Gynecology Flashcards
Contraindications of IUDs
Large intracavitary pathology, breast CA, recurrent/recent PID
Caution with patients who are severely immunocompromised
What are some potential harming effects of estrogen therapy?
Increased risk of endometrial and breast carcinoma, MI, stroke and venous thromboembolism (VTE).
When should treatment of vasomotor symptoms associated with menopause be considered?
Patient experiencing mod-severe symptoms, significant impact on QOL
What are some non-pharm interventions for VMS?
- Cooling techniques (e.g., dressing in layers, using fans, lowering the ambient temperature)
- Trigger avoidance (e.g., spicy foods, hot drinks, caffeine, alcohol).
- Weight loss
- Smoking cessation
- CBT - doesn’t help VMS but assists with coping
- Clinical hypnosis
- Exercise, yoga and paced respiration. Exercise to improve mood, reduce cardiovascular risk and improve bone health
- Self help groups
- Mindfulness based stress reduction
What are some contraindications to estrogen therapy?
- undiagnosed vaginal bleeding
- pregnancy
- Active liver disease, cancer (breast or estrogen sensitive tumor), thromboembolic disease
- Age >60
- > 10 years since menopause onset (inc CV harm)
- high CV risk
Which hormone therapy is required for those with an intact uterus? Why?
Estrogen - Progestogen Therapy
- Estrogen controls VMS symptoms
- Progesterone is needed to prevent endometrial hyperplasia
What is the difference between continuous and cyclic administration of Estrogen-Progestogen therapy?
Estrogen always taken continuously
Progesterone can be taken 1 of 2 ways:
Continuous: taken every day of month
Cyclic: taken on days 1-12/14 of each month
*continuous associated with better protection against endometrial hyperplasia
What signs of bleeding are expected with cyclic vs continuous Progestogen therapy
Continuous - unexpected spotting, or vaginal bleeding may occur
Cyclic - expect a withdrawal bleed when the progestogen is stopped at the end of the cycle.
How soon would you expect to see results of estrogen therapy on VMS?
Dose-related but typically within 4 weeks of standard doses
When would transdermal estrogen be preferred?
- high VTE risk
- women with hypertriglyceridemia (transdermal eliminates the first-pass effect through the liver = less of an increase of triglyceride levels)
- obese women with metabolic syndrome
- ↑CVD risk/smoking/HTN/DM/gallstones/obesity.
- shift workers
Would transdermal or oral estrogen be best for a smoker?
Transdermal
A patient started on estrogen therapy and is concerned as she is experiencing breast tenderness, bloating, and spotting? What can we do for her?
If she has just started on therapy - Explain that these are expected side effects within the first year of initiation and typically temporary
If she has been on a stable dose for awhile - consider decreasing dosing?
What are some contraindications to progestogen therapy?
- Undiagnosed vaginal bleeding
- Known or suspected carcinoma of the breast
- Pregnancy
What progestogen routine would be preferred if the LMP was <1yr ago?
If last menstrual cycle was < 1yr ago, use 10-14
days progestogen/month; otherwise continuous HT to avoid monthly withdrawal bleed.
How is transdermal estrogen administered?
Patch - alternate sites (abdo, thigh, buttocks)
Gel - same site (arm, abdomen, thigh)
Which therapy would be preferred for VMS treatment in the women with an intact uterus, is 52yrs and had the LMP 8 years ago?
Hormone Therapy = Combo estrogen + prestogen
T/F: Women on estrogen & progestogen were at an increased risk of breast ca after 5 or more years.
As per The Women’s Health Initiative (WHI) - True
Contraindications to hormone therapy
ABCD
Acute liver disease
Bleeding undiagnosed
Cancer (breast/uterine) /Cardiovascular disease
DVT (thromboembolic disease)
+ pregnancy
Post hormone therapy initiation when should discontinuation be reviewed?
Annually review, no good evidence to say when to DC, should be based on the individual patient and ongoing symptom relief
T/F: hormones should be weaned
False: Not necessarily, no evidence indicating difference between abruptly stopping and slowly tapering when it comes to return of menopause symptoms
General recommendation: Avoid abrupt discontinuation of therapy by gradually reducing the dose and frequency. If the patient becomes symptomatic with lower doses when tapering, continue that dose until the VMS abate
What can be used for vaginal atrophy?
local estrogen: cream (Premarin), vaginal suppository (VagiFem), ring (Estring).
Lubricants (Replens)
Vaginal moisturizers improve vaginal dryness & dyspareunia when used at least twice a week.
How to prevent osteoporosis while on hormone therapy?
The primary prevention of osteoporosis should be achieved through diet, exercise, and calcium and vitamin D
Rx Ca 600 mg BID, Vit D 800-2000 iu
Non-pharm: Regular exercise (especially impact type), Reduce risk of falling
For menopausal women requiring treatment of osteoporosis in combination with treatment for vasomotor symptoms, hormone therapy can be used as first-line therapy for prevention of hip, nonvertebral and vertebral fractures
Which hormone therapy treatment can be used for osteoporosis prevention and treatment?
The estrogen-bazedoxifene combination
*must have a uterus?
What is one of the main determining factors when deciding on treatment options for AUB?
Desire for fertility
Medical treatment should be first line, approx 50% will go on to have surgical intervention
