Male & Female Health Flashcards
FDA rule with hormonal contraceptives
requires dispensing with patient package insert with ALL oral contraceptives
Drospirenone
a unique progestin, it is a mild potassium-sparing diuretic with lower androgenic activity = less bloating, weight gain, PMS symptoms, acne
Progestin-Only Pills (Mini-Pills)
28 day pack (all pills are active)
Primary uses:
–> women who are breastfeeding (estrogen dec milk production)
–> women who have migraines with aura (estrogen increases the risk of stroke)
*Adherence is essentail!
-take at the same time of day, daily
-id > 3 hrs have elapsed from the regularly scheduled time, a back up contraceptive is required for 48 hrs
Non-oral Hormonal Contraceptives
-Xulane contraceptive patch: higher estrogen exposure, less effective in women > 198 lb
-Vaginal contraceptive rings: inserted into the vagina once a month
-Injectable contraception: Depo-Provera (medroxyprogesterone acetate, DMPA), IM or SC q 3 months
-Intrauterine devices (IUDs): long acting
COCs: Seasonique
-extended cycle COC that has 84 days (12 weeks) of active hormone pills, bleeding occurs every 3 months
–> 84 days of EE and levonorgestral (LNG)
COCs: Amethyst
-continuous contraception, no inactive pills; no periods occur
–> 28 days of EE + LNG with no placebo pills
Contraceptive types/naming tips *
Lo: <35 mcg of estrogen (Loestrin)
Fe: includes an iron supplement (Junel Fe)
24: shorter placebo time, 24 active + 4 inactive (or Fe) pills (Minastrin 24 Fe)
Tri or 7/7/7: 3 diff hormone strengths for each “phase” or week (Tri-Sprintec, Nortrel 7/7/7)
Nor: contained the progestin norethindrone (Nora-BE)
Pro: contains a progestin (Depo-Provera)
AEs of hormonal contraceptives: Estrogen*
-Common and nonspecific: nausea, breast tenderness/fullness, bloating, weight gain, elevated BP (lower estrogen = less side effects but more breakthrough bleeding)
SEVERE & RARE:
-Abdominal pain (mesenteric or pelvic vein thrombosis)
-Chest pain (heart attack or pulmonary embolism
-Headaches (stroke)
-Eye problems (vision loss due to blood clot in the eye)
-Swelling (deep vein thrombosis)
AEs of hormonal contraceptives: progestin
late cycle breakthrough bleeding?
–> a higher dose of progestin needed
Drospirenone-containing products:
–> increased clotting risk, K+ retention
Depo-Provera:
–> bone density loss - take adequate calcium and vitamin D
Adverse effects of hormonal contraceptives: BBWs*
A. all estrogen containing products: do not use in women > 35 y/o who smoke due to risk of serious cardio events
B. Estrogen + Progestin patches (Xulane, Zafemy, Twirla): do not use in women with BMI > 30 due to increased risk of thromboembolism or decreased efficacy (T)
–> do NOT use estrogen with these conditions: hx of CVT/PE, stroke, CAD, hx of breast, ovarian, or liver cancer or migraines with aura
Considerations for drug selection: POP or non-hormonal method
-breastfeeding
-3-6 weeks postpartum
-CI to estrogen
-migraine w/ aura
-uncontrolled BP
Considerations for Drug selection: Drospirenone-Containing products
-acne
-fluid retention/bloating
-mood changes or disorder
-premenstrual dysphoric disorder (YAZ)
Considerations for drug selection: others
-mood changes or disorders: use mono phasic, extended or continuous style COCs (wont have changes in hormone levels)
-menorrhagia (heavy bleeding): Natazia or Mirena IUD
Drugs that decrease hormonal contraception efficacy
Strong inducers:
-Rifampin (requires a back up method for 6 weeks after d/c)
-Anticonvulsants (phenytoin, carbamazepine, topiramate)
-St. John’s wort
-Tobacco
Risk with hep C tx: Mavyret (liver toxicity)
Drospirenone: inc potassium risk
