Exam III - Lorinda Flashcards
What are the contraindications for HRT?
Severe liver dysfunction Acute vascular disease Hyper-coagulability Severely elevated TGL Abnormal vaginal bleeding Any history of current breast cancer
General conclusions from the WHI study:
Pretty safe for perimenopausal women to use HRT
Increased risks for older ages
Stroke and breast cancer risk are still increased
Overall reduced death in younger ages with those taking HRT
What HRT contains peanut oil?
Micronized progesterone
What HRT has an FDA warning about keeping away from children?
Evamist - 17B Estradiol spray
What vaginal ring gives you systemic coverage? Non-systemic coverage?
Estring is 17B estradiol = non-systemic
Femring is estradiol acetate = systemic
What estrogen product do you have to rub for three minutes into the thigh?
Estrasorb topical gel
One pouch per thigh
What SERM can be used for painful sexual intercourse but has a SE of hot flashes?
Ospemifene
What SERM + estrogen complex can be used to treat hot flashes or osteoporosis.
Bazedoxifene/Estrogen
What non-hormonal options are there for perimenopause?
Megastrol Venlafaxine SSRI's (Fluoxetine, Paroxetine, Citalopram) Clonidine Gabapentin
Risk factors for PCOS
Obesity DM Sporatic periods premature adrenarche/delayed menarche Family history Anti-epileptic drugs (valproate esp)
PCOS symptoms
Hyperandrogenism Menstrual irregularities Obesity Insulin resistance Acanthosis nigricans
What is the risk associated with developing diabetes if you have PCOS?
2-5x more likely
PCOS criteria:
NIH
Rotterdam
Adrogen Excess Society
NIH - Hyperandrogenism, oligo or a-ovulation
Rotterdam - 2/3 requirements
Adrogen Excess Society - hyperandrogegism and one more
Longterm risks of PCOS
Hypertension Dyslipidemia Infertility Sleep apnea Endometrial hyperplasia and caner
PCOS treatment
First line: non-pharm (spearmint tea, shaving/waxing, vaniqa cream)
Second line: Treat to goal
- Infertility: clomiphene, metformin, gonadotropins, ovarian drilling, aromatase inhibitors
- Androgen symptoms (no pregnancy): combined oral contraceptives and metformin, spironolactone (monitor potassium)
When should you take clomiphene if you are trying to get pregnant?
Take for 5 days starting on the 5th day of the cycle
Do not use for more than 6 cycles (increases ovarian cancer risk)
What could you use if you are trying to get pregnant but don’t want cancer side effects?
Aromatase inhibitor like Letrozole
Take on days 3-7 of cycle
Similar efficacy to clomiphene
What is dexamethasone used for in conjunction with clomiphene?
Use on days 3-12 to increase ovulation rate to 75% from 15%, and pregnancy to 40% from 5%.
How is endometriosis diagnosed?
Only with surgery, where a camera is used laparoscopically.
What are some of the signs of endometriosis?
Infertility (if endometrial tissues grows in the ovaries)
Gi complications like constipation
Menorrhagia and anemia
What are treatments for endometriosis?
Treat pain with COC (continues use), GnRH agonist, Levonogestrel IUD.
Treat infertility with GnRH analogs and antagonists, surgery, IVF.
How do you differentiate PMS from PMDD?
They both include a set of symptoms that appear cyclically before menses and disappear. When work or lifestyle is affected, then it progresses to PMDD.
How do you diagnose PMDD?
They need at least 5 symptoms from the PMS symptom list, including one that has to do with mood, anger, anxiety, or tension. These symptoms have to be affecting the work or lifestyle of the woman.
What do the guidelines say for treating PMS/PMDD?
- Lifestyle changes (1200mg calcium, vit B6, stress reduction and management, exercise)
- SSRI’s (fluoxetine, sertraline) - luteal phase
- OC’s (may increase symptoms)
- GnRH agonists - Leuprolide
Spironolactone 25mg TID x10 days prior to menses for bloating
What folic acid dose is recommended?
400mcg/day
What percent of women experience unintended pregnancy in their lifetime?
48%
What are the contraceptive choices available?
Permanent LARCs COC Other hormonal methods Barrier Other
What is the only thing that is used for STD prevention?
Condoms
What would you talk about when assisting in choosing a contraceptive method for someone?
Most effective options first If they want to have children Medical history/age Patient's preference of options Lifestyle/risk of STDs Ability to pay Partner support
What contraceptive method is first line now?
LARCs
What did the Contraceptive Choice Project in St. Louis find?
That LARCs were preferred and the most effective for preventing pregnancy if the access to care was provided for. There was a reduction in abortions and teenage births. Save $17 for every $ spent. And these are spendy devices.
What is in the implant?
Etonogestrel
Effective for 3 years
SE irregular periods, but sometimes no periods
Use backup for 48 hours afterward
CI with breast cancer, cirrhosis, undiagnosed vaginal bleeding
What are the levonorgestrel choices for IUDs?
Skyla
Mirena
Liletta
PID risk
What is the mechanism for a copper IUD?
ParaGard Spermacide EC SE Increased bleeding and cramping. Benefits = non-hormonal No concerns of breast cancer CI - cervical or uterine cancer, recent endoetriosis
Go to the doctor if you experience these with an IUD:
PAINS
Period late/abnormal bleeding Abdominal pain/pain with intercourse Infection exposure/abnormal discharge Not feeling well, fever, chills String missing, shorter or longer
What are the benefits of COC therapy?
Decreased: ovarian cancer endometrial cancer colon cancer ectopic pregnancy anemia benign breast disease
Increased:
Possibly bone density
What type of COC can we use continuously?
monophasic
Who is the progestin only pill indicated for?
Breastfeeding women
What is the normal starting dose of ethinyl estradiol?
20mcg. Can go down to 10mcg if dose is too high, can go up to 30mcg-50 if breakthrough bleeding is occurring.
What doses of estradiol valerate are used?
1, 2, 3mg
What is the equivalent ethinyl estradiol to 50mcg mestranol?
35mcg ethinyl estradiol
What are estrogen SE’s?
Breast tenderness Nausea Breakthrough bleeding Headache? Thrombo events
What are progesterone-related SE’s?
Tiredness
Mood swings
BTB (#1)
Lighter flow
No risk of clots
If SE’s occur, switch type of progesterone
What lab value needs to be monitored in someone taking drospirinone?
Potassium
What are the effects of COC on androgenicity?
- LH levels
- Ovarian testosterone production
- SHBG levels
- Free testosterone levels
- LH levels: Decrease
- Ovarian testosterone production: Decrease
- SHBG levels: Increase
- Free testosterone levels: Decrease
Decreases acne
What are the categories in the CDC US-MEC, and what do they mean?
- No restrictions for contraceptive use
- Condition where benefits outweigh risks
- Condition where risks usually outweigh benefits
- Unacceptable health risk if contraceptives are taken
What age is the cutoff for birth control use if you also smoke?
35
What route of administration of HC’s gives the highest area under the curve?
The patch
When can you start hormonal contraceptives postpartum? Why?
After 42 days. High blood clot risk.
Why is there a push to get the pregnancy category X changed on birth control?
because women may think that their children will have birth defects if they got pregnant on the pill, and try to abort them.
What hormonal contraceptives have a higher risk of VTE?
Ortho Evra
2nd and 3rd gen progestins other than levonorgestrel.
What are the serious adverse reactions to COC?
ACHES
Abdominal pain Chest pain Headaches Eye problems Severe leg pain
