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Pharm III > Lecture 9, part 1 (GYN)- Exam 5 > Flashcards

Lecture 9, part 1 (GYN)- Exam 5 Flashcards

1
Q

*

Ovarian Cycle: Follicular (preovulatory)
* What does the hypothalamus release? What is released because of that?
* What grows? What does it release?
* Estrogen surge causes what?

A
  • Hypothalamus releases GnRH from anterior pituitary
  • FSH/LH released
  • Dominant follicle grows and releases estrogen
  • Estrogen surge causes FSH/LH surge and ovulation 24 to 36 hours later
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2
Q

*

Uterine Cycle
* What is menstruation? What is the proliferative phase?

A

Menstruation (~5 days)
* Bleeding; shedding of functional layer

Proliferative phase
* Rising estrogen
* Rebuilds endometrium

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3
Q

*

For the follicular and menstruation and proliferative phase, the duration is what? Dominant in what?

A

Duration variable : estrogen dominant

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4
Q

*

What surges in ovulation? When does it occur?

A

Ovulation – LH surge on day 14ish (most fertile days 11 to 15)

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5
Q

*

Ovarian cycle: Luteal (postovulatory)
* What does corpus luteum release? What happens to it?
* What declines if no pregnancy?

A

Corpus luteum releases progestin and estrogen to help support pregnancy
* Disintegrates if no pregnancy
* Becomes Corpus albicans

Progestin and estrogen decline if no pregnancy

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6
Q

*

Uterine Cycle: Secretory phase
* Prepares what? How?
* What does corpus luteum progestin cause?
* What dclines with disintegration of C. luteum?

A

Prepares endometrium for fertilization
* Spiral arteries grow
* Uterine glands -> mucous

C. Luteum progestin
* Endometrium more receptive to implantation

Estrogen and progestin decline with disintegration of C. luteum

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7
Q

For the luteal and secretory phase, what is the duration and what is dominant?

A

Duration is not variable and progestin dominant

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8
Q

Follicular phase
* Theca cells develop what? What does that secrete?

A

Theca cells develop receptors and bind LH
* Secrete large amounts of androstenedione

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9
Q

Follicular phase
* Granulosa cells develop what? What does that secrete?

A

Granulosa cells develop receptors and bind FSH
* Secrete the enzyme aromatase

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10
Q

Follicular phase
* What does aromatase do?

A

Aromatase converts androstenedione into 17β-estradiol

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11
Q

Under notes:

Follicular phase
* Hypothalamus releases what? What does it anterior pituitary release?
* LH/FSH controls what?

A

Hypothalamus releases GnRH

In response the anterior pituitary releases LH and FSH

LH/FSH control the maturation of the follicles
* Primary oocyte
* Theca cells
* Granulosa cells

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12
Q

*

Follicular Phase (Day 10-14)
* Follicles grow causing more what? What is the casade?

A
  • Follicles grow causing more estrogen release
  • Increased estrogen act as a negative feedback signal -> pituitary secretes less FSH
  • Less FSH -> some follicles regress and die
  • The follicle with the most FSH receptors will continue to grow and become the dominant follicle
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13
Q

*

Follicular phase: Days 10-14
* What continues to grow? What does it begin to secrete more of/ what is the cascade?

A
  • Dominant follicle continues to grow
  • Begins secreting more estrogen -> pituitary more responsive to GnRH
  • Estrogen release from dominant follicle -> positive feedback
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14
Q

Follicular phase: Days 10-14
* What does the estrogen positive feedback trigger the pituitary do?
* When does it occur? Responsible for what?

A

Triggers the pituitary to release a surge of FSH and LH
* Occurs 1 to 2 days prior to ovulation
* Responsible for rupture of ovarian follicle and release of oocyte

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15
Q

LY

Types of Contraception
* What are all the examples?

A
  • Barrier
  • Contraceptive Foam, Cream, Film, Sponge, Jelly & Suppository
  • Contraception based on awareness of fertile periods
  • Oral contraception
  • Contraceptive injections & implants
  • Complex Delivery System Contraceptives
  • Intrauterine devices
  • Emergency contraception
  • Sterilization
  • Abortion
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16
Q

Contraception
* How many unwanted pregnancies are they? What happened to them?

