Menopause, osteoporosis, pediatric gynecology

Question 1

Primary outcome of WHI

Answer 1

MI and acute coronary death

Question 2

Primary adverse event of WHI

Answer 2

Breast cancer

Question 3

Interventions assessed in WHI

Answer 3

HRT, low fat diet, calcium / vit D supplementation

Question 4

CVA and DVT outcomes with HRT in WHI

Answer 4

CVA increased in women >65 y/o

DVT risk doubled

Question 5

Impact of HRT on fracture risk

Answer 5

Significant decrease in fracture risk, especially hip

Question 6

Stratified for women 50-59 y/o, WHI outcomes for HRT use…

Answer 6

30% decrease in all-cause mortality

CHD risk indeterminate

Question 7

Contraindications to HRT

Answer 7

Pregnancy, breast cancer, estrogen-sensitive tumor, undiagnosed VB, severe liver disease, history of DVT

Question 8

Non-hormone alternatives to HRT

Answer 8

Progesterone (not FDA approved), SSRI (paroxetine, contraindicated with Tamoxifen), clonidine, gabapentin, soy products

Question 9

DXA measurement sites

Answer 9

Lumbar spine, total hip, femoral neck

Question 10

How T score works

Answer 10

Compares to growth phase peak cohort, intended for use in postmenopausal women

Question 11

T score values

Answer 11

-1 to -2.5 is osteopenia

< -2.5 is osteoporosis

Question 12

How Z score works

Answer 12

Compares to age-matched cohort for women <40 y/o

Question 13

When to start screening with DXA

Answer 13

65 y/o or younger if FRAX 10-year risk >9.3%

Question 14

When to repeat DXA screening

Answer 14

q2yrs during treatment
q1-5 yrs if osteopenic
q15yrs if normal T-score

Question 15

Start pharmacologic treatment in osteopenia if…

Answer 15

FRAX 10 yr hip risk >3% or major fracture risk >20%

Question 16

Prevention of osteoporosis

Answer 16

Lifestyle factors, calcium / vit D supplementation, HRT (loses benefit 2 yrs after stopping)

Question 17

Mechanism of bisphosphonates

Answer 17

Inhibit osteoclasts, reduce inhibition of osteoblasts

Question 18

Contraindications to bisphosphonates (specifically zoledronate)

Answer 18

1. Renal failure
2. Cr >2.0
3. Hypocalcemia

Question 19

Side effects of bisphosphonates

Answer 19

GI irritation, ulcers, hypocalcemia, atypical hip fracture, esophageal cancer (rare), osteonecrosis of jaw (rare except with IV dosing)

Question 20

SERMs for osteoporosis treatment

Answer 20

Raloxifene (dec spine fx and inc BMD), tamoxifen (does same but not FDA approved)

Question 21

Sequential therapy for osteoporosis

Answer 21

Consider early SERM use < 60 y/o then bisphosphonates > 60 y/o x 5-10 yrs

Question 22

Teriparatide (Forteo) mechanism

Answer 22

PTH analogue = increase osteoblasts, decrease osteoclasts

Question 23

Time frame for teriparatide use

Answer 23

Up to 2 yrs, then rapid bone loss of discontinuation (consider bisphosphonate or SERM)

Question 24

Denosumab (Prolia) mechanism

Answer 24

KB ligand nuclear receptor monoclonal antibody that blocks osteoclast activation

Question 25

Indication for denosumab

Answer 25

Menopausal women with high fracture risk, intolerance of bisphosphonates

Question 26

Risk of denosumab

Answer 26

Serious infection

Question 27

Infectious causes of vulvo-vaginitis in young girls

Answer 27

Respiratory pathogens like GAS
Enteric pathogens like Shigella (bloody discharge)
STIs
Vaginal candida (suspect immunocompromised)
Pinworm / enterobiasis

Question 28

Treatment for labial adhesions

Answer 28

Topical estradiol BID x 2-3 wks, emollients, hygiene; surgery only if acute urinary retention