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Thera II > Gyno Part 2 > Flashcards

Gyno Part 2 Flashcards

1
Q

Pregnancy and fertility testing

A
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2
Q

COC side effects?

A

amenorrhea
nausea and vomiting
breast pain
bloating
mood changes such as depression
headache

Acne
B-breakthrough bleeding, breast tenderness, bloating (wt gain)
C- chloasma

Headache
Nausea /vomiting
Mood changes

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3
Q

Can plan B be used in patients at risk of thrombosis?

A

yes

In addition, Depo Provera, progestin-only pills, condoms, and diaphragms are all also estrogen-free and safe for people with a high blood clot risk. Emergency contraception (such as Plan B, One-Step, and Take Action) does not contain estrogen, so it does not increase blood clot risks.

Highest blood clot in COC

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4
Q

What are absolute CI to COC

A
  1. breast cancer or hormone dependent cancer
  2. CVD or history
  3. complicated valvular heart disease
  4. current or past history of VTE/PE
  5. DM with microvascular complications
  6. hx of current MI/ ischemic heart disease, vascular disease
  7. uncontrolled HTN
  8. current pregnancy
  9. <6 wk PP if BF
  10. migraine with aura
  11. Liver disease
  12. smoker >35 years
  13. Smoker >15 cigs/day
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5
Q

CHC danger signs

A

ACHES
a-abdominal pain (severe)
c- chest pain (severe)
h- headaches (severe)
e- (eye problems; blurred vision, flashing lights, blindness)
s-severe leg pain (DVT)

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6
Q

when is plan B most effective

A

within 72 hours of unprotected intercourse

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7
Q

Which contraceptive is CI if patient has migraines with aura?
and which contraceptive can they use instead?

A

COC

instead can use progestin only contraceptive (depot provera, implant) or Copper IUD (flex T)

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8
Q

are tampons recommended while using nuvaring?

A

concurrent use of vaginal tampons are not recommended, can use tampons after vaginal ring is removed

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9
Q

Nuva ring:
-can be self inserted
-worn continuously x3 weeks, removed x1 week

if ring left out of vagina >3h, use backup method x 7days

if ring removal <3 hours, OK- just re-insert SAME ring

Who is the ring CI for?

A

same people as CHC

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10
Q

Patch (Evra):
-apply ONCE weekly x 3 weeks (on same day each week) follow by 1 week off
-apply to dry intact skin of buttock, abdomen, upper outer arm or upper torso

if off for <48 hours, apply NEW patch
-> detachment <24h; OK, just reapply the SAME patch

if off for >48 hours, apply NEW patch and use back up method x7 days

When is the patch CI?

A

Relative: body weight ≥90 kg (decreased efficacy).

Same CI as CHC

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11
Q

which medications decrease CHC efficacy?

A

anti-convulsants

rifamycin

Antivirals

GLP1 Agonists (space admin)

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12
Q

Progestin only pill
(Norethindrone, Drospirenone)

Noretindrone -> if you miss >3hours (use back up contraception for 2 days; if unprotected sex in the last 5 days use EC)

Drospirenone -> if missed 1 pill, take ASAP, use back up contraception x 7 days

What is CI to progestin? when do you use this vs. estrogen po

A

preferred if CI to estrogen in COC

BUT
CI:
-abnormal uterine bleeding
-adrenal insufficiency
-renal impairment
-hepatic impairment

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13
Q

Your patient is having breakthrough bleeding during CHC, what is the management?

A

common in first 3 months

if persists beyond, check for other causes (chlamydia, poor adherence, smoking or DI)

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14
Q

Your patient is having early breakthrough bleeding, what is the management?

A

change to CHC with increased estrogen (1-9d) ->have a estrogen deficiency

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15
Q

Your patient is having late breakthrough bleeding, what is the management?

A

change to CHC with increased progestin if later bleeding (10-21d) -> they have a progestin deficiency

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16
Q

Your patient is having breast tenderness with CHC, what is the management?

