L16-Men/Women Flashcards
List the women conditions covered in this lecture.
- PMS
- Mastalagia
- Dysmenorrhea
- Perimenopause/menopause
List the women conditions covered in this lecture.
- BPH
____ of people use NHPs and among the higher users are ____ w/ ______.
-~70-80%, women w/ adv education.
T/F: The use of NHPs by women is increasingly popular. Why or why not?
TRUE.
- Frustation over AE of mainstay pharm therapies.
- Concern over LT safety of hormonal agents (Women’s Health Initiative)
- Misconception that NHPs are safer.
What is the Women’s Health Initiative?
- longitudadal study found a corrrelation between specific hormonal therapies w/ certain types of cancer, etc
- came out in 2002
- caused a lot of concerns w women who used hormonal therapies and steered more people to NHP.
W/ regards to NHPs, safety is the main concern.
If pt wants to take a product, what do you tell them if not safe?
Safety is the main concern. If pt wants to take a product that has limited benefits but safe, ok to give but educate them on the limited studies done on efficacy. BUT if NOT safe for the patient, then MUST educate them on that.
- PMS & Mastalgia.
What is PMS?
- Both physical/behavioral Sxs occurring repetitively in 2nd half of the menstrual cycle & interfere w/ aspects of women’s life.
- Etiology unknown; women who suffer are ++ sensitive to normal hormone
- PMS & Mastalgia.
Define affective Sx of PMS.
depression, irritability, anxiety, nervousness, decreased concentration
- PMS & Mastalgia.
Define somatic Sx of PMS.
breast pain, bloating and swelling, headache, tiredness, body aches
- PMS & Mastalgia.
What is the general approach to Tx PMS?
- exercise, relaxation techs (mild, mod, severe)-effective?
- SNRI, SSRI (mod-sev)-> more for affective (mood): can be used continuously or cyclically
- cyclic OC use (drospirenone) or continuous OC use (any progestin)
- role of NHP??
- PMS & Mastalgia.
Define mastaglia.
Hint: list Sx.
- bresast tenderness or pain: dull ache, heaviness, tightness, burning sensation
- cyclic vs noncyclic; can be variable depending on hormonal fluctuation
- PMS & Mastalgia.
T/F: New onset of Mastalgia does not need to be evaluated by MD - can just self-Tx.
FALSE
-new onset must always be evaluated by MD; rule out pathology (breast cancer)
- PMS & Mastalgia.
Define cyclic mastalgia.
List Sx.
- 70% of women experience some mild pain/ swelling cyclically; before menstruation (1wk)
- usually presents initially btwn ages of 20-40y
- generally bilateral; can radiate to axilla area
- caused by hormonal changes related to ovulation that stimulate the proliferation of normal glandular breast tissue= pain
1) PMS & Mastalgia.
List the NHPs used to Tx. Indicated whether product is indicated for PMS and/or Mastalgia.
- Ca - PMS
- Vit B6 - both
- Chasteberry - both
- Mg - PMS
- Ginkgo biloba - both
- Ca
List MOA.
MOA: variations in estrogen levels during premenstrual period may limit Ca absorption and metab-> lower Ca levels; may contribute to mood and other sx associated w PMS
-Ca involved in production of 5HT
- Ca
Safety rating?
Likely safe!
- must consider all intake sources
- SE= GI upset, constipation
- Ca
Effectiveness?
- likely effective at 1000mg dose
- > water retention and pain of PMS (and this was found in multiple studies)
- Ca
Would you recommend? If so, what dosage?
YAS
- DOSE= 1000 mg daily
- Ca
We often do not account for Ca intake via dietary sources, would you recommend a lower dose of Ca to accommodating this?
PENDING (i.e. NOT YET)
-there was another study comparing 500mg to placebo, which did have mild benefit BUT then they tried to compare it to 1000mg which they cannot (and until they actually do more studies, 1000 is considered more effective)
- Vit B6.
Indication?
