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Thera II > Gyno Part 1 > Flashcards

Gyno Part 1 Flashcards

1
Q

diagnosis of osteoporosis

A

T-Score < 2.5

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2
Q

what are the meds associated with increase fracture risk

A

-androgen deprivation therapy
-anticoagulant
-antiepileptic drugs
-antiretroviral therapy
-aromatase inhibitor
-chemotherapy
-corticosteroids, prolonged use
-cyclosporine
-loop diuretics
-PPI
-SSRI
-thiazolidine
-Vit A, high dose
-antipsychotics

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3
Q

conditions associated with high risk for osteoporosis

A

> 65 (high risk)

50-64
-parent with hip fracture
-osteopenia identified on xray
-current smoking
-high alcohol intake
-low body wt (<60kg)
-major wt loss >10% since 25 years

Any age
-hx of fragility #
-hypogonadism or premature menopause (<45)
-hyperthyroid
-cushing syndrome
-hyperparathyroid
-renal disease
-organ tranplant
-GI Disease (gastric surgery)
-RA, multiple myeloma

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4
Q

Osteoporosis nonpharm approaches

A

regular weight bearing exercise

Fall prevention

Smoking cessation

Dietary measures (adequate protein, calcium, Vit D)

Avoid excessive alcohol (>3 units/day)

Avoid excessive caffeine (>4/day)

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5
Q

what are nutritional supplements recommended in osteoporosis

A

adequate calcium and vitamin D
Calcium should be obtained through dietary measures (1200 mg/day)
Vit D 800-2000 units/day for >50

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6
Q

What are first line agents for osteoporosis with moderate risk?

A

Biphosphonates (mainstay of treatment)
1. Oral Alendronate 10 mg daily
2. Risedronate 35 mg once weekly PO
3. IV Zoledronate 5mg Qyearly -> reserve for those who cannot tolerate PO

Other first line agents:
IF MENOPAUSAL and need osteoporosis prevention can do estrogen/progesterone therapy

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7
Q

Biphosphonates must be taken how? and what are the s/e

A

empty stomach with water only

-do not lie down after for 30 min d/t risk of esophageal ulceration

SE=mild GI upset and allergic reactions

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8
Q

What are the risk with biophosphonate therapy?

A

atypical femoral fracture = if greater than >2 years on biphosphonate therapy

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9
Q

How do you manage the risk of atypical femoral fracture risk of biphosphonate therapy

A

-education pt on risk
-if pt on >5 years of biphosphonate therapy -> monitor for AFF symptoms

AFF symptoms = groin pain or thigh pain, unilateral or bilateral

if symptoms identified -> xray stat, stop med and referral to ortho stat

Should do drug holidays to avoid risk
1. after 5 years of PO or 3 of IV -> stop for 1-3 years then r/a
2. Measure BMD after and assess FRAX 10 year risk
3. If lost BMD and is in high risk -> resume for another 3 years

when is this not appropriate?
-if pt at high risk of fracture - may be appropriate not to have drug holiday (no safety data on >10 years treatment-> use clinical judgement
-can continue on current regimen or switch agents (denosumab or terapatide)
-if previous # of hip or spine

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10
Q

What are first line agents for low risk osteoporosis fracture risk?

A

nonpharm prevention
not likely to benefit from pharmacotherapy

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11
Q

what are the first line agents for high risk osteoporosis fracture risk

A

Biphosphonates
(Zolidronate IV)

Denosumab
(antiremodelling agent/ Rank ligand I)

Anabolic therapy
->Teripatide -> MAX 24 months

Menopause E/PT

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12
Q

what are the first line agents for very high risk osteoporosis fracture risk?

A

terapatide (24 months only) or romozumab (12 months only) (anabolic agent) followed by biphosphonate or denosumab

ROMOZUMAB CI= cardiovascular disease history (MI or stroke)

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13
Q

When should you consider treating patients for osteoporosis who have been on high corticosteroid dose

A

if <40 years with long term high dose corticosteroid dose or prior fragility fracture -> should consider pharm interventions

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14
Q

read:
CKD increases risk of osteoporosis.
All therapies are acceptable for all stages EXCEPT for biphosphonate
Biphosphonates are CI in eGFR <30-35
If the patient is already on dialysis -> consult nephrologist

A
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15
Q

how frequent can you do BMD?

A

Q1-3 years

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16
Q

What are nonpharm options for neuropathic pain

A

physio
mindfulness
yoga
exercise
psychotherapy
attempt to decrease sleep deprivation and improve functioning
some pt with nerve root compression -> surgery
*if nerve root compression ->surgery

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17
Q

What are first line pharm therapies for nerve root compression associated with disc changes and disc herniations. When do you consider surgery?

