Mens/Womens Health Flashcards
benefits of estrogen HT in menopause
decrease hip fx 25%
decrease vertebral fx 50%
decrease vaginal atrophy
decrease hot flashes
do not forget this if you do HT and have a uterus
also use a progesterone
risks of estrogen HT
gallbladder increases
increased risk of breast cancer - increases w/progesterone
endometrial cancer - lessens w/progesterone
heart disease
benefits of progesterone HT
decreases estrogen effects of irregular bleeding and hyperplasia and carcinoma
risks of progesterone HT
weight gain
irritability
depression - worse with higher doses
unpredictable bleeding w/continuous estrogen/progestin during first 8-12 months
when to use trandermal estrogen vs oral
if moderate risk of CHD and estrogen is needed
or does not tolerate oral well
vaginal estrogen for vasomotor symptoms
femring vaginal ring q3mo
estradiol acetate
estrogen/progesterone strategies
use progestin for 10-14 days and have a normal period
use continuous progestin, irregular bleeding, then amenorrhea
could do 3 days on and 3 days off but that’s rarely used any more
where do you apply the Divigel estrogen gel and the evamist estrogen spray?
gel - thighs
spray - forearm
progesterone primarily used in menopause for unopposed estrogen
medroxyprogesterone acetate
estrogen receptor agonist/antagonist for menopause sxs
ospemifene 60mg tabs (Osphena) - for vaginal atrophy
conjugated estrogens/bazedoxifene - prevent osteoporosis and mod to severe vasomotor symptoms - SERM
prasterone
vaginal atrophy
inactive steroid converted to androgen or estrogen
vaginal insert
caution in hx of breast cancer
definition of T scores in osteoporosis
-1 = 2x more likely to have a fracture
low bone mass and osteoporosis in relation to T score
-1 to -2.5 = low bone mass
>-2.5 = osteoporosis
low trauma spine or hip fx regardless of T score
low bone mass AND fragility fx or high FRAX score
drugs that increase risk of osteoporosis
SSRI’s
anticonvulsants, lithium
steroids
estrogen deficiency
excess levothyroxine
heparin
GNRH agonists
oncology
PPI’s
recommended daily Ca and Vit D intake
Calcium 1g
Vit D 1000 units
osteoporosis screening recommendations
women >70 and men >80 - Xrays of spine, hips, femoral neck
DXA scan or quantitative CT to measure T scores
may do younger women if T scores high or low trauma fractures or height loss significant
first line therapy for osteoporosis
bisphosphonates (except ibandronate - doesn’t help non-vertebral fx)
bisphosphonate side effects
GI - esophageal ulcer - don’t lie down 60 mins after
esophageal cancer
musculoskeletal pain
osteonecrosis of jaw
atypical fractures
duration of bisphosphonate therapy
treat orally for 5 years of IV for 3years and then reassess risk
may use for double this time frame if high risk of fractures
only bisphosphonate to show decreased mortality
zoledronic acid
bisphosphonate CrCl cut offs
CrCl <35 in alendronate and zoledronic acid
CrCl <30 in risedronate or ibandronate
RANKL inhibitors
denosumab - second line therapy for osteoporosis
SERMs
raloxifene 60mg daily
Duavee (conj. estrogen + bazedoxifene)
raloxifene
decreased bone turnover, estrogen antagonist in uterus and breast
does not reduce hip fractures
can cause hot flashes, leg cramps, VTE
conj. estrogens and bazedoxifene
prevention only
ADE: hot flashes, muscle cramps, throat/neck/muscle pain, N/V
VTE contraindications
human parathyroid hormone peptide analogs
teriparatide
abaloparatide
teriparatide
Forteo
regulates bone metabolism, Ca absorption and Ca/Phos absorption
treatment only, usually T -3 and fracture hx
not shown to decrease hip fractures
contraindicated in high Ca, bone tumors, alk Phos elevations
caused osteosarcoma in rats after 2 years
20mcg/daily SQ
abaloparatide
Tymlos
regulates bone metabolism, Ca absorption and Ca/Phos absorption
treatment only, usually T -3 and fracture hx
not shown to decrease hip fractures
caused osteosarcoma in rats after 2 years
80mcg/daily SQ
Evenity Romosuzumab
sclerostin inhibitor, build bone and decrease resorption
treatment only
precaution for major CV outcomes, atypical fracture
calcitonin salmon
inhibits bone resorption
increased risk of malignancies, not used as much, not a first line agent
intranasal therapy
first line agents for osteoporosis
