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CDM 4 Exam 1 > Lecture 9 - PCOS & Adrenal Disorders > Flashcards

Lecture 9 - PCOS & Adrenal Disorders Flashcards

1
Q

PCOS

A

Polycystic Ovary Syndrome

diagnosed by presence of 2 of 3 following criteria…

Hyperandrogenism
ovulatory dysfunction
polycystic ovaries

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2
Q

PCOS Pathophysiology

A

Never get to Corpus Luteum stage and make the primary follicle

Abnormal LH/FSH production in anterior pituitary. Pts with PCOS have 2-3 times normal ratio LH/FSH (Making more LH)

LH prevents primary follicle

Can have infertility

LH causes a lot of excess androgen production

convert cholesterol to testosterone more efficiently = more test

have some insulin resistance, and hyperinsulinemia = more test

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3
Q

Menstral irregularities

A

Oligomenorrhea = < 8 periods per year or menstruation cycle with duration > 35 days

Amenorrhea = no menstration for > 3 months w/o pregnancy

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4
Q

PCOS Clinical presentation, any of the 2 to be diagnosed

A

Central irregularities
Hyperandrogenism
Polycystic ovaries
Insulin resistance
Obesity

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5
Q

Polycystic ovaries defintion

A

> 20 follicles measuring 2-9mm or an inc in ovarian volume of 10ml in either ovary with no evidence of dominant folicclesa or corpora lutea

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6
Q

PCOS complications

A

Reproductive consequences
Endometrial cancer
Metabolic consequences
CVD risk
Obstructive sleep apnea
Depression

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7
Q

PCOS Risk factors

A

Menarche at early age
Weight
Family history of PCOS

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8
Q

Clomiphene MOA:

A

Selective estrogen receptor modulator

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9
Q

Clomiphene Clinical benefit

A

Management of infertility

higher risk of multiple births compared to letrozole

rec adding metformin in pts > 28yrs old who have clomiphene resistance and visceral obesity

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10
Q

Clomiphene Dosing

A

50mg PO 5 days, start 5th day of cycle

can titrate up to 100-150mg in subsequent cycles

dont do more than 6 cycles

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11
Q

Clomiphene CI

A

Preg or breastfeeding

preg test before each cycle

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12
Q

Clomiphene ADE

A

Vasomotor symptoms
Flushing
headache
vision changes

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13
Q

Letrozole MOA

A

Aromatase inhibitor, reduces estrogen production

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14
Q

Letrozole Clinical Benefit

A

Management of infertility

1st line option

Alternative for clomiphene failures

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15
Q

Letrozole dosing

A

2.5-7.5mg PO QD on cycle days 3-7

can take up to 5 cycles

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16
Q

Letrozole ADE

A

Edema
hot flashes
Headache
Fatigue
nausea
dizziness
bone pain

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17
Q

Letrozole CI

A

Preg

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18
Q

Letrozole DI

A

CYP3A4 and CYP2A6 substrate

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19
Q

Gonadotropins info

A

second line therapy for those who failed other treatments

MOA: ovulation induction

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20
Q

Metformin for infertility

A

2nd line
can add to clomiphene for resistance
can be used as adjunctive therapy during IVF

Dosing: 500mg TID

helps with weight loss, improvement in menstrual cycle, hyperandrogegism symptoms, and insulin resistance

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21
Q

PCOS treatment Algorithm

A

Obese = start Lifestyle mod 3-6 months then meds
Non obese = meds

if still no preg add metformin

if ovulation returns, try for 6 months

if ovulation not return, see expert

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22
Q

Contraception info PCOS

A

use very low doses of estrogen (NMT 35mcg ethinyl estradiol)

preference for middle to low androgen or anti androgen progestin

can do intermittent or continuous progestin only

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23
Q

PCOS Oligomenorrhea Treatment Algo

A

Obese = lifestyle mod for 3-6 months, then continue previous pathway if they want baby

Non obese = if want baby then do previous pathway, if no baby then contraception

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24
Q

Preferred Hyperandrogenism treatment

A

Spironolactone

Dose: 50-100mg BID

ADE: Hyperkalemia, HA, fatigue

Pt ed : use contraception to prevent feminization of male fetuses; months to see benefit maybe