A

In acute phase -> NSAID or tylenol
~usually pain settles with conservative management
-rest and avoid further aggravation

Consider surgical treatment if:
-med fails over 6-12 weeks
-CT or MRI show treatable lesion
-if acute pain is excruciating and intractable or if neurological deficit and correctable lesion is present

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18
Q

what are first line, second line and third line agents for chronic peripheral neuropathic pain and chronic regional pain syndrome

(both are treated the same)

CRPS S/S = burning pain, wide anatomical area, allodhynia, hyperesthesia, hyperalgesia, sweating, coldness of affect limb

A

1 - TCA (Amitryptilline 10-25 mg HS), Gabapinoids (pregabalin 50-150 mg BID or gabapentin 300-400mg HS), SNRI (duloxetine)

if pain persists, trial and error approach, including cannabinoid, methadone, lamotrigine, topiramate, botox

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19
Q

first line agents for acute neuropathic pain related to herpes zoster

A

oral antivirals to treat (acyclovir, famciclovir, valacyclovir -> usually first 72 hours of onset of rash)

Pain= #1 Amitryptilline or gabapentin
IF necessary can do opioids

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20
Q

First line pharm for trigeminal neuralgia
(confined to face, unilateral, >50y, shock like quality)

A

carbamazepine #1

~if symptoms not tolerated, switch to oxcarbamazepine or decrease dose of carbamazepine

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21
Q

how long should you trial a pharm agent for neuropathic pain in general?

A

trial a med for 2-3 months, if drug ineffective try different drug within the same class, drugs from a different class or a combination of drugs

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22
Q

abnormal uterine bleeding causes

A

PALM COEIN
P-polups
A-Adenomyomas
L-Leiyomas
M-malignancy

C-coagulopathy
O-ovulation dysfunction
E-endometrial factors
I-iatrogenic
N-not otherwise indicated

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23
Q

Pharm for abnormal uterine bleeding

A

Desire for fertility is the #1 question to determine how to guide medical interventions vs surgical

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24
Q

non pharm for abnormal uterine bleeding and heavy menstrual bleeding

A

Pharm is usually considered first line

Surgery/ hysterctomy is the only definitive treatment

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25
Q

what are pharm options for abnormal uterine bleeding in adolescents and pre-menopausal women

A

Prior to implementation, you must r/o pregnancy and infection

Adolescents- > Oral contraceptives

Pre-menopausal -> LNG-IUS

Hormonal options:
1. LNG-IUS (first line) (levonorgesterel intrauterine system)

  1. monophosic CHC (containing progestin/ estrogen) // Triphasic not suitable
    -Nuva Ring
    -Evra patch
    -Min-Ovral
  2. Depo- Provera
  3. Progestin-only pills (provera, norethindrone)

Anti-fibrinolytics
1. Tranexamic acid

NSAIDS
1. Naproxen
2. ibuprofen
(start the day before menses and continued until bleeding ceases 3-5 days)

other hormonal agents
1. Danazol 100-400mg OD
(generally short term use <6 mo)

GnRH angonist
Leuprolide (lupron)
Goserelin
Nafarelin
Triptorelin
(use max 6 months, need add back therapy to preserve bone health)

GnRH Antagonist
Elagolix
(limited duration due to decrease BMD)

SECOND LINE AGENTS ARE REALLY
GnRH agonist or DANAZOL

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26
Q

what are pharm interventions for perimenopausal women with AUB

A

should r/o endometrial hyperplasia/ carcinoma first

Assess if there are any contraindications to OCs

if there are none then options include:
1. Tranexemic acid
2. NSAID
3. CHC
4.LNG-IUS
5. Progestin only pill
6. Depo provera

27
Q

what are CI to combined oral contraceptives

A

-history of stroke or VTE
-uncontrolled HTN
-migraine with neurological signs
-CAD
-active liver dx
-hx of breast cancer
-smoker >35 years
-Smoker >15 cigs/day

28
Q

what is the difference between heavy menstrual bleeding and abnormal uterine bleeding

A

AUB= abnormal frequency, duration, amount of blood between cycles

HMB= excessive menstrual blood flow that interferes with QOL and may result in IDA

29
Q

do you treat AUB and HMB the same?