A

50% of World Wide pregnancies in 2015-2019 were unintended (totaling 121 million)
* Disproportionately impacts developing countries
* 61% ended in abortion
* 13% miscarriage
* 38% resulted in unplanned birth

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17
Q

Contraception
* What is critical? Give examples (3)

A

Contraception education critical –Applies to all disciplines
* Teratogenic effects from medications prescribed in specialty offices
* Risk to mother’s health from underlying medical conditions
* Prevent transmission of disease to partner or to fetus

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18
Q

Barrier methods
* Prevents what?
* Wha are the examples? (3)
* Caution?

A

Prevent sperm access to uterus

Examples:
* Condoms: Male & Female
* Diaphragm
* Cervical Cap

Caution: many made with latex (allergies)

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19
Q

Male Condoms
* What is the effectiveness? What is can effect the effectiveness?

A

Effectiveness (latex, polyurethane or animal membrane):
* 6-16% failure rate
* When used with spermicide, perfect use failure 2%, typical use 15%

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20
Q

Male Condoms
* What are the benefits? (3)

A

Protection from STDs
* Latex condoms
* Polyurethane and animal membrane not as effective

No hormonal side effects

Available without prescription

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21
Q

Male Condoms
* What are the disadvantages? (4)

A
  • Higher failure rate; spillage of semen due to tearing, slipping or leaking with detumescence of the penis
  • Dulling of sensation
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22
Q

What do you need to educate on about male condoms? (3)

A
  • Proper application of condom
  • Do not use oil-based lubricants or other substances; use water-based or silicone-based lubricants
  • Never reuse
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23
Q

Male condoms
* What is key?
* Available how?
* Age?
* Who will give it away for free?

A
  • Proper use key
  • Available without a prescription
  • No minimal age to purchase
  • Clinics (e.g., Planned Parenthood) will give for free
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24
Q

Female Condom
* Made of what?
* What is the effectiveness?
* What are the benfits? (3)

A

Made of polyurethane or synthetic nitrile

Effectiveness:
* Failure rates range from 5-21%

Benefits:
* Protects from STD
* No hormonal side effects
* No prescription required

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25
Q

Female Condom
* What do you need to educate on? (4)

A
  • Proper use
  • Recommend lubrication
  • Do not use with male condom-causes tearing
  • Do not reuse
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26
Q

Diaphragm (with spermicidal jelly)
* What is the effectiveness?
* What are the benefits? (3)

A

Effectiveness:
* Failure rate 6-16%

Benefits:
* No systemic side effects
* Significant protection from pelvic infection
* Protection from cervical dysplasia

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27
Q

Diaphragm (with spermicidal jelly)
* What are the disadvantages? (2)

A
  • Must be inserted near the time of coitus (when about to have sex)
  • Pressure from the rim predisposes some women to cystitis after intercourse
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28
Q

Cervical Cap (with spermicidal jelly)
* What is the efficacy? (nulliparous and parous)
* What is a benefit? (2)

A

Efficacy:
* Failure in nulliparous female: 9% perfect use and 16% typical use
* Failure in parous female: 26% perfect use and 32% typical use

Benefits:
* Can be used in women that cannot be properly fitted for diaphragm or with recurrent bladder infections from diaphragm

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29
Q

Cervical Cap (with spermicidal jelly)
* What is the patient education? (3)

A
  • Should not be left in the vagina for over 12-18 hours, risk of toxic shock syndrome.
  • Should not be used during menstrual cycle
  • Does not protect from STD
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30
Q

combination hormonal contraception (CHC)
* MC what?
* Contains what?
* Provides what?

A
  • MC oral contraception
  • Contain synthetic versions of estrogen and progesterone
  • Provide steady levels of exogenous estrogens and/or progesterone
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31
Q

combination hormonal contraception (CHC)
* What does it trick?
* Stops what?

A
  • Trick the pituitary gland into thinking woman is pregnant
  • Stops hormone release that triggers ovulation
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32
Q

combination hormonal contraception (CHC)
* What is the MOA?

A

Administration of exogenous estrogen and progesterone results in:
* Inhibition of ovulation
* Thickens cervical mucus

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33
Q

combination hormonal contraception (CHC)
* Discontinuation during the 7 days of placebo?
* May choose what?
* What is the effectiveness(2)?