DI: ACE/ARBs

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25
Finasteride for Hyperandrogenism
Dosing: 5-7.5mg QD ADE: Hypersensitivity, dec libido DI: St. Johns Wart CI: dont use pregnancy Pt ed: use contraception, can take months Used for management of hirsutism/alopecia
26
Eflornithine info
used for Hyperandrogenism Applied to face BID ADE: stinging, burning, rash Pt ed: stop if preg, effects not permanent, weeks to see benefit, apply 5min after hair removal & dont wash for 4hrs after, can apply lotion/sunscreen once dry
27
PCOS Hirsutism Algo
Obese = lifestyle changes = Contraception for 6 months then can add on meds Non obese = contraception for 6 months, then add on meds nonpharm: shaving, waxing, etc
28
PCOS monitoring
Height, weight, BMI ADE of pharm therapy BP Lipids Depression/Anxiety Quality of life Clinical signs/symptoms of PCOS
29
Which zone releases mineralcorticoids
Zona glomerulosa, adrenal cortex
30
Which zone releases glucocorticoids
Zona fasciculata, adrenal cortex
31
Which zone releases androgens
Zona reticularis, adrenal cortex
32
Which zone releases stress hormones
Epi & Norepi Adrenal medulla
33
Adrenal Gland Excess is called...
Cushing syndrome hyeraldosteronism
34
Adrenal Gland excess is called...
Cushing syndrome Hyperaldosteronism
35
Adrenal Glass insufficiency is called...
Addison disease
36
Addison Disease info
also known as primary adrenal insufficiency severe and life threatening cortex doesnt produce enough glucocorticoids, mineralocorticoids, dehydroepiandrosterone
37
Primary vs secondary Adrenal insufficiency
Primary #1 cause = autoimmune, happens at adrenal gland Secondary #1 cause = long-term glucocorticoid therapy, happens outside adrenal gland
38
PAI clinical presentation
Hyperkalemia Hyperpigmentation Vitiligo
39
SAI clinical presentation
Pale Skin Small balls secondary hypothyroidism Headache, Visual symptoms Amenorrhea, dec libido
40
PAI and SAI clinical presentations that overlap
Tiredness, weakness Dizziness, orthostatic hypotension Hyponatremia, hypolycemia
41
Pharm therapy PAI
Corticosteroids Mineralocorticoids potentially DHEA
42
Pharm therapy SAI
Corticosteroids
43
preferred therapy for adrenal deficiency
Hydrocortisone
44
Glucocorticoid dosing
Hydrocortisone = 15-25mg/day Cortisone acetate 20-35mg/day in 2-3 divided doses preferred avoid late due to insomnia, give majority in morning and rest later
45
Glucocorticoid pt education
Take w/ food minimize GI discomfort dont self D/c, have to be tapered slowly over time wear med ID indicating on long term steroids
46
Fludrocortisone (Mineralocorticoids)
ADE: Edema, hypokalemia, HA, muscle weakness, inc BP, hypernatremia DI: diuretics and AA used adjunctive therapy PAI
47
DHEA info
used women on appropriate therapy with low libido ADE: acne, hirsutism DI: SSRI, lithium, triazolmam, carbamazepine, estrogen, testosterone Monitor: morning serum DHEA lvls before taking dose
48
DHEA implement and monitoring
Pt ed is key consequences of missed dose Signs/symptoms of adrenal insufficiency and crisis stress management wearing medical alert bracelet
49
Signs and symptoms of adrenal insufficiency or adrenal excess
Body weight postural BP energy lvls Signs of frank glucocorticoid excess (edema, weight gain)
50
ACTH Dependent (80%)
known as Cushing Disease (Pituitary Adenoma) produce too much cortisol
51
ACTH Dependent (20%)
at level of cortex
52
General diagnosis of Cushing syndrome
too much cortisol
53
non-pharm Cushing Syndrome therapy
Surgical intervention (1st line) radiation therapy
54
Pharm Cushing Syndrome therapy
Adjunctive to surgery or potential use in pts unable to get surgery
55
Etomidate info
AE: sedation, nausea, vomiting, hypotension IV, rarely used
56
Ketoconazole info
v high dose ADE: GI, elevated LFTs, gynecomastia CI: Pts w/ hepatic disease, strong CY3A4 substrate and inhib not preferred in men
57
Metyrapone
ADE: Androgenic effect CYP3A4 inducer Not preferred In women need special permission to use in USA
58
Cabergoline
ADE: Nausea, Dizziness, psychiatric syndromes not best option if already psychiatric
59
Pasireotide
$$$$ Hepatic dose adjustment potential DDI w/ Ketoconazole Monitoring: Serum glucose, potassium, A1C, LFTs, UFC, thyroid function, HR, ECG
60
Mifepristone
Abortifacient, cant use in preg women ADE: Hypokalemia Req renal and hepatic dosing preg testing before take
61
Mitotane
ADE: GI upset, nausea, vomiting, diarrhea, lethargy, somnolence, CNS Take w/ food for GI, CYP3A4 inducer Avoid women designing pregnancy, stay in fat for years monitor: UFC and Urinary steroid production
62
Cushing Monitoring
Sodium conc Free T4 conc Prolactin conc Cortisol conc improvement in signs/symptoms SE of meds

CDM 4 Exam 1 (12 decks)

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