Natural sources?
MOA?
- used for both PMS and mastalgia
- found in cereal grains, legumes, veggies, liver, meat and eggs
mech: unclear, may possess some anti-inflam properties. Some theories minor Vit B6 def
- Vit B6.
Safety?
POSSIBLY SAFE!
-When taken orally, exceeding RSA (1-2mg)
- SE: n/v, heartburn, loss of appetite, headache
- Sensory neuropathy at high dose (>1000mg daily)-> therefore if pt does use it you have to keep them at a safe dose
- Vit B6.
Effectiveness?
-possibly effective (50-1000) may improve mastalgia and possibly PMS-related depression (limited evidence-> need more studies); more evidence as combo w Mg
- Vit B6.
Would you recommend? If so what dosage?
MEH - don’t recommend… unless they DESPY.
-50-100 mg - but probs won’t even recommend.
- Chasteberry.
Indication?
AI?
- both PMS and mastalgia
- AI: berry (fruit) - flavonoids, linoleic acid, progestins, ect
- some women w PMS and mastalgia have elevated prolactin levels
- Chasteberry.
MOA?
-components of chsteberry inhibit prolactin release through DA receptor agonism (D2)
- Chasteberry.
Safety?
LIKELY SAFE!
- safety use in studies up to 1.5y
- SE: mild, Gi rxn, itching, rash, headache, fatigue, acne, and menstrual disturbances
- Chasteberry.
Efficacy?
POSSIBLY EFFECTIVE!
Dose: 20-40mg (typical dose) may improve mastalgia and PMS-related sx
- Chasteberry.
Would you recommend? If so, what dose?
APPROVED!
Dose: 20-40 mg
-evidence rating B
-bottom line: a safe well-tol herbal med that may be effective in tx of cylical breast discomfort and PMS
- Mg.
DA NATTY SOURCE?
-found in legumes, whole grains, veggies (broccoli, squash, green leafy veggies), seeds and nuts (almonds)
- Mg.
MOA?
-intracellular levels of Mg found to be lower in women w PMS
- Mg.
DIS SAFE?
LIKELY SAFE.
SE: loose stools
>counsel them to drink lots of fluids and NOT go over recommended dose of 350mg
- Mg.
Efficacy?
- POSSIBLY EFFECTIVE: for 200mg elemental Mg (common dose) may improve PMS sx (mood, fluid retention)
- often combined w B6 to help w PMS reltaed anxiety sx (nervous tension, mood swings, irritability)
- Mg.
Is you going deal dis? if so what dose?
YEEE!
-200 mg elemental Mg!
- Ginko biloba.
AI: flavonoids, several terpene trilactones unique to ginko
-supposed to be used for both PMS and mastalgia BUT mech is unclear (possibly due to anti-inflam properties)
- Ginko biloba.
Safety?
LIKELY SAFE!
- BUT some concern over carcinogenic effects in animals -> therefore probs not likely safe.
- SE: mild GI upset, headache, dizziness, palpitations, constipation and allergic skin rxns
- Ginko biloba.
EFFECTIVE?
POSSIBLY EFFECTIVE - ginko leak extract
-Dose: 80mg bid or 40mg tid) may reduce breast tenderness and other physical/psychological PMS syndrome (start on day 16 or cycle and continue until day 5)
- Ginko biloba.
Would you recommend? Dose?
LOL NAH we aint fucking with this.
- v low efficacy, potentially carcinogenic effect
- Dose: 80 mg BID, 40 mg TID mg if despy
1) PMS & Mastagalia
What would you recommend for PMS?
What would you recommend for mastalgia?
PMS: Ca, chasteberry, Mg
Mastalgia: chasteberry
2) Dysmenorrhea
Describe.
- presence of recurrent, crampy, lower ab pain that occurs in menses in the absence of demonstratable disase that could account for these sx
- n/d, fatigue, headache
2) Dysmenorrhea
____% of reproductive age women experience painful periods.
-50-90%
2) Dysmenorrhea.