A

Discontinuation during 7 days of placebo cause rapid decline in estrogen and progesterone levels – withdrawal bleeding

May choose no withdrawal bleeding

Effectiveness:
* Perfect use failure rate 0.3%
* Typical use failure rate 8%

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34
Q

*

combination hormonal contraception (CHC): ethyinyl estadiol
* Suppresses what?
* Stabilizes what?
* Poteniates what?

A

Suppresses FSH/follicular development
* Less in low doses

Stabilizes endometrium and controls bleeding

Potentiates the action of progestins

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35
Q

*

combination hormonal contraception (CHC): Progestin
* Suppresses?
* Atrophies?
* Thickens what?
* Disrupts what?

A

Suppresses LH/ovulation
* Dose-dependent

Atrophies endometrium

Thickens cervical mucous

Disrupts fallopian tube secretion and peristalsis

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36
Q

CHC Dosing:
* how do you take it?
* What initial therapy is recommended?
* Specific combination dependent on ?

A
  • One pill once a day round the same time each day
  • Initial therapy with monophasic recommended
  • Specific combination dependent on concomitant disease states and symptoms
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37
Q

CHC Dosing: Special circumstances
* What are the least androgenic progestins recommended? (3)
* Some pills contain what?

A

Least androgenic progestins recommended:
* Desogestrel
* Drospirenone
* Norgestimate

Some pills contain iron
* Decrease anemia for heavy menses / prolonged duration

38
Q

CHC dosing
* MC timeline?
* What are the two choices?

A

MC twenty-one days of active pills followed by 7 days of placebo
* Monophasic - provide a continuous concentration of estrogen and progesterone
* Multiphasic - provide varying levels of estrogen and progesterone
* Attempt to mimic normal hormone fluctuation
* Decrease overall exogenous hormone dose per cycle

39
Q

CHC continued
* What are the benefits? (5)

A
  • Highly effective
  • Rapid reversibility
  • Regulation of menstrual bleeding
  • Decreased menstrual blood loss/lighter menses
  • Improved dysmenorrhea symptoms
40
Q

CHC continued
* Decreased risk of what? (2)

A

Decreased risk ovarian and endometrial cancer
* Reduces risk of endometrial CA by 40% after 2 years of use and 60% after 4 or more years of use
* Reduces risk of ovarian CA by 30% if used for <4 years, by 60% if used 5-11 years, by 80% if used >12 years

41
Q

CHC continued
* What are four more benefits?

A
  • Improvement in acne and hirsutism
  • Decrease functional ovarian cysts
  • Decreased risk developing uterine myomas if taken for >4 years
  • Beneficial effect on bone mass/improved bone density
42
Q

What is the US medical eligibility criteria for contraception

A

Provides guidance for safe use of contraception
* 1 - No restriction
* 2 - Advantages generally outweigh risks
* 3 - Theoretical or proven risks usually outweigh advantages
* 4 - Unacceptable health risk

43
Q

*

CHC Continued
* What are the risks? (4)

A

Increased risk of MI

Thromboembolic Disease

Strokes

Liver tumors

44
Q

*

CHC Continued
* What are the unacceptable risk (containdicated)? (10)

A
  • Age ≥35 and smoking (can be older if no smoking)
  • Multiple risk factors for CV disease (advanced age, smoking, DM, HTN)
  • HTN (Systolic ≥140 mmHg or Diastolic ≥ 90 mmHg)
  • History of venous thromboembolism
  • History of breast cancer
  • Systemic lupus erythematous
  • Migraine with aura
  • Known ischemic heart dx, hx CVA, complicated valvular dx
  • History of stroke
  • Severe liver cirrhosis or liver cancer
45
Q

Chc Patient Education
* What are the SE?

A
  • Nausea
  • Breast tenderness
  • Bloating
  • Mood changes
  • Headaches
  • Irregular vaginal bleeding
  • ± weight gain
  • May take QHS if symptoms
46
Q

Patient Education: CHC
* Take when?
* When do you start?
* When do you use backup method?

A

Take everyday around the same time of day
* Start on the first day of the menstrual cycle OR the first Sunday after the onset of the cycle OR any day of the cycle
* If started >5 days after the first day, use backup method for the first 7 days

47
Q

Patient Education
* What happens if an active pill is missed and if they did and di not have intercourse for the last 5 days?