Starting BC pills
Combo Oral Contraception:
-takes ~ 7 days of tx to achieve efficacy (requires 7 days of non hormonal method)
-start today: maximizes protection from unintended pregnancy
-Sunday start: start the Sunday after onset of menstruation
Progestin-Only Pills:
-takes 48 hrs to achieve efficacy (use back up method for 48 hrs)
-start at any time, all come in 28 days packs and all pills are active
Instructions for late or missed Hormonal Contraceptive Pills
COCs:
–> 1 late or missed pill (< 48hrs): take missed pill ASAP & take next dose on schedule (even if it means 2 pills in 1 day)
-NO EC or back up method needed
–> 2 missed pills (> 48 hrs): take the most recent missed pill (discard the rest of missed pills), take the next dose as scheduled
- if missed 2 or more pills during week 3: omit hormone free week and start next pack
-back up contraception needed for 7 days, can consider EC if unprotected sex in last 5 days
POPS:
–> if > 3 hrs past scheduled time: take pill ASAP and take next dose on schedule
-back up method needed for 48 hrs, consider EC if unprotected sex in past 5 days
Long acting reversible contraceptives
IUDS: contain levonorgestrel
–> Mirena: inserted for up to 5 yrs, approved fro heavy menses
–> Skyla: inserted for up to 3 yrs
–> Paragard: copper-T IUD, inserted for up to 10 yrs, can be used for EC or regular BC
Implant:
–> Nexplanon: rod SC that releases estongesterel for 3 yrs
Emergency Contraception (EC)
A. Paraguard IUD: 99.9% effective, use within 5 days, placed by provider, good for up to 10 yrs
B. Ullipristal (Ella): less effective if > 195 lbs or BMI > 30, use ASAP or within 5 days. RX required, take after every episode of unprotected sex
–> 30 mg dose, taken up to 5 days, delays ovulation (chemical cousin to mifepristone - Ella is lower potency)
C. Levonorgestrel (Plan B): less effective if > 165 lb or BMI > 25, use ASAP or within 3 days, available OTC, use after every episode of unprotected sex
–> LGN 1.5 mg PO x 1 take within 72 hrs of sex (vomit within 2 hrs, repeat dose)
Infertility drugs*
-not being able to reproduce after 1 yr of sex
1st line: Clomiphene (SERM): ses- hot flashes, thrombosis
2nd line: gonadotropin : SC or IM
-inc LH/FSH = ovualtion/egg release
–> Clomiphene acts as estrogen to inc LH/FSH = causes ovulation
–> aromatase inhibitors suppress. estrogen to in FSH = causes ovulation
–> Gonadotropin durgs act as LH, FSH, or hcG = causes ovulation
Pros:
-infertility drugs trigger ovulation
-they can trigger the release of multiple eggs and inc risk of multiple births
Vitamin and Mineral supps in pregnancy
-vitamin D 600 IU/day
-folic acid 600 mcg/day (400 mcg daily for adults)
-calcium 1,000 mg/day
Immunizations in preganacy*
-Influenza vaccine (inactivated)
-Tdap x1 with each pregnancy (between weeks 27 and 36)
-live vaccines are CI
Teratogens: Danger in Pregnancy*
-Acne: Isotretinoin, topical retinoids
-Antibiotics: quinolones, tetracyclines
-Anticoagulants: Warfarin
-Dyslipidemia,HP,HTN: Statins, RAAS inhibitors, ARBs, aliskiren, valsartan
-Hormones: estrodial, progesterone, raloxifene, Duavee, testosterone, contraceptives
-Migrains: Dihydroergotamine, ergotamine
-Others: hydroxyurea, lithium, methotrexate, missoprostol, NSAIDs, Paroxetine, Ribavirin, Thalidomide, Topiramate, weight loss drugs, valproic acid, Divalproex
Management during pregnancy: Morning Sickness
1) lifestyle: eat smaller, more frequent meals, avoid spicy foods
2) vitamin B6 (pyridoxine) +/- doxylamine
RX: Bonjesta, Diclegis
-Doxylamine (Unisom) 25 mg tab
-Pyridoxine (B6) 25 mg daily 2-4 x daily
Management during pregnancy: Heartburn, Constipation, Gas
