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Therapeutics Fall 2016 > Module 2 - Men's and Women's Health > Flashcards

Module 2 - Men's and Women's Health Flashcards

1
Q

LUTS definition

A

Lower Urinary Tract Symptoms; broadly grouped into voiding (obstructive) symptoms or storage (irritative) symptoms

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2
Q

At what age should screening begin for prostate cancer? And how often f/u?

A

Being screening: age 40
Follow up: every 2-4 years
F/u every year if high risk group (AA, family hx, etc)

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3
Q

Symptoms of testosterone deficiency

A
  1. Decreased libido
  2. Weight gain
  3. Loss of energy
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4
Q

Diagnosis of Hypogonadism

A

low testosterone levels WITH symptoms

  • total T less than 300 ng/dl
  • free T less than 5 ng/dl
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5
Q

Which testosterone replacement formulation is most similar to physiologic testosterone levels?

A

Patch

Dose: 1-2 5mg patches applied nightly (back, thigh, or upper arm)

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6
Q

What are the contraindications for testosterone replacement therapy?

A
  1. Prostate cancer
  2. Breast cancer
  3. Hct > 50 %
  4. PSA > 4 ng/ml (> 3 if high risk)
  5. Recent or poorly controlled CVD
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7
Q

Goal testosterone level

A

Monitor every 3-6 months after initiating therapy

Goal T: between 400-700 ng/dl

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8
Q

Normal size of prostate gland

A

Less than 20 g

-growth common after age 40

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9
Q

What hormone is responsible for prostate enlargement and growth?

A

Dihydro-testosterone (DHT)

-5-alpha reductase converts T. to DHT

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10
Q

BPH obstructive symptoms

A

-decreased force of stream
-hesitancy to initiate voiding
-strain/push to urinate
-terminal dribbling
-intermittency
Results in incomplete emptying (residual urine)

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11
Q

BPH irritative symptoms

A

Secondary to incomplete emptying

  • nocturia
  • frequency
  • urgency
  • dysuria
  • urge incontinence
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12
Q

Diagnosis of BPH

A

clinical sx PLUS digital rectal exam

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13
Q

Classification of BPH severity

A

Mild: AUA less than 7
Moderate: AUA 8-19
Severe: AUA greater than 20

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14
Q

In which BPH patients should antimuscarinics be avoided?

A

-post-void residual: greater than 200 mL
-max urine flow rate: less than 5 mL/sec
Because could cause urinary retention
-Alzheimer’s
Because decrease cognition

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15
Q

What combination of drug classes provide better symptom control for men with BPH and OAB (incontinence)?

A

alpha-antagonists plus anti-muscarinics (anticholinergics)

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16
Q

Onset of alpha-1a adrenergic blockers?

A

1-6 weeks

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17
Q

alpha-1a adrenergic blocker MOA

A

relaxes smooth muscle tone of prostate gland and bladder neck for improved urine flow
(does NOT reduce size of prostate)

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18
Q

Selective alpha-1 adrenergic blockers

A
  1. tamsulosin (Flomax)
  2. alfuzosin (Uroxatrol)
  3. silodosin (Rapaflo)
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19
Q

Non-selective alpha-1 adrenergic blockers

A
  1. terazosin (Hytrin)
  2. doxazosin (Cardura)
    * bedtime dosing to prevent first-dose effect (orthostatic hypotension)
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20
Q

Hormonal therapy MOA

A

5-alpha reductase inhibitors decrease DHT production which results in 20-25% reduction in size of prostate gland

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21
Q

Which patients benefit most from hormonal therapy for BPH?

A

Men with prostate size greater than 40 g

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22
Q

Onset of 5-alpha reductase inhibitors?

A

may be as long as 6 months

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23
Q

SE of hormonal therapy

A

impotence, decreased libido, category X

-usually mild and transient

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24
Q

What is an option for patients with severe BPH that are not surgical candidates?

A

Botox injections; induce prostatic atrophy

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25
Q

Which drug classes may induce sexual dysfunction (decrease libido)?

A

Antidepressants
Antihypertensives
Estrogens/Anti-androgens
Cancer Chemotherapy

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26
Q

Erection MOA

A
  1. NO released upon sexual stimulation
  2. cGMP levels elevated
  3. smooth muscles in penis relax
  4. arterial blood floods chambers
  5. veins squeezed shut (prevents draining)
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27
Q

Which PDE-5 inhibitors must be taken on an empty stomach?

A
  1. sildenafil (Viagra)
  2. vardenafil (Levitra)
    * food delays absorption by 1 additional hour
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28
Q

Which PDE-5 inhibitors is the longest acting?

A

tadalafil (Cialis)

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29
Q

What is the main DDI for PDE-5 inhibitors?

A

CYP3A4 inhibitors prolong effect of PDE-5 inhibitors

ex: cimetidine, ketoconazole, erythromycin, ritonavir, grapefruit juice

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30
Q

Which ED treatment option should be avoided in pts with sickle-cell anemia?

A

Vacuum Erection Devices

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31
Q

What is the drug of choice if pts fail PDE-5 inhibitors?

A

Alprostadil (Caverject)

-intracavernosal injection

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32
Q

Which treatment is best for neurogenic ED?