A
  • No intercourse in the past 5 days, take two pills immediately and backup method for 7 days
  • (+) intercourse last 5 days, offer emergency contraception and restart pills the following day, backup method for 5 days
48
Q

Patient Education: CHC
* Call office immediately for what?
* Does not protect from what?
* Do not what?
* When do most ADRs improve? Bleeding?

A
  • Call office immediately for ACHES
  • Does not protect from STDs
  • DO NOT SMOKE
  • Most adrs improve in 2 to 3 months
  • Bleeding – must take for 3 months before changing
49
Q

CHC
* What are the medications that may reduce efficacy?

A

CYP450 inducers
* Antiretrovirals
* Antieplielptics (phenytoin, carb, phenobarbital, topiramate, lamotrigine)
* Rifampin and rifabutin

50
Q

CHC – transdermal patch
* What are the current available patches?

A
  • 150mcg norelgestromin /35 mcg ethinyl estradiol per day (Xulane)
  • 120 mcg levonorgestrel / 30 mcg ethinyl estradiol per day (Twirla)
51
Q

*

CHC – transdermal patch
* Apply one patch how?
* Can apply how to avoid w/d bleeding?
* What is additional contraindication?
* Apply where?

A
  • Apply one patch once per week for 3 consecutive weeks; one patch-free week
  • Can apply continuously to avoid withdrawal bleeding
  • Additional contraindication: BMI ≥ 30 kg/m2
  • Apply to abdomen, upper torso, upper arm or buttock
52
Q

*

CHC – transdermal patch
* Do not apply to what?
* Apply to what?
* Improved what?

A
  • DO NOT apply to breasts, chest, and ovaries (cancer risk)
  • Apply to clean, dry skin; rotate sites
  • Improved compliance over oral hormonal pills
53
Q

Vaginal Ring
* What is it?
* Ring is placed where and how long?
* How do you avoid w/d bleeding?

A

Etonogestrel 120mcg/ethinyl estradiol 15mg per day (NuvaRing, et al)
* NuvaRing reports 98% effective

Ring placed in in the upper vagina for 3 weeks, removed and replaced 1 week later

May replace immediately to avoid withdrawal bleeding

54
Q

Vaginal Ring
* May increase what?
* May move into different what?
* Okay to use with what?

A
  • May increase vaginal discharge
  • May move into different positions is vagina, does not need to be in exact position to work.
  • Ok to use with tampons
55
Q

Progestin only contraception
* What is the example?
* Efficacy similar to CHC but MUST be taken how?
* What is the back up contraception needed for?
* Start when?

A

Progestin only pill: 0.35 mg norethindrone or 4 mg drospirenone (Slynd) or 0.075mg nogestrel PO daily

Efficacy similar to CHC but MUST be taken within same 3-hour window daily
* Back up contraception needed for 48 hours if > 3 hours late
* Start 1st day of menses and take continuously, no placebo week

56
Q

Progestin only contraception
* What is the MOA?

A
  • Thickening of the cervical mucus / endometrial atrophy
  • Ovulation inhibition (inconsistent)
57
Q

Progestin only contraception
* What is unique?

A
58
Q

Progestin only contraception: Pills
* What are the benefits (3)

A
  • Safe during lactation
  • Preferred for minimal doses of hormones
  • Alternative for women with contraindications to estrogen-containing birth control
59
Q

Progestin only contraception: Pills
* What are the disadvantages? (3)

A
  • Inconsistent ovulation inhibition
  • Bleeding irregularities—prolonged, spotting, or amenorrhea
  • May require regular pregnancy tests if bleeding irregularities and concern for effectiveness
60
Q

Progestin only contraception: shot
* What is the shot?
* What is it?
* Route?

A

Depot-medroxyprogesterone acetate [DMPA (Depo Provera)]
* Long-acting progestin
* Intramuscular or subcutaneous

61
Q

Progestin only contraception: Depo
* Only started when?
* when MUST have pregnancy test before injection?