alendronate
risedronate
zoledronic acid
denosumab
recommended duration of estrogen HT for menopause side effects
5 years, should evaluate after 3 months though and continually
when to jump to injectables for first line therapy in osteoporosis
T -3 or greater and history of fractures already, skip PO
known teratogenic drugs
alcohol
all hormones
ACE / ARB / ARNI
statins
anticonvulsants
antineoplastics / oncology
cocaine
fluconazole in high doses
isotretinoin (Acutane)
metals - lead, lithium, mercury
methotrexate
methimazole
paroxetine
TCN
warfarin
drugs contraindicated in lactated
amphetamines
oncology
benzos
bromocriptine
cocaine
ergotamine
kava
lithium
nicotine
yohimbe
herbs
opioids
first line agents in morning sickness
doxylamine and pyridoxine 10mg-10mg: 2 HS, max 4 daily
doxylamine ER 20-20mg: 1 BID
may use Benadryl, dimenhydrinate, ondansetron, reglan, or promethazine if necessary
drugs to avoid for constipation for pregnancy
stimulants are not first line
mineral oil may interfere with vitamin k absorption
drugs to avoid for headache with pregnancy
ergotamine
NSAIDs
triptans
pre-eclampsia problems
HTN > 140/90 + one of the following
proteinuria
renal insufficiency
thrombocytopenia
impaired liver function enzymes x2 ULN
pulmonary edema
HA unresponsive to therapy
vision changes
eclampsia definition
pre-eclampsia plus seizures
prevention of pre-eclampsia
ASA 81mg daily or BID
drugs that decrease contractions
terbutaline - beta agonist - must use IV/SQ, off label, <48 hrs use
magnesium - DOC in DM, keep high level, antagonizes calcium
prostaglandin inhibitor - indomethacin - limit 72 hrs lot of scary side effects
CCBs - limited to 48 hrs, nifedipine - caution if using with mag b/c doubling down on calcium decrease, hypotension
induction using prostaglandins
misoprostol - off label - prostaglandin E1
dinoprostone - vaginal only, gel or insert applied to uterus
breakthrough bleeding during contraceptive use and how to adjust
if early in cycle - increase estrogen
if mid cycle - increase progesterone
when in doubt - increase hormone content
ACHES with contraceptives
Abdominal pain - possible liver problems or gallbladder
Chest pain - SOB, blood cough, MI or PE
Headache - stroke or blood clot
Eye problems - optic neuritis, stroke or clot
Severe leg pain - DVT
emergency contraceptive comparison
levonorgestrol - OTC - most effective 72 hours, BMI <25
ulipristal - RX, 120hrs, BMI < 35
copper IUD - 120 hrs, office implant, no weight restriction
reasons for progestin only birth control
> 35yo and smokes
migraine with aura
cardiovascular risks, MI, stroke, afib, HTN > 160/100
liver disease, diabetic vision problems
breastfeeding
surgery in last 4 weeks
drugs that decrease efficacy of birth control
anticonvulsants (carbamazepine and oxcarb), phenytoin, phenobarb, primidone
some abx - TCN, PCN, cephalosporins
emend
HIV meds
modafinil
actos
oral contraceptive start times
any day or Sunday start - use bc for 7 days
first day of period
missed 2 pills of contraceptives advice
back up method for 7 days
emergency contraceptive if sex in past 5 days
high and very low estrogen contraceptive cutoff
35mcg ethinyl estradiol
10mcg ethinyl estradiol
drosperinone pros and cons
decreased acne, hair excess, estrogen bloating
increased risk of VTE
birth control patch cannot be used for which weights
BMI > 30 or weight over 90kg
duration a vaginal ring can be out for birth control
3 hours by manufacturer, others say 4 8 hours like others
vaginal ring for birth control and suppository rule
do not use oil based suppositories like those for miconazole
administration of progestin only birth control pills
must take within 3 hours of same time every day
birth control shot notes
can take up to 18 months to regain fertility
decreases bone mineral density when used for years - reversible
progressive weight gain
Side effects for long acting birth control
Period late - abnormal bleeding
Abdominal pain
Infection exposure, discharge
Not feeling well, chills
String missing
Weight limits on implanted birth control etonogestrel
Not studied in women > 130% ideal body weight
Ulipristal and resuming contraceptives note
Should not resume contraceptives hormonally for 5 days or decreases effectiveness of EC.