H: small meals, avoid trigger foods, calcium antacids (TUMs)
Gas: Simethicone (Gas-x, Mylican)
Constipation: inc dietary fiber, water, exercise, bulk forming laxatives (Metamucil, Fibercon), docusate
Management during pregnancy: Cough, Cold and Allergies
1st line: Cromolyn
2nd line: 1st gen antihistamines (Chlopheniramine - preferred, diphenhydramine)
–> if nasal steroids are needed: Budesonide (Rhinocort Allergy) or beclomethasone (Beconase AQ)
Management during pregnancy: Pain
acetaminophen is 1st line
**DO NOT use NSAIDs, especially in 3rd trimester
Management during pregnancy: Asthma, Anemia
Asthma: maintain control! - budesonide (Respules for baby), albuterol if needed
Anemia: Iron
Management during pregnancy: Hypertension and Diabetes
HTN: labetalol, methyldopa, nifedipine (low dose aspirin is rec for preeclampsia in high risk groups)
Diabetes: Insulin is the drug of choice (glyburide and metformin are used), screen for gestatinal DM, dietary modifications
-ADA: daily low dose aspirin for pregos w/ type 1 and type 2 dm to lower the risk of preeclampsia
Management during pregnancy: Infections
SAFE: penicillins, cephalosporins, erythromycin, azithromycin
AVOID: Quinolones (cartilage damage), tetracyclines (tooth discoloration)
–> vaginal fungal infections: topical antifungals x 7d
–> UTI:
-cephalexin 500 mg q6h x7d
-ampicillin 500 mg Qy6h x7d
(nitro & bactrim: should be considered LAST line during 1st trimester, and SHOULD NOT BE used in the last 2 weeks of pregnancy)
*must treat bacteriuria, even if asymptomatic w/ neg urinalysis; leads to premature birth, pyelonephritis and neonatal meningitis
Management during pregnancy: Anticoagulation & Thyroid Disorders
Anticoagulation: Low molecular weight heparin
-mechanical valve: LMWH, can go back to warfarin after 13th week of pregnancy, then back to LMH close to delivery
Hypothyroidism: Levothyroxine- needs a 30-50% dose INCREASE
Hyperthyroidism: ideal to normalize before pregnancy
-1st trimester: propythiouracil (PTU)**
-2nd and 3rd trimester: Methimazole **
**liver toxicity, crosses placenta & can cause congenital defects
Lactation
-breastfed bbys need 400 IU of vitamin D daily
-need 1 mg/kg daily of iron during months 4-6
DRUGS TO AVOID: amphetamines, aminodarone, ergotamines, lithium, metronidazole, phenobarbital and statins
–> HIV + females: breastfeeding is NOT recommended
-drugs for lactation resources: Lactmed, Briggs, Hales
Treating pain during breast feeding
DO NOT use codeine and tramadol: risk of excessive sleepiness, breathing diffculty and/or death
–> breastfed infant have died, esp in mothers who were CYP2D6 ultra-rapid metabolizers
Select factors conditions with Osteoporosis Risk*
-Patient characteristics: advanced age, ethnicity *white and asian women are at inc risk), family hx, gender (females), low body weight
-Medical Diseases/Conditions: anorexia, DM, Gi diseases (IBD, celiac disease, gastric bypass), hyperthyroidism, hypogonadism in men, menopause, RA, epilepsy, HIV/AIDS, Parkinson’s Disease
-Lifestyle Factors: smoking, excessive alcohol intake (> 3 drinks/day), low calcium intake, low vit D intake, physical inactivity
-Medications: anticonvulsants (carbamazepine, phenytoin, phenobarbital), aromatase inhibitors (letrozole), GnRH agonists, lithium, PPIs (dec calcium), steroids (> 5 mg daily for > 3 months), thyroid hormones, heparin, loop diuretics, SSRIs, TZDs
Diagnosis of Osteoporosis*
What is a T-score?
–> compares the pts measured BMD to the average peak BMD of a healthy, young, white adult of the same sex
-a DEXA (DXA) measured BMD so a T-score can be determined (T-scores are neg, > -1 = denser bones
Who should have BMD measured?