T/F: Pain begins at onset of menses, improves over 12-72h post
TRUE!
2) Dysmenorrhea
General Tx approach.
- heat, exercise, yoga, sex, diet (maybe veg or increased dairy)
- acupunture
- NSAID, OCs, IUDs, injectable contraception
2) Dysmenorrhea
List NHP products.
- Omega
- Vitamin E
- Vitamin B1
- Magnesium
2) Dysmenorrhea
T/F: According to Cochrane review, the evidence to support effectiveness for days is low, however safe.
FALSE.
- HQ evidence for effectiveness
- Lacking for safety
- Omega 3 FA
Describe.
List AI.
Natural sources.
AI: EPA, ALA, DHA-> diff ratios depending on source
-> natural sources are fish oil, flax, nuts, eggs, soy beverage, edamame
- Omega 3 FA
MOA?
-mech is unclear but is possibly due to anti-inflam properties (blocks inflam cytokines)
- Omega 3 FA
Safety?
LIKELY SAFE.
-Doses: <3g
>higher doses have concerns of anticoag effect/ bleed risk
-SE: halitosis (fish oil), fishy burps, heartburn, loose stool
- Omega 3 FA
Efficacy?
POSSIBLY EFFECTIVE.
@ decreasing pain, NSAID consumption, and interference w daily activities
(bit more efficacy for O3 than the other options)
- Omega 3 FA
Would you recommend? If so WHAT DOSEY-DOE?
PENDING… not enough evidence..
Dose <3 g daily
- Vit E
- fat sol vitamin
- natural sources: wheat germ oil, veg oils, cereal grains, animal fats, meat, poultry, eggs, f&v
- Vit E
T/F: 8 isomers-> may have unique roles in action of Vit E, available as natural or synthetic
TRUE!
- Vit E
MOA?
-unclear on MOA (maybe BG release)
- Vit E
Safety?
LIKELY SAFE.
>UL= 1100 IU synthetic; 1500 UI natural
>BUT if unhealthy (heart disase, DM) dose <400IU
-SE: n/d, intestinal cramps, fatigue, weakness, headache, bleed risk at elevated doses.
- Vit E
Effectiveness.
POSSIBLY EFFECTIVE.
> (200 IU BID or 500 IU daily) > starting 2d before menstruation to 3d of bleeding
> decrease pain severity/ duration and blood loss BUT cochrane studies were only able to identify low/very low quality studies
- Vit E
Would you recommend?
Dose?
NO - YA CRAZY?
> (200 IU BID or 500 IU daily)
- Vit B1
GOOD PROMISE… BUT… V safe, may be effective at blocking PG release.
What is the catch?
1996 study claiming to completely cure 87% of women - BUT:
- not much done since
- only done by 1 person
- Vit B1
Would you recommend?
mmmmm NOT until more studies have be done.
- Mg
T/F: Use for dysmen is indicated on NNHPD monograph
FALSE - its NOT.
- only few small RCTs show benefit on pain
- limitations: lack of dietary control, small sample size, high D/O rates, etc.
- Mg
MOA?
-unclear:
>some resources cite possible Mg deficiency as root cause
-Ca agonist effect of Mg ion on smooth muscle(?) Used in preterm birth (IV) to inhibit uterine contractions - possibly via similar mech for dysmen
(in theory it has some promise, bc its mech works on uterine contactions-> more studies needed)
- Mg
Would yah recommend? Dose?
PENDING!
-Doses range from 200-360mg Mg2+ (within limit of dose; nearing max)
- Mg
List da ones you recommend.
- Omega 3
2. Mg
3) Perimenopause/Menopause
Perimenopause: menopausal transition starting ____ before cessation of menstruation.