A

If persist beyond 3 months, evaluate the cause

Change CHC to less estrogen

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17
Q

Your patient is having acne with CHC, what is your management/

A

sometimes worsens before it gets better ; usually improves long term

Can change to CHC with less androgen or none (Yasmin, Yaz= Drospirenone, noregestimate)

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18
Q

Your pt is having nausea due to CHC, what do you recommend?

A

Often subsides in 3 months but if not take with food, or at HS or change to a lower estrogen content

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19
Q

Your pt is complaining of excessive weight gain while taking OCP, what do you recommend?

A

may increase appetite in 1st month but overall little or no weight gain with low dose CHC
-> review lifestyle factors

Yasmin/ yas possible less weight gain (diuretic effect)

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20
Q

contraceptive for bulimia? which do you recommend if she continues to vomit

A

long acting reversible contraceptive methods (IUD) is first line for women with eating disorders

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21
Q

Pregnancy- can return to ovulation <1 month for most once discontinue of OCP

A
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22
Q

Your patient is 3 weeks post partum and is hoping to start a contraceptive, which is the most appropriate?

A

Progestin only if planning on BF

If not breastfeeding can start COC at 3 weeks PP

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23
Q

What are emergency contraceptive options?

Emergency contraceptive prevents FERTILIZATION NOT IMPLANTATION.
-> if egg already fertilized not going to work.

A
  1. Levonorgestrel 1.5 mg x1 dose (plan B)
  2. Ulipristal (ella) 30mg x1 dose

OR

IUD insertion stat
#1 Copper IUD (insert within 5-7 days if pregnancy r/o)
or
(off label) Levonorgestrel 52 mg IUD

Timeline:
PILLS: Taken 3-5 days (ideally within 72hs)

IUD: insert within 5-7 days

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24
Q

What if Debbie had also been taking carbamazepine (Tegretol) for seizures? How would this impact the NP-PHC’s decision to prescribe emergency contraception for Debbie?

A

Tegretol is a strong (CYP 3A4 inducer) which decreases the concentration of hormonal contraceptives; and can result in contraceptive failure.
When using levonorgestrel (Plan B) for emergency contraception; recommendations suggest doubling the dose of levonorgestrel to 3mg x1 dose for women who have used enzyme-inducing drugs in the last 4 weeks.

