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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
what are pharm options for abnormal uterine bleeding in adolescents and pre-menopausal women
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) 2. monophosic CHC (containing progestin/ estrogen) // Triphasic not suitable -Nuva Ring -Evra patch -Min-Ovral 3. Depo- Provera 4. 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
26
what are pharm interventions for perimenopausal women with AUB
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
what are CI to combined oral contraceptives
-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
what is the difference between heavy menstrual bleeding and abnormal uterine bleeding
AUB= abnormal frequency, duration, amount of blood between cycles HMB= excessive menstrual blood flow that interferes with QOL and may result in IDA
29
do you treat AUB and HMB the same?
yes for non pharm and pharm approaches
30
what are hormonal and nonhormonal options for HMB
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
what are second line agents if HMB not reduced with hormonal or non-hormonal options
Consider GnRH agonist +/- add back hormonal therapy if >6mo use or Danazol (only 6 months) (androgenic side effects ++)
32
what is the major side effects of danazol
Voice deepening, decrease beast size, increase weight, hirsustism, increase LDL, lower HDL + vasomotor signs (hot flashes, vaginal dryness)
33
if pharm internventions do not work for HMB, what is the next plan
consider: -uterine artery embolization -hysteropic resection -hysterectomy
34
Dysmenorrhea nonpharm approaches
-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
Pharm options for dysmenorrhea
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
nonpharm approaches to menopause treatment
-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
What are vasomotor symptoms in menopause? what are nonhormonal and hormonal pharm approaches for menopause vasomotor symptoms?
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) 2. 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 ** 3. Other hormonal options: 1. Tibolone (intact uterus only) 2. 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
CI to progestogen
undiagnosed vaginal bleeding known or suspected breast cancer pregnancy
39
estrogen CI
-undiganosed vaginal bleeding -active liver disease -breast cancer -pregnancy -active thromboembolic disease (stroke, VTE, MI) -DVT/PE -sm
40
What are first line agents for GU syndrome in menopause
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
prevention of osteoporosis with hormone therapy
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
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
43
HT should only be considered for women <60 and <10 years of pas menopause. If >, offer non-hormonal pharmacological options
44
which factors influence female sexual dysfunction
mood stress feelings for partner past sex medical condition obesity surgery radiation aging
45
drugs associated with female sexual dysfunction
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
nonpharm for female sexual dysfunction
-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
pharm interventions for female sexual dysfunction
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
Nonpharm approaches for penetration disorder
-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
pharm interventions for penetration disorder
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
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
51
If pain is not thought to be primary dysmenorrhea-> consider it endometriosis unless proven otherwise
52
nonpharm approaches for endometriosis
-> surgery / removal of typical and atypical endometriotic implants Hysterectomy or hyesterectomy + bilateral oophorctomy = 90-95% relief
53
pharm approaches for endometriosis pain
FIRST LINE #1 NSAIDS -start at onset of menses and given t/o period #2- Opioids (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
management of endometriosis symptoms while pregnant
symptoms are suppressed and no treatment required
55
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
56
Heavy menstrual bleeding pathway
57
Dysmenorrhea pathway
58
Endometriosis treatment pathway
59
Having late bleeding and spotting days 10-21 What does that tell you with your COC
Progestin deficiency
60
Early bleeding and spotting days 1-9 Atrophic vaginitis Vasomotor symptoms Continuous bleeding or spotting What does that tell you re your COC
Estrogen deficiency
61
Hypermenorrhea, increase breast size, increase uterine or fibroid growth, vascular headaches, dysmenorrhea,l What is wrong with my COC
Excess estrogen
62
Experiencing Depression Breast tenderness Libido decrease Weight gain Increase appetite What’s going on with the COC
Excess progestin
63
Having oily skin, increase libido, rash, pruritus, hirsustism, edema and acne What is going on with my COC
Excess androgens

Thera II (12 decks)

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