-~4 yrs
3) Perimenopause/Menopause
List physical changes of peri!
irregular menstrual cycles, marked hormonal fluctuations, hot flashes, sleep disturbances, mood sxs, and vag dryness
3) Perimenopause/Menopause
Define: Menopause
- permanent cessation of menstrual periods (after 12m of amenorrhea wo any other obvious pathological or physiological cause)
- median: 51.4y
3) Perimenopause/Menopause
LT effects.
- bone loss and OP (PM is a chance to implement some preventative medicine)
- increase CV disease risk
3) Perimenopause/Menopause
Tx strategies.
- tx sx
- prevention plan for post-meno complications
3) Perimenopause/Menopause
List NHPs.
- Black Cohosh
- Evening Primrose Oil
- Soy/isoflavones
- Calcium
- Black Cohosh
AI?
MOA?
Rhizomes.
Estrogen-like effects, MOA unknown.
- Black Cohosh
Safety?
POSSIBLY SAFE
-study data up to 1 year
-Concern re: liver tox - case reports of liver failure, acute hepatitis, monitor liver function
>hard to determine correlation tho.
- Black Cohosh
Efficacy?
POSSIBLY EFFECTIVE @ dose 40-80 mg.
-conflicting benefit on decreasing hot flashes (40-80mg) + weak evidence for menopausal sx
- Black Cohosh
Risk info?
- Caution in hormone therapy
>Note: study showed only 3 contained an Asian herb related to black cohosh rather than the proper herb
• not to be confused with blue cohosh which is cardiotoxic
- Black Cohosh
Would you recommend? Dose?
MEEEEHHHHH
Dose: 40-80 mg
- Evening primrose oil
AI?
MOA?
Gamma-linolenic acid, linoleic acid.
GLA has anti-inflammatory properties.
- Evening primrose oil
Safety?
LIKELY SAFE
- Dose: up to 6g/day for up to 1y
- SE: mild, transient GI
- Evening primrose oil
Efficacy?
POSSIBLY INEFFECTIVE
-1-4g daily for 6wks-6m does NOT reduce daily or nightly hot flash counts v placebo
- Evening primrose oil
Recommend? Dose?
NO but if insistent then counsel on ineffectiveness. Let them know is likely safe.
- Soy
AI?
MOA?
- contains isoflavones
- found in soybeans
- mechanism: weak estrogenic activity, may act as SERMs
- Soy
Safety?
LIKELY SAFE!
- 16wk study
- se: minor GI rxns; allergic response
- Soy
Efficacy?
POSSIBLY EFFECTIVE.
- 20-60g soy protein (providing 34-100mg isoflavones) daily
- effects: modestly decrease frequency/severity of hot flashes, increase bone mineral density (important for OP related menopause)
- Soy
Recommend? Dose?
omg mer…
>60g daily
- Calcium
Efficacy?
Dose?
- prevent OP/bone fractures
- Ca (1000mg) & Vit D (800IU)
- adequate intake of both throughout life as a part of healthy diet (along w pa) may help prevent bone loss/OP (in peri- and postmeno)
- Calcium
LIKELY EFFECTIVE.
- first 5 years after menopause - little effect of Ca supp
- 5+ years, calcium supp reduces bone loss of 2%/year by up to 1% (initially, while bone remodeling foci are being filled), then ~0.25% per year.
- 30 y Ca supp might translate to 10% improvement in bone mineral dens& a signif reduction in fracture rates (as high as 70%)-> therefore even if a woman starts supp in peri meno, we can explain to these women that while benefit might not been seen immediately, but after 30y (which is very reasonable 50->80) will have a large effect and now we will be preventing falls/ fractures in the most signif portion of their lives
- Calcium
Counselling points.
- single dose cannot exceed 500mg (due to absorption issues)
- may cause GI upset, belching, constipation, diarrhea at high dose
- Calcium
Recommend? Dose?
YES.
Dose: 1000 mg
3) Perimenopause/Menopause
- black cohosh
- soy
- Ca
4) BPH
What is it?
-prostate enlargement that occurs more freq as age advances
>50% of 50yo men, up to 80% in 80y)
4) BPH
Presentation?