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25
Your client vomited 2 hours later after taking plan B; what is your recommendation?
if vomiting <2 hours after ingestion -> repeat dose.
26
when is HCG highest in your blood?
9am-12pm
27
when is it best to test for pregnancy test?
first urine test 1 day after missed period
28
which are ways to monitor fertility
**basal body temp** -must be taken same time each day -elevated levels cause a rise in body temp about 12-24 hours prior to ovulation -temp rise occurs over a period of up to 3 days and is usually maintained until pt day of menses -once you see the rise in temp; have sex q2 days **cervical mucus** (abundant water discharge 3-4 days BEFORE ovulation) **endometrial biopsy** **urinary LH (peak 20-48h before ovulation)** -superior -usually ovulation likely to occur 36 hours following LH surge **menstrual cycle hx** **saliva based kits** -prior to ovulation, estrogen levels rise causing an increase in salinity of saliva, which produces fern like patterns when the saliva is dried = usually 3-4 days prior to ovulation **fertility monitors**
29
**if trying for a baby -> need to avoid artificial lubes (it interferes with motility) How often should you have intercourse?
Q2days before expected ovulation -sperm lives in reproductive tract for 5 days -sperm needs 2 days for replenishment (more frequent intercourse, smaller volumes and less sperm count)
30
what are risk factors for PMS
-increase BMI -hx domestic violence, physical or emotional trauma -substance abuse -major depression -postpartum depression
31
diagnosis of PMS -present during luteal phase -reach peak during menses and remit at onset of menses -severe enough to affect interpersonal relationship -absent during follicular phase want women to watch daily symptoms x 2 cycles What are nonpharm interventions one can do
1. Lifestyle modification -relaxation, stress reduction techniques (acupuncture, reflexology, massage, light therapy) -appropriate sleep hygiene -moderate exercise could be beneficial (3-4x/weekly) 2. Dietary modification -caffeine restriction -small frequent carbohydrate services for women with symptoms -restrict salt intake in luteal phase (can help with fluid retention)
32
pharm interventions for PMS, Pain, Fluid retention and breast tenderness
**Pain,headache**, muscle aches -> NSAIDS **For fluid retention:** Mg 200-400mg t/o menstrual cycle or Calcium carbonate 1200mg daily **PMS** Low dose calcium carbonate 400mg daily could alleviate symptoms of MILD PMS Pyrodixine (B6) ->could help SSRI: (offer short term clinical benefits **/ can take continuously or only during luteal phase) SNRI also helpful but less effective than SSRI (clomipramine, duloxetine, venlafaxine) **breast tenderness** Spironolactone bromocriptine cabergoline
33
what are PMS options for severe and unresponsive cases?
GnRH agonist (goserelin, leuprolide, naferelin) or Danazol (used during luteal phase)
34
perineum care after childbirth:
-change sanitary pads Q4-6h -do not use tampons -perineal squirt bottles with warm water after going to bathroom -use sitz bath after BM -apply cold gel pack several times during 12-24 hours (wet freeze a clean maxi pad or newborn diaper) -kegal exercises to increase circulation and help promote healing -rest with feet elevated -use medicated wipes to soothe -tylenol, ibuprofen for pain
35
If your menopausal patient has suddenly developed vaginal bleeding after HT, what does this mean
unexpected vaginal bleeding may occur in the first year pf estrogen therapy with EPT; patient can expect a withdrawal bleed when the progestogen is stopped at the end of the cycle. Can change to cyclical to reduce the amount of breakthrough bleeding or to TSEC (estrogen + bazedoxifene) [Duavive]
36
Which foods are high in calciium?
oranges brocoli cereals that are fortified dairy
37
Complementary therapies instead of HRT for menoapuse? what are they? do they work?
vitamin E 400-800 units marginal effect Mixed evidence with soy products Black cohosh= no better than placebo **for VMS** Chasteberry = possibly effective but insufficient evidence Dong Quai = no better than placebo Evening primrose = no better than placebo Fennel= insufficient evidence red clover= not better than placebo wild yam = insufficient evidence valerian = insufficient evidence
38
what if your patient wants to discontinue HRT/ has been on it for 5 years