This is a progesterone antagonist and birth control overrides it
High prolactin treatments
Bromocriptine 2.5mg daily
Cabergoline 0.25mg BIW
Endometriosis drugs
Birth control
GnRH agonist - goserelin, leuprolide, nafarelin, triptorelin
GnRH antagonist - elagolix
Danazol - androgen agonist
Aromatize inhibitors - anastrozole, letrozole
Drugs for fertility
Clomiphene - 5 days early in cycle
Aromatize inhibitors - letrozole, single births usually
Human menopausal gonadotropin
Human chorionic gonadotropin - given before implantation
FSH - inj
GnRH
HSV drug dosing - initial
Acyclovir 400mg TID
Famciclovir 250mg TID
Valacyclovir 1g BID
7-10 days
HSV treatment second time
Acyclovir 800mg BID X 5D or 800mg TID 2 days
Famciclovir 125 BID 5d, or 250mg BID 5 D or 1g BID
valacyclovir 500mg BIDx 3, or 1g daily x 5 days
Disseminated HSV
Acyclovir 5-10mg/kg IV q8h 2-7 days then oral for ten total days of therapy
HSV suppressive therapy
If > 6 episodes a year
Acyclovir 400mg bid
Famciclovir 250 bid
Valacyclovir 500daily up to 1g if severe
Syphilis dosing
PCN 2.4 mil or doxy 100 bid 14d
If over 90 days of injection go to 28d
Latent or tertiary- PCN weekly x 3, doxy 4 wks
Neuro syphilis treatment
PCN 3-4 mil IV Q4h 10-14 days
Ceftriaxone 2g
Chlamydia treatment
Doxy bid seven days
Zmax 1g x 1
Levofloxacin 500 daily x 7
Gonorrhea tx
Ceftriaxone 0.5mg IM (1g if over 150kg)
Gent 240 + zmax 2g
PID tx
Ceftriaxone 1g + doxy+ flagyl bid
Cefotetan 2g q12h + doxy
Cefoxitin 2g q6h + doxy
Unasyn 3g q6h + doxy
Clinda 900mg q8h + gent 2mg/kg, then 1.5 q8h
IV for 24-48 hrs then oral to finish 14 days
Std. When should partners be treated?
90 days past for syphilis
Past 60 days for others
Bacterial vaginosis tx
Flagyl 500 bid x 7 or clinda gel Hs
Clinda 100mg PV HS x 3
Clinda 300mg bid x7
Tindazole 2g daily X2 or 1g x 5
Secnidazole 2g sache
Trichomoniasis tx
Flagyl 500mg bid x 7
Men 2 g x 1
Tindazole 2g x 1@
Prophylaxis for yeast infection
OTC vaginal 7 days course
Recurrent yeast infection tx
Fluconazole 100-200mg q72h x3
Or weekly x 6 months
Prostatitis tx
Cipro 500 bid or levaquin 750 daily
Bactrim bid or trimethoprim 200bid
14-28 days
Chronic prostatitis
4-6 weeks, up to 12 wks
Cipro 500bid, levaquin 750, ofloxacin or norfloxacin bid
Mini cyclone 100mg bid, doxy 100 bid, bactrim bid
Epididymitis tx
Chlamydia, gonorrhea, enteric
Ceftriaxone 0.5g (1g over 150kg) + doxy 10 days
Enteral - levaquin 500 daily x 10
Timing of PDE 5 inhibitors
Tadalafil 5mg 36 hrs before or 5mg daily
Sildenadil and other 30-1 he before