A
  • ONLY started in the first 5 days of normal menstrual cycle, then every 10-15 weeks
  • If time between injections >15weeks, MUST have pregnancy test before injection

Effectiveness: 99.7%

62
Q

Progestin only contraception: Depo
* What is the benfits? (2)
* What are the risks? (4)

A

Benefits:
* Effective for 10-15 weeks
* Increased compliance

Risks:
* Irregular bleeding, amenorrhea
* Ovulation may be delayed after cessation (6 to 12 months)
* Decreased bone mineral density
* Weight gain (> 2kg) common

63
Q

Progestin only contraception: Shot
* What are is the patient education? (3)

A
  • Irregular bleeding, unpredictable bleeding or spotting, usually decreases to amenorrhea
  • Should not use for more than 2 years unless other contraception methods inadequate
  • VitD and Ca++ supplements for bone density prevention
64
Q

Progestin only contraception: Implant
* What is the example?
* How long does it last?

A
  • LARC = Long-acting Reversible Contraception –progestin implant, etonogestrel (Nexplanon)
  • Five-year contraception protection (previously 3yrs)
65
Q

Progestin only contraception: Implant
* Must have negative what?
* Implanted where?

A
  • MUST Have negative pregnancy test prior to implantation (No UPIC since last menstrual period or EC candidate)
  • Implanted inner aspect of nondominant arm (about the size of matchstick)
66
Q

Progestin only contraception: Implant
* When do you implant? (5)

A
  • Implant within first 5 days of cycle if not on combination hormonal contraception; OR any time during cycle after confirmation not pregnant and use alternate form contraception for 7 days
  • Implant on the day after the last active pill if on oral hormonal contraception (combo or progestin only)
  • Implant day next IM progestin shot due
  • Implant day of removal of IUD
  • Removal in office procedure
67
Q

Implant Continued
* Effectiveness?
* What are the benefits? (2)

A

Effectiveness:
* Over 99% effective
* Pregnancy rate 0.0% with 3 years of use

Benefits:
* 5 years continuous contraception (used to be 3yrs)
* No delay in return of fertility after removal

68
Q

Implant Continued
* What is the patient education? (3)

A
  • Contact provider if unable to palpate implant at any time (potential of migration, moving)
  • If implanted after fifth day of menses, use backup contraceptive method for first 7 days after implant
  • May have change in normal menstrual bleeding patterns
69
Q

Intrauterine Device (IUD)
* What is the MOA?

A
  • Inhibitory effects of sperm migration and viability
  • Sperm cannot get to egg
  • Sperm do not like copper
  • Levonorgestrel – thickens uterine mucosa, sometimes stop ovulation
70
Q
A

Skyla: 5 years now

71
Q

Intrauterine Device (IUD)
* What are the benefits? (6)

A
  • Highly effective
  • Compliance high
  • Do not need partner compliance
  • May be used in nulliparous patient
  • May be used in adolescent
  • No estrogen
72
Q

IUD
* What are the risks?(3)

A

Increased risk of PID

High risk of spontaneous abortion with failure; 50% if left in place, 25% if removed
* Spontaneous abortion with IUD high risk severe sepsis

Spontaneous expulsion
* 10-20% of cases during the first year
Perforation of the uterus with abdominal migration of the IUD

73
Q

IUD
* What is the patient education? (4)

A
  • Does not protect from STDs
  • Copper IUD increased risk of menorrhagia or severe dysmenorrhea
  • Self check for strings not recommended anymore;String check with provider – if not visible, use Back Up method, RTC or diagnostic imaging
  • IUD IS NOT AN ABORTIFACIENT
74
Q

Contraceptive Foam, Cream, Film, Jelly-> Nonoxynol-9: Locally acting, non-hormonal
* Effectiveness?
* MOA?

A

Effectiveness:
* Failure rate 10-22%

Mechanism of action
* Immobilize/inactivate/damage and/or kill sperm

75
Q

Contraceptive Foam, Cream, Film, Jelly
* What are the benefits? (3)

A
  • Available without prescription
  • No hormonal effect.
  • Increases lubrication during intercourse
76
Q

Contraceptive Foam, Cream, Film, Jelly
* What is the patient education? (3)

A
  • Does not protect from HIV or other STD; vaginal and rectum irritation can cause epithelia disruption and increased risk of HIV transmission
  • Some formulations may contain base ingredients that can interact and break down latex and the barrier device (latex)
  • Increased risk of UTI and vaginal irritation
77
Q

Fertility awareness Contraception
* Recognizing what?
* Avoid what?
* ACOG general effectiveness data for all types: (2)

A

Recognizing fertile time in cycle

Avoid intercourse or use barrier method during fertile times

ACOG general effectiveness data for all types:
* 1-5 pregnancies/100 first year perfect use
* 12-24/100 typical use

78
Q

Fertility awareness Contraception: Symptothermal
* What is the calendar method?