vaginal estrogen should be continued at the lowest effective dose for as long as they wish (may be continued indefinetely). Discontinuation leads to the vaginal mucosa returning to a hypoestrogenic state MHT can be stopped abruptly or tappered (if tappering, decrease dose over alternate day dosing due to MHT pharmacokinetics)
39
Depo provera (medroxyprogesterone acetate) inject 150 mg witin first 5 days of onset of menses * -> if injected at any other time, must use back up contraception for 7 days Interval between injections must NOT EXCEED 13 weeks What are CI?
-pregnany -vaginal or urinary tract bleeding -breast cancer diagnosis -know sensitivity -liver disease **long term use, decrease in BMD, delayed return to fertility**
40
how often do you need to check BMD if youre on depot provera?
if on depo >2 years, should have bone mineral density monitored Preventative measure in interim vit D + calcium Monitor: metabolic profile can alter glucose and lipids
41
What if your patient is 68 and stopped menstruating 14 years ago and reported vaginal bleeding over the last 2 weeks? What is your plan of care?
r/o endometrial cancer with endometrial biopsy + transvaginal ultrasound
42
N/v of pregnancy nonpharm
-rassure normality -women should eat anything they find appealing -eat small, bland foods, frequent meals, avoid fatty friend or spicy foods -eat at time of day where nausea is less severe -eat before getting out of bed in am to prevent early morning nausea -avoid strong odors -separate solid and liquid consumption, drink small amounts of liquid regularly before meals -iron supp(can take intermittent to help with nausea) -take prenatals at bedtime -acupuncture may work
43
mild N/V pharm approaches
1. Ginger 250 mg Q6h PRN 1. Pyrodixine 25mg Q8h PRN 1. Doxylamine/Pyrodoxine (Diclectin) 2 tabs qHS + 1 tab Qam + 1 tab midafternoon
44
moderate to severe n/v approaches
#1 dimenhydrinate 50mg Q4-6h PRN Dimehydramine (benadryl) 50 mg q6-8h prn Promethazine 12.5-25 mg q4h PRN Second line: -Chlorpromazine -Metoclopramide -Prochloperazine Refractory cases: -methylprednisolone -zofran
45
What are CI to medical abortions
1. Confirmed ectopic pregnancy 2. IUD in place 3. hemorrhagia disorders or using anticoagulants 4. anemia (<95) 5. known hypersensitivity with drugs 6. ambivalence
46
nonpharm approaches to medical abortions
-confidential counselling -discuss pregnancy options -assess emotional needs,values, coping skills -medical abortion through meds -vacuum aspiration *both surgical and medical methods are available to terminate a pregnancy at 5 weeks after LMP
47
Eligibility criteria for medical abortion?
<63 days ( 9weeks)
48
What are pharm approaches for medical abortion
**FIRST LINE** Mifepristone 200 mg PO, vaginal or SL (Day 1) + Misoprostol 800mcg PO, vaginal or SL (Day 2 or 3) *Combo pills are med of choice* **SECOND LINE** Methotrexate 50 mg PO/IM (day 1) + Misoprostol 800 mcq (day 4,5, or 6)
49
red flags for post medical abortion
- >2 sanitary pads/ hr for 2 consecutive hours -1 pad/hr x 10 hours straight -pt feels dizzy, lightheaded, racing heart >24hrs -heavy bleeding or cramping >16 days -fever, chills >6hrs -> seek immediate medical attention if this happens
50
What is to be expected from medical abortion? regarding bleeding, pain and prostaglandin effects
bleeding- to be expected that is heavier than menses -should use thick, full size pads (not tampons) pain-may have pain and cramping, usually 2-4 hours post misoprostol -> NSAID #1 Prostaglandin effects -may have nausea, vomiting, diarrhea, headache, dizziness, thermaregulatory symptoms -> could take gravol, zofran, loperamide etc.
51
when do you follow up post medical abortion?
in clinic- @ day 7 post treatment Beta should be >80% reduced = confirms completion can also see @ day 3 (beta at 24hrs after misoprostol should have a drop of >50%; this could indicate completion) **If beta not dropped, should be followed** US= conclusively confirms but only perform if concerned. serum hcg sufficient
52
What should you advise your patients about contraception after MA?
should be on contraception should avoid getting pregnant during next menses to inadvertent expose the pregnancy to abortive meds, Contraceptives can be started on the day of misoprostol. IUD can be inserted after abortion complete
53
vaginal hygiene -avoid douching -avoid harsh soaps -labia should be seperated and cleaned -wash daily with unscented soaps avoid -deodorant sprays for vag -talcum powder could use -genital wipes -genital washes (no specific indication but not harmful)
54
nonpharm for vaginal dryness
