA, abdominal pain, dizziness
Nuvaring
15mcg ethinyl estradiol + 120mcg etonogestrel
Removed for 4th week
Progestin only hormonal contraceptives
Does not suppress LH + FSH; primary effect is through changing endometrial and cervical mucus environments
Oral, IM, Subdermal
IM Depo
Decreases ovulation and effects cervical mucus
Given every 13 weeks
Safe for women with CV disease
More prolonged bleeding possible
IUD
Causes sterile inflammatory reaction within uterus that interferes with sperm transport
Can decrease bleeding
Implant
Nexplanon–contains etonogestril
Blocks LH surge and prevents ovulation and thickens cervical mucus and thins endometrial lining
Progestin only OC good for
Women unable to tolerate estrogen, smokers, women over 35, lactating women
If taken pill more than 3 hours late
Use back up for 7 days
Depo prevera may cause
Osteoporosis
Recommend regular exercise, calcium, vitamin D
Can be given for breastfeeding women
IUD good for women with history of
Dysmenorrhea, menorrhagia, anemia
CI for OC
Hypersensitivity, thrombophlebitis, thromboembolic conditions, DVT, CVA, MI, CAD, breast CA, endometrial CA, hepatic CA, liver disease, abnormal genital bleeding, pregnancy, jaundice of pregnancy
Warnings for OC
Smoking, thromboembolism signs, CVD, ocular lesions
Why does menopause occur
Due to failure of ovary to produce estrogen
Risk factors for early menopause
History of irregular menses, African American, smoking, weight loss diets
Ospemifene
Estrogen agonist/antagonist
Indicated mostly for treatment of genitourinary symptoms
Acts as agonist at receptors in vaginal tissue and antagonist in breast tissue and endometrial tissue
Tissue selective estrogen complex
CEE + bazedoxifene
Indicated for moderate to severe VMS
Hormone therapy for menopause
Estrogen + Progestin
Decreases night sweats, insomnia, hot flashes
Estrogen therapy can cause
Increased endometrial hyperplasia and increased risk of endometrial CA
Progestin therapy may cause
Breast CA
SE progestin
Bloating, irritability, weight gain, HA, acne
Paroxetine
Treatment of VMS
Preoptic area of anterior hypothalamus, responsible for temperature regulation, is under influence of 5HT and NE
SE of estrogen therapy
HA, depression, gallbladder disease, N/V, breast tenderness, breast CA, breakthrough bleeding, CVA
May increase levels of corticosteroids
MOA of progestin therapy
Decreases risk of estrogen induced irregular bleeding, endometrial hyperplasia, carcinoma
SE progestin
Bloating, irritability, weight gain, HA, acne
SE testosterone
Hepatocellular neoplasma, edema, possible elevation of cholesterol
Absolute CI for menopausal hormonal therapy
Breast CA, endometrial CA, genital bleeding, liver disease, thromboembolic diseases, pregnancy
CAM for menopause
Black Cohosh, St Johns Wort, Soy, Remifemen
Follow up with menopause treatment
2 months after starting therapy and then 6 months and then annually
Monitoring for menopause therapy
BP, mammogram, vaginal bleeding, height for osteoporosis, weight for obesity, pap test
Menopause cause of osteoporosis
Decreased estrogen levels cause up regulation of RANKL–increases osteoclast activity
Prevention of osteoporosis
Ca supplements (1200-1500mg/day), Vitamin D (800-1000IU/day)
Biphosphanates
-dronate
Inhibits bone resorption and increases bone density
Bone turnover increases to previous levels after 6-9 months
Take on empty stomach with 8oz water, stay in upright position 30 mins after administration
SE: esophageal ulcers, acid reflux, nausea; injectable can cause flu like symptoms
May increase risk of jaw bone destruction and atypical femur fractures
CI: esophageal problems, gastritis, PUD
Calcitonin
Inhibits action of osteoclasts
Available as injection and nasal spray
Decreased risk of vertebral compression fractures
SE: rhinitis (inspect nasal mucosa every 6 months), GI upset, flushing, rash, back pain
Raloxifene
Selective estrogen receptor modulators
Decreases bone resorption
Decreased risk of vertebral fractures but not hip fractures
Mimics effects of estrogen on bones but not breasts/uterus
Also decreases TC and LDL levels
CI: pregnancy, lactation, history of clots
D/C 72 hours prior to prolonged immobilization
SE: hot flashes, GI distress, flu like symptoms, leg cramps, DVT, arthralgias
Follow up for osteoporosis
DEXA every 2 years; follow up at 1-2 months when initiating treatment then every 3-6 months
Denosumab
RANK ligand inhibitor
Decreases osteoclast activity
1st line therapy for osteoporosis
Raloxifene or biphosphanates for prevention
Biphosphanates for treatment
Ca and Vit D supplement
2nd line therapy for osteoporosis
Calcitonin, teriparatide, denosumab
Most common cause of vaginitis
vulvovaginal candidiasis, bacterial vaginosis, trichomonas vaginalis
S/S vaginitis
vaginal/perineal itching, burning, vulvar irritation, abnormal discharge
Bacterial vaginosis
Due to hydrogen peroxide producing lactobacillus normally present in the vagina being diminished; allows other bacteria to proliferate
Bacteria responsible for BV
Gardnerella vaginalis, preotella, mobiluncus, mycoplasma hominis
Medication for vaginitis
Topical azoles
Oral azoles
Antibiotics–Metronidazole, topical clindamycin
Topical azoles for vaginitis
Time frame for response: 3 days
SE: local irritation, abdominal cramps, headache
Interactions: may weaken latex condoms and diaphragms
Oral azoles for vaginitis
Fluconazole
CI: hypersensitivity
Time frame for response: 2-3 days
SE: headache, nausea, abdominal pain
SE + interactions metronidazole
metallic taste, headache, GI distress
Do not consume alcohol during treatment and up to 24 hours after treatment stops
Interactions: anticoagulants
Medication for yeast infections
OTC: clotrimazole + miconazlee creams
Oral fluconazole rx
S/S BV
grayish, sometimes frothy, fishy discharge
Tx for trichomonas
Metronidazole, avoid sex, treat sex partners
2nd line: tindazoel
S/S trichomonas
pruritus, malodorous frothy/yellow-green discharge, diffuse vaginal erythema, red macular lesions on cervix
Metronidazole and pregnancy
CI
CAM for vaginitis
probiotics