–> women > 65 y/o
–> men > 70 y/o
–> younger pts at high risk for fracture
Interpreting T-score Results:
–> normal = > -1
–> Osteopenia (low bone mass): -1 to -2.4
–> Osteoporosis: < - 2.5
Prevention of OS: calcium and Vit D supplementation *
CALCIUM: rec daily intake: 1,000-1,200 mg of elemental ca daily (do not exceed 500-600 mg/dose)
–> Calcium Carbonate (TUMs): 40% elemental CA, acid dependent absorption, must take w/ meals
–> Calcium Citrate (Citarcal): 21% elemental Ca, not acid dependent, can take w/ or w/o food
VITAMIN D: required for Ca absorption, 600 IU daily
-deficiency = serum Vit D (25(oh)D) < 30 ng/ml
–> Cholecalciferal (D3) 125-175 mcg daily OR
–> Ergocalciferl (D2) 1,250 mg weekly
*Osteoporosis treatment: Bisphosphonates
1st line for tx and prevention - stops osteoclasts (bone breakdown)
-Alendronate (Fosamax) PO weekly
-Ibandronate (Bonvia) monthly PO, IV q 3 mon
-Zoledronic acid (Reclast) IV q year
-take 1st thing in the am before you eat or drink w/ full glass of water, must sit or stand upright for 30 mins (60 mins w/ Ibandronate (Boniva)) and do not eat or drink
SE: esophagitis, hypocalcemia, GI effects, bone pain
Rare SEs: atypical femur fractures, osteonecrosis of the jaw
-has PO given weekly or monthly, IV (Zoledronic acid (Reclast)) - IV once yearly
*treatment duration is 3-5 yrs
*Osteoporosis treatment: Estrogen Antagonist-Antagonist Containing products
-alt to bisphosphonates if high risk of vertebral fractures
–> both increase risk of VTE and stroke
Raloxifine (Evista): SERM, can be used if low VTE risk or high breast cancer risk, d/c at least 72 hrs prior and during surgery or w/ prolonged bed rest
-SEs: vasomotor symptoms
Bazedoxifene/Estrogen (Duavee): can be used in women w/ an intact uterus for prevention
-SEs: inc risk of breast cancer
*Osteoporosis treatment: Parathyroid Hormone 1-34
-Teriparatide (Forteo) inj- requires protection from light
-Abaloparatide (Tymlost)
recommended for very high risk pts only
-daily SC
-SEs: hypercalcemia, urinary stones, bone cancer, leg cramps,
*Osteoporosis treatment: Denosumab (Prolia)
-alt to bisphosphonates
-SC admin every 6 months
SE: hypocalcemia
*Osteoporosis treatment: last line or not recommended
-estrogen (with or w/o progestin) fro prevention only in postmenopausal women with vasomotor symptoms: use lowest possible dose for shortest duration of time
-calcitonin for tx only if other options are not suitable (less effective and has a risk of cancer with long term use)
*Menopause hormone therapy: Estrogens
-most effective tx for vasomotor symptoms: use topicals when you can
-women w/ a uterus use in combo with a form of progesterone; unopposed estrogen increases the risk of endometrial cancer
-associated with significant safety risks: BBW for VTE, stroke, dementia and breast cancer
*Menopause hormone therapy: Progestin
-Progestins (norethindrone, levonorgesterol, drospirenone) can be given as part of combo pill w/ estrogen or as a separate tab (MPA)
-can cause mood disturbances, spotting
-micronized progestins (Premetrium) are considered safer than synthetic progestins (medroxyprogesterone)
*Menopause hormone therapy criteria
-healthy, symptomatic women who are within 10yrs of menopause, < 60 y/o and have no CI to use
-extended tx beyond age 60 may be acceptable if the loest poss dose is used
-pts with risk factors (age, time since menopause, risk of blood clots, heart disease, stroke and breast cancer) should use nonhormonal options: SSRIs, SNRIs, gabapentin or pregabalin
Other products for menopause
Natural products: black cohosh, red clover, soy, flaxseed, dong quai, st. johns wort and evening primrose oil
SSRIs: Paroxetine (CYP2D6 inhibitor, bleeding risk)
-Osphemifene (Osphena): oral estrogen agonsits/antagosnit for painful intercoutse (dyspareunia) - VTE risk
Testosterone BBWs- C-III
-reports of virilization of children d/t testosterone exposure (androgel- daily application on shoulders)
-breast/prostate cancer risk
-BPH symptoms would be expected to worsen w/ testosterone tx
SEs: inc appetite, acne, edema, hepatotoxicity, reduced sperm count
Natural products for ED
-Yohimbe (GI, anxiety, CVD effects)
-L-argninine (dizziness, HA & flushing)
-Panax Ginseng
Drug that can cause erectile dysfunction*
-alcohol
-antidepressants: SSRI/SNRIs