increase blood flow through sexual stimulation
55
pharm for vaginal dryness
FIRST LINE vaginal lubricants and moisturizers SECOND LINE estrogen and progesterone supplementation (Topical) -> only consider this when nonhormonal thearpies have faild
56
nonpharm for vulvovaginal candidiasis
no treatment but preventative measures -good genital hygiene -regular use of panty liners have not been shown to promote the occurence but you should change often -tight clothing and synthetic underwear should be avoided -cotton underwear and loose fitting undergarments and pants are recommended -no clear association with dietary changes severe diets like sugar free and yeast free can be tried but no data to support this could try probiotic yogourt
57
pharm for vulvovaginal candidiasis
first line nonprescription antifungals Clotrimazole 1% vaginal cream 1 applicator full x 7 days or fluconazole 150 mg x1 Second line boric acid 600 mg vaginally OD x 14 days sex partners do not ned to be treated BUT males can get balanitis which is the same treatment Symptoms should resolve by day 7 regardless of the regimen
58
toxic shock syndrome >38 hypotension rash in hands/feet vomiting profosued diarrhea * if untreated = fatal * what is prevention strategies for toxic shock?
never wear tampons longer than 8 hours use sanitary pads overnight instead of tampons
59
What drugs are teratogenic to humans
BP: -ACEI Anticoagulants: -Coumadin Antibiotics: -tetracyclines Antiseizures: -Cabamazepine -phenytoin -topiramate -valproic acid Mood stabilizers: lithium -> supp folic acid 5mg daily Others: Ethanol Folic Acid agonists Misoprostol Retinoids (vit A > 10000) Mycophenolate corticosteroids
60
should you avoid statin use in pregnancy?
possibly teratogenic if used before pregnancy, keep. Don't start in pregnancy
61
Should you avoid methimazole in pregnancy (hyperthyroidism)
yes, sub propylthouracil in first trimester *remember then switch back to methimazole after first trimester*
62
post episiotomy pain nonpharm
-localized cooling -kegal -rinsing area with water bottle from squirt -sitz bath after BM
63
post episiotomy pain pharm
wipes containing witch hazel may decrease pain and itching #1 NSAIDs or Tylenol for pain
64
PP depression nonpharm
psychotherapy supportive counselling, CBT interpersonal therapy psychodynamic therapy light therapy peer support groups regular exericse
65
PP depression pharm
antidepressants Min: 9 months treatment
66
laxative drug of choice during pregnancy
bulk forming agents preferred (psyllium) PEG (unlikely to cause harm tho) AVOID mineral oil or osmotic laxatives in pregnancy
67
decongestants of choice while pregnant
saline rinses #1 pseudophedrine is safe but can decrease milk production
68
acid suppressor during pregnancy
calcium carbonate #1 (helps replace calcium lost during BF) PPI safe (omeprazole most studied) H2RA also good (ranitidine)
69
antidiarrheals
bulk forming (psyllium) loperamide unlikely to cause harm
70
suppresion of lactation nonpharm approaches
to help with discomfort -wear a tight fitting and supportive bra -express milk gently (hand or pump) just enough to relieve pressure but not fully empty either -warm shower or compress helps induce milk let down to facilitate expression -placing ice packs or cold cabbage leaves in bra can decrease swelling and pain
71
suppression of lactation pharm approaches
non opioid analgesics
72
Calcium intake prenatal nutrition dosage
<19 = 1300 mg/day >19= 1000 mg/day (dietary intake preferred) If having heart burn could do calcium carbonate (doubly wammy)
73
vitamin d dosage prenatal nutrition
vit d 600-2000 units/day
74
min folic acid supplementations
0.4 mg
75
what are foods that contain folic acid
fortified grains spinach lentils chick peas asparagus brussel sprouts corn oranges
76
What if your patient had a family history of NTD, GI malabsorption what should you supplement with? (moderate risk of NTD)
1 mg daily, 3 months prior
77
what if mom or dad had NTD, what should you supplement with (high risk)
5 mg daily
78
Iodine recommended supplementation dose
250 mcq/day total (can supplement with 150 mcq/day) 1 tsp of table salt =380 mcq of iodine
79
iron total dosing recommended prenatally
27 mg daily
80
what are heme and nonheme sources of iron
heme = meat, poultry, fish nonheme= fortified food, tofu, lentils, beans Vit C should be taken with non-heme foods`
81
which cold natural medicine should you avoid in pregnancy
zinc lozenges echinacea
82

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