- Can initially be asympt but often results in sx and bladder, urinary tract and kidney complications
- Storage sxs - increased daytime frequency, nocturia, urgency, and urinary incontinence
- Voiding sxs - Slow urinary stream, splitting or spraying of the urinary stream, intermittent urinary stream, hesitancy, straining to void, and terminal dribbling
4) BPH
Complications?
-untreated BPH can cause acute urinary retention, recurrent UTIs, hydronephrosis (swelling of kidney), and renal failure
4) BPH
Tx options?
- Alpha-1-adrenergic antagonists
- 5-alpha-reductase inhibitors
- Anticholinergic agents
- Phosphodiesterase-5 inhibitors
4) BPH
List NHPs?
- saw palmetto
- pygeum
- phytosterol/ beta-sitosterol
- pumpkin seed
4) BPH
T/F: Make sure they have first seen a primary care provider to rule out prostate pathology
T!
- Saw palmetto
AI?
NS?
MOA?
- AI - in lipid fraction in berries
- NS: soybeans
- mech: redues prostate specific antigen, mech unclear
- Saw palmetto
Safety?
LIKELY SAFE
-studies of up to 3y duration
- Saw palmetto
Effectiveness?
POSSIBLY INEFFECTIVE.
-Appears NOT to offer significant benefit for sxs of BPH, any benefits are modest at best.
= no differences in urinary symptom scores, measures of urinary flow, or prostate size
- Saw palmetto
Would you recommend? Dose?
NO - because complications of NOT properly tx BPH
- Pygeum
AI?
MOA?
- AI: bark
- MOA: appears to inhibit prostatic 5-alphareductase (less than finasteride)
- reduction of urethral obstruction and improvement of bladder fxn have been observed
- Pygeum
Safety?
LIKELY SAFE!
-up to 12m
- Pygeum
Effective?
LIKELY EFFECTIVE @ 75-200mg capsules daily
- reduces functional sx of BPH
- decreases nocturia, increases peak urine flow, and resces residual urine volume
- essentially can be used but when pharm product (finasteride) can be used, why would we not use it
- Pygeum
Recommend? Dose?
APPROVED!
75-200mg capsules daily
Studies only up to 12 m just need monitor after that
- Phytosterols/Beta-Sitosterol
NS?
MOA?
NS: plants (f/v, soybeans, breads, peanuts, plant oils)
- similar to human cholesterol; beta sitosterol most common dietary phystosterol
- mech: animal studies-> might inhibit 5-a-reductase activity (finasteride more potent)
- Phytosterols/Beta-Sitosterol
LIKELY SAFE
- up to 18m
- SE: n/d/c, gas, reduced appetite
- Phytosterols/Beta-Sitosterol
Efficacy?
LIKELY EFFECTIVE
- taking 60-130mg orally in 2-3 divided doses daily
- signif improves urinary sx, increases max urinary flow (does not affect prostate size)
- > seems to help w sx but did not reduce the prostate size (this can be concerning bc you are not treating the actual condition and may be under-treated)
- Phytosterols/Beta-Sitosterol
YAh? dose?
APPROVED
- taking 60-130mg orally in 2-3 divided doses daily
- up 10 18 m
- Pumpkin Seed
DASRIBE
-MOA?
- often used in combo w saw palmetto
- MOA: possibly diuretic effect-> relieves bladder discomfort, causing the perception of reduced prostate gland swelling wo reducing the gland size
- Pumpkin Seed
Safety?
POSSIBLY SAFE
-se: n/d/c, indigestion, gas, reduced appetite
- Pumpkin Seed
Effectiveness?
POSSIBLY EFFECTIVE.
-480mg orally in 2-3 divided doses daily (w or wo saw) may help BPH sx; very limited evidence
(while they say possibly, very few studies have been done)
- Pumpkin Seed
Recommend? Dose?
PENDING
-480mg orally in 2-3 divided doses daily