A

yes for non pharm and pharm approaches

30
Q

what are hormonal and nonhormonal options for HMB

A

hormonal:
-LNG-IUS (#1) (Progestin only)
-CHC (#1- if menses irregular)
-Depot medroxyprogesterone (depo provera) (progestin only)
-Progestin only pills (medroxyprogesterone acetatetaken for at least 21 days/month)

nonhormonal:
-Tranexeamic acid 1g TID x 3-4 d (start at first day of heavy menses)
-NSAIDS during menses (1 day before and continued until bleeding ceases (usually 3-5 days)

31
Q

what are second line agents if HMB not reduced with hormonal or non-hormonal options

A

Consider
GnRH agonist +/- add back hormonal therapy if >6mo use

or

Danazol (only 6 months) (androgenic side effects ++)

32
Q

what is the major side effects of danazol

A

Voice deepening, decrease beast size, increase weight, hirsustism, increase LDL, lower HDL

+ vasomotor signs (hot flashes, vaginal dryness)

33
Q

if pharm internventions do not work for HMB, what is the next plan

A

consider:
-uterine artery embolization
-hysteropic resection
-hysterectomy

34
Q

Dysmenorrhea nonpharm approaches

A

-exercise = greatest reduction in pain
-hot pad, warm baths or hot water bottle may decrease discomfort
-massage, biofeedback, pain management (evidence lacking)

for most pharm therapy is needed

35
Q

Pharm options for dysmenorrhea

A

Ask if they want hormonal contraceptive.

If no:
NSAIDS (ibuprofen, naproxen)

if yes:
COC ***
can do x3 cycles of continuous or 28 day regimen
LNG-IUS (need further study)

Can also combine NSAID + COC

36
Q

nonpharm approaches to menopause treatment

A

-cooling techniques (fans, layers)
-avoid triggers (spicy foods, coffee)
-wt loss (can decrease vasomotor symptoms)
-smoking cessation
-CBT for vasomotor symptoms
-weekly hypnosis x5 weeks helped
-yoga, exercise 150 min mod intensity/week
-lack of efficacy with acupuncture

37
Q

What are vasomotor symptoms in menopause?

what are nonhormonal and hormonal pharm approaches for menopause vasomotor symptoms?

A

vasomotor= hot flashes, night sweats

non-hormonal
FIRST LINE
1. SSRI (CEP)
SNRI (VD)
~quick onset, and results within 2 weeks

SECOND LINE
-Gabapentin 300 mg at HS gradually up to 600-900mg
-Pregabalin 75 mg BID and 150 mg BID x 6 weeks

Others:
1. Clonidine
2.Oxybutynin

Steps:
1. SSRI/SNRI
2. Gabapentinoids
3. CLonidine
4. Oxybutynin

hormonal (first line)
1. Combination estrogen+ Progesterone (WITH INTACT UTERUS ONLY)
-Angeliq; Activelle (PO)
-Estalis (transdermal)

  1. Estrogen only (without uterus)

THINK- you removed the organ, now youre left with ESTROGEN ONLY)
-Premarin, Estrace (PO)
-Estradiol-17B patch or gel, vaginal tab or ring

***consider topical/ transdermal estrogen if increased risk for CVD, smoking, HTN, DM, gallstones, obesity **

  1. Other hormonal options:
  2. Tibolone (intact uterus only)
  3. Estrogen wth bazedoxifene (TSEC) (with intact uterus)->can prevent osteoporosis and treat vulvovaginal atrophy

SECOND LINE
if patient refusing to use estrogen. can do ORAL PROGESTERONE as alternative
must have intact uterus

38
Q

CI to progestogen

A

undiagnosed vaginal bleeding
known or suspected breast cancer
pregnancy

39
Q

estrogen CI

A

-undiganosed vaginal bleeding
-active liver disease
-breast cancer
-pregnancy
-active thromboembolic disease (stroke, VTE, MI)
-DVT/PE

-sm

40
Q

What are first line agents for GU syndrome in menopause

A

hormonal therapy
-vaginal estrogen therapy
(consider if breast cancer hx and failed nonhormonal)
** progestogen is not indicated**

non-hormonal therapy
(best for breast cancer pt)
-Hyaluronic acid
-Vaginal lubricants PRN

41
Q

prevention of osteoporosis with hormone therapy

A

HRT can be first line if c/o vasomotor symptoms and suffers osteoporosis

Prevention:
vit D 800-2000u
Calcium 1200 mg/day (preferably dairy)

-exercise (weight bear)
-fall prevention
-diet

42
Q

Consider use of CHC or LNG-IUS during PERIMENOPAUSAL period when contraceptive is required

** DO NOT USE CHC during postmenopausal, pills have higher concentration of estrogen compared to HT

A
43
Q

HT should only be considered for women <60 and <10 years of pas menopause.