-antihypertensives: BBs, clonidine, thiazides
-antipsychotics: 1st gen (chlorpromazine), risperidone, paliperidone
-BPH meds: finesteride, dutasteride and sildosin
-nicotine
-cimetidine
-opioids (chronic use- methadone)
PDE-5 inhibitors for ED
-sildenafil (Viagra) -also used for PAH, 1 hr before sex
-vardenafil (Levitra), 1 hr before sex
-tadalafil (Cialis) - also used for PAH, 30 mins before sex
-Avanafil (Stendra)- take 15-30 mins before sex
CI: use with nitrates (“nitr” in the name, bidil)
Warnings: impaired color discrimination, hearing loss, vision loss, hypotension, priapism
SE: HA, flushing, dizziness, dyspepsia
PDE-5 inhibitor dosing guide*
reduce dose if: > 65 y/o, using an alpha blocker (doxazisin, tamsulosin), using a CYP3A4 inhibitor, severe renal or liver damage
-Viagra - blue 50 mg –> 25 mg
-Cialis (brown), Levitra (orange): 10 mg –> 5 mg
-Stendra (yellow): 100 mg –> 50 mg
Alprostadil (Prostaglandin E1) for ED
-shot or pellet urethral suppository
SEs: penile pain, priapism, HA, dizziness
pp shot SE: hematoma, bruising at injection site
Hypoactive sexual desire disorder
poss causes: menstrual cycle, hormonal contraceptives, postpartum states and lactation, oophorectomy and hysterectomy, menopause things
–> Fibanserin (Addyl):
CI: w/ alcohol (REMS)
Warnings: hypotension, syncope, CNS depression
SEs: dizziness, somnolence, nausea, fatigue, dry mouth
(not effective, bad effects)
Key drugs that can worsen BPH *
-anticholinergics (benztropine)
-antihistamines (Diphenhydramine)
-caffeine
-decongestants (pseudoephedrine)
-diuretics
-SNRIs
-TCAs (amitriptyline)
-testosterone products
Diagnosis: digital rectal exam + prostate specific antigen
BPH drug treatment: Alpha Blockers
–> Non-selective: terazosin, doxazosin (Cardura)
-tirate slowly, give at bedtime
–> Selective: Tamsulosin (Flomax): 0.4 mg daily, Alfuzosin- QT prolongation, Silodosin: retrograde ejaculation
CI: hepatic and renal impairment
Warnings: orthostatic hypotension/syncope, intraoperative floppy iris syndrome can occur in cataract surgery if on or previously used
SE: dizziness, fatigue, headache, abnormal ejaculation
BPH tx: 5 Alpha-reductase Inhibitors
shrink the prostate and decrease PSA levels
-Finasteride (Proscar)
-Dutasteride (avodart) + tamsulosin (Jalyn)
SEs: impotence, libido, breast enlargement/tenderness
-hazardous drug
Risk factors for overactive bladder
-age > 40
-DM
-prior vaginal delivery
-obesity
-neurological conditions
-drugs that increase incontinence (alcohol, cholinesterase inhibitors, diuretics, sedatives)
Anticholinergics used for overactive Bladder
-Oxybutynin
-Oxybutinin XL (Ditropan)
-Oxybutynin patch (Oxytrol)
-Oxybutynin 10% topical cream
-Soliifenacin (VESIcare)
-Tolterodine (Detrol)
Anticholinergics safety/SEs/Monitoring
CI: uncontrolled narrow angle glaucoma
Warnings: agitation, confusion, drowsiness, dizziness, blurred vision
SEs: dizziness and drowsiness, xerostomia, constipation
Notes:
–> Ditropan XL is OROS formulation = ghost shell in stool
Patches to be removed before an MRI*
-Clonidine (Catapres-TTS)
-Diclofenac (Flector)
-Estrogen
-Rotigotine (Neupro)
-Scopolamine (Transderm Scop)
-Testosterone (Androderm)
Anticholinergic Side effects *
Peripheral:
-Dry mouth
-Dry eyes/blurred vision
-Urinary retention
-Constipation
-Tachycardia
Central:
-Sedation
-Dizziness
-Cognitive impairment
Decreasing risk of dry mouth w/ anticholinergics *
-extended release formulations
-oxybutynin gel or patch
-beta 3 agonists have a lower incidence of dry mouth and can be helpful in pts who cannot tolerate anticholinergics
-non drug options: avoid mouthwashes with alcohol, use ice chips, water, sugar-free candy or gum
Beta-3 Agonist for Overactive Bladder
-Mirabegron (Myrbetriq)
-Vibegron (Gemtesa)
–> relax the detrusor muscle + increase bladder capacity by activating beta-3 receptors (less dry mouth)
SEs: hypertension, angioedema of face/lips/mouth
-effective within 8 weeks
-moderate inhibitor of CYP2D6
Last line tx for Overactive Bladder
-Onabotulinumtoxin A (Botox)
Dose: 100 units total over 20 sites, max Q3 months
SEs: UTIs, urinary retention, dysuria
–> requires ab before and after administration
Nocturia Treatment for adults
Desmopressin (DDAVP)
-antidiuretic hormone that temporarily decreases urine production
BBW: hyponatremia