A

Calendar Method: Avoid intercourse during fertile period
* Track cycle for 8 months
* First fertile day= subtract 18 days from the shortest cycle
* Last fertile day=subtract 11 days from the longest cycle
* Efficacy is 91% with perfect use

79
Q

Fertility awareness Contraception: Symptothermal
* What is the basal body temperatiure method?

A
  • Slight drop in temp 12-24 hours before ovulation; raises 1-2 days after
  • Pregnancy risk starts 5 days before, highest day of ovulation, sharply drops 1 day after
80
Q

Fertility awareness Contraception: Symptothermal
* What are the standard days method?

A
  • Can only use if menses regular, never shorter than 26 days or longer than 32 days.
  • Avoid unprotected coitus days 8-19
  • Use an App or color-coded circle of beads, called CycleBeads, to remind couple when to avoid intercourse or use barrier method.
  • Effectiveness:Failure 5% perfect; 12% typical
81
Q

Emergency Contraception/Postcoital Contraception
* Not be confused with what?
* What does it prevent?
* Medical abortion used to do what?

A

Not to be confused with medical abortion
* Emergency contraception prevents pregnancy and only effective before pregnancy established
* Medical abortion used to terminate an existing pregnancy

82
Q

Emergency Contraception/Postcoital Contraception
* What is not necessary?
* Plan B available how?
* MC SE?

A
  • No clinical examination or pregnancy testing is necessary before prescribing
  • Plan B available OTC without age restrictions in the US
  • MC adverse reactions of hormonal agents includes headaches, nausea, vomiting
83
Q

Emergency Contraception/Postcoital Contraception

A
84
Q

Emergency Contraception/Postcoital Contraception

A
85
Q

Emergency Contraception: Patient education
* Oral medication most effective when?
* Other forms of contraception recommended when?
* May be taken more than once when?

A
  • Oral medication most effective when taken as soon as possible after unprotected or contraception failure
  • Other forms of contraception recommended for regular use
  • May be taken more than once within same menstrual cycle; should not be used for long term contraception
86
Q

Emergency Contraception: Patient education
* All victims of sexual violence should be offered what?
* May need what?
* Irregular bleeding may occur when?
* Does not need what?

A
  • All victims of sexual violence should be offered emergency contraception
  • May need antinausea medicine; more so with combination pills
  • Irregular bleeding may occur in one week to one month after treatment; most have next menstrual period within 1 week of expected time.
  • Does not need follow-up
87
Q
A
88
Q

Sterilization
* benefits? (2)
* What is the efficacy?

A

Benefits:
* Highly efficient
* Excellent for those with medical contraindications to reversible methods

Efficacy:
* Female sterilization failure <1% first year; 10-year failure 1.85%; 0.75% for postpartum partial salpingectomy and laparoscopic unipolar coagulation to 3.65% for spring clips
* Male sterilization slightly more effective than female sterilization at 1 year mark;

89
Q

Sterilization
* What do you need to educate your patients on? (3)

A
  • Does not protect against STDs
  • Back up method required for 3-months post vasectomy
  • May be reversible in some cases
90
Q

Abortion
* When are they usually done?

A

Surgical, medical or combination may be used
In US:
* 60% performed before 9 weeks
* 90% performed before 13 weeks
* 1.2% are performed after 20 weeks

91
Q

*

Abortion
* What are the two abortion pills? How far along can you take it?

A

*Mifepristone – blocks progesterone and stops pregnancy
* Misoprostol – cramping and uterine bleeding (48 hours later-> day 3)
* Up to 11 weeks gestation

Two part method-> TAKE BOTH

92
Q

Abortion
* How do you do clinic abortion? How far along?

A
  • Open cervix and expel pregnancy tissue
  • Exact procedure depends on gestation
  • Up to 23 weeks gestation

Pharm III (14 decks)

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