If >, offer non-hormonal pharmacological options

A
44
Q

which factors influence female sexual dysfunction

A

mood
stress
feelings for partner
past sex
medical condition
obesity
surgery
radiation
aging

45
Q

drugs associated with female sexual dysfunction

A

alcohol
alkylating agents
amphetamines
anti-androgens
antidepressants
anticholinergic
anti-epileptic
anti-histamine
antipsychotics
aromatase inhibitors
barbiturates
benzos
beta blockers
climetdine
clonidine
digoxin
GnRH agonist
ketoconazole
Lithium
methadone
matoclopramide
spironolactone
trazodone

46
Q

nonpharm for female sexual dysfunction

A

-CBT
-sex therapy
-mindfulness based
-address lack of stimuli
-address psychological factors
-address biological factors (estrogen deficiency, meds, fatigue, irregular menses, hypo/hyper thyroid, urinary incontinence)

47
Q

pharm interventions for female sexual dysfunction

A

Topical:
-estrogen (if lack of pleasure)
-vaginal lubricants and moisturizers

Systemic:
Fibanserin (serotonin agonist/antagonist)
alcohol must be avoided

or
Sildenafil (but not data unless on antidepressant)

Treatment of depression improves sex desire; should try sex neutral meds (bupropion, vortioxetine, vilazodone)

48
Q

Nonpharm approaches for penetration disorder

A

-CBT
-assess pelvic muscle hypertrophy and identify physical methods
-reverse kegal exercises with inserts that increase in diameter
-explain role of stress in chronic pain and counsel on management
-focus on sexual activity that does not include vaginal penetration
-address concomittant lack of arousal a
-refer if pelvic pathology suspected

49
Q

pharm interventions for penetration disorder

A

GU syndrome of menopause:
-intravaginal estrogen (tablets, creams, rings)
-vaginal lubricants, moisturizers

*evidence is lacking but:
-lidocaine to some benefit
-local anesthetic in conjunction with psychological therapy

Others:
-topical testosterone 2% apply and r/a in 3 months

50
Q

most patients c/o lack of arousal and have normal vulvar and vaginal congestion. Focus ax and therapy on adequate stimuli and biological and pschological factors intefering with arousability

if it comes from deepened themes in childhood -> refer to psychiatrist or psychologist

if lack of sexual stimuli, eroticism etc. -> sex therapsit

A
51
Q

If pain is not thought to be primary dysmenorrhea-> consider it endometriosis unless proven otherwise

A
52
Q

nonpharm approaches for endometriosis

A

-> surgery / removal of typical and atypical endometriotic implants

Hysterectomy or hyesterectomy + bilateral oophorctomy = 90-95% relief

53
Q

pharm approaches for endometriosis pain

A

2- Opioids

FIRST LINE
#1 NSAIDS
-start at onset of menses and given t/o period

(consider if NSAIDS ineffective or CI)

SECOND LINE/ Adjunct
If persistent mild pain can consider:
-oral conctraceptives (cyclic or continuous)

THIRD LINE
If pain ineffective again
GnrH agonist + add back HT
(REDUCED BMD IF >6mo use; calcium 1200 mg/day, vit d 400-1000u/day)
or
LNG-IUS (lack of data on endometriosis)
or
Danazol (use only <6 mo)
or
Elagolix (gnRH antagonist) ->reserve for refractory cases
or
or
-progestin alone

if all else fails -> surgery

54
Q

management of endometriosis symptoms while pregnant

A

symptoms are suppressed and no treatment required

55
Q

during breastfeeding, symptoms of endometriosis remain in remission initially, treatment is not required as long as BF is frequent to inhibit estrogen release from ovaries but symptoms may recur during long term feeding

A
56
Q

Heavy menstrual bleeding pathway

A
57
Q

Dysmenorrhea pathway

A
58
Q

Endometriosis treatment pathway

A
59
Q

Having late bleeding and spotting days 10-21
What does that tell you with your COC

A

Progestin deficiency

60
Q

Early bleeding and spotting days 1-9
Atrophic vaginitis
Vasomotor symptoms
Continuous bleeding or spotting

What does that tell you re your COC

A

Estrogen deficiency

61
Q

Hypermenorrhea, increase breast size, increase uterine or fibroid growth, vascular headaches, dysmenorrhea,l

What is wrong with my COC

A

Excess estrogen

62
Q

Experiencing
Depression
Breast tenderness
Libido decrease
Weight gain
Increase appetite

What’s going on with the COC

A

Excess progestin

63
Q

Having oily skin, increase libido, rash, pruritus, hirsustism, edema and acne

What is going on with my COC

A

Excess androgens

Thera II (12 decks)

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