A

Alprostadil (Caverject)

-intracavernosal injection

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33
Q

MUSE (brand)

A

Alprostadil Pellets (generic)

  • transurethral suppository
  • less effective than injection
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34
Q

Which treatment for ED results in spontaneous erection without sexual stimulation?

A 
Alprostadil injection (Caverject)
-titrate to dose that produces erection lasting 1 hour
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35
Q

Which ED treatment is rarely used d/t its higher incidence of ADRs?

A

Papaverine (intracavernosal injection)

-35% incidence of priapism and fibrosis

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36
Q

Pap smear recommendations

A

Every 3 years starting at age 21

Every 5 years after age 30 (co-test with HPV)

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37
Q

When are pap smears not needed?

A
  1. younger than 21
  2. older than 65 if low risk
  3. after hysterectomy with cervix removal if no hx of cancer
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38
Q

What are the 5 fertility awareness methods (FAM) and natural family planning (NFM)?

A
  1. Basal Body Temp (BBT)
  2. Billings Ovulation Method
  3. Calendar/Rhythm Method
  4. Standard Days Method
  5. Two-Day Method
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39
Q

Billings Ovulation Method

A
  • cervical mucus patterns throughout cycle to determine time of ovulation (minimal, increased, decreased)
  • good for irregular cycles
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40
Q

Calendar Rhythm Method

A

Based on past cycles to determine fertile window when higher pregnancy risk

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41
Q

Standard Days Method

A

Bracelet with movable rubber ring; white beads represent fertile window when pregnancy is most likely

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42
Q

Basal Body Temperature

A
  • predict ovulation with regular cycles

- temp first thing in the morning; initial drop then increase indicates ovulation

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43
Q

Two-Day Method

A

-cervical secretion: if present today or yesterday, then indicative of fertile period (avoid intercourse to avoid pregnancy)

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44
Q

Amount of estrogen that classifies contraceptive as very low, low, or high dose

A

Very low dose = 20-25 mcg EE
Low dose = 30-35 mcg EE
High dose = 50 mcg EE

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45
Q

Progestin classes

A
  1. Estranes
  2. Gonanes
  3. Dropirenone
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46
Q

Estranes

A

Derivatives of norethindrone

-norethindrone, norethindrone acetate, ethynodiol acetate

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47
Q

Gonanes

A

Derivatives of norgestrel
-norgestrel, levonorgestrel, norgestimate, etonogestrel/desogestrel
(no estrogenic activity)

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48
Q

Drospirenone

A

Analogue of spironolactone

no estrongenic or androgenic activity; minimal progestational activity

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49
Q

Serious SE from COC

A

ACHES

  • Abdominal pain
  • Chest pain (SOB, coughing)
  • HA (severe, dizziness)
  • Eye problems (double/blurry vision)
  • Severe leg pain (calf/thigh)
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50
Q

Directions if missed in week 2 or 3 of COC pills

A
  • if missed 1 dose: take when remember and no backup needed
  • if missed 2+ doses: take 2 pills in one day (regardless of # missed), then resume normal schedule; backup needed x 7 days
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51
Q

Directions if missed in week 1 of COC pills

A

Use backup x 7 days regardless of how many doses missed

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52
Q

Transdermal hormonal contraceptive directions

A

Ortho-Evra
1 patch/week x 3 weeks
patch free x 1 week

*less effective if > 90 kg

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53
Q

Patch/Ring dysfunction directions

A

Patch:
off > 1 day = new patch, restart 4 week cycle

Ring:
out > 3 hours = new ring if week 3, restart cycle (that day or wait till next cycle begins)

*back up method x 7 days for both

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54
Q

Progestin-only contraceptives

A
  • Oral: norethindrone or norgestrel (Minipill)
  • Injectable: medroxyprogesterone acetate (Depo-Provera)
  • Subdermal: etonogestrel (Nexplanon)
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55
Q

Dosing considerations of progestin-only contraceptives

A
  • Oral: take continuously; must be taken within 3 hours of scheduled time or backup x 48 hours
  • SQ/IM: every 3 months (12 weeks)
  • Subdermal implant: up to 3 years
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56
Q

Progestin-only Contraceptive contraindication

A

Current breast cancer

57
Q

Intrauterine Devices (IUD)

A
  1. Paragard (copper; 10 years)
  2. Mirena (52 mg levonorgestrel, 5 yrs)
  3. Skyla (13.5 mg levonorgestrel, 3 yrs)
  4. Liletta (52 mg levonorgestrel, 3 yrs)
58
Q

Methods of Emergency Contraception

A
  1. Levonorgestrel ECPs
  2. Combination ECPs
  3. Ulipristal acetate (ella)
  4. Copper IUD
59
Q

Levonorgestrel ECP dosing

A

(Plan B/Next Choice One-Step)

1.5 mg levonorgestrel within 72 hours of unprotected intercourse

60
Q

Combination ECP dosing

A

At least EE 100 mcg and levonorgestrel 0.5 mg per dose (2-4 tablets/dose)

  • 1 dose q 12 hrs x 2
  • first dose within 120 hours
61
Q

Ulipristal acetate dosing

A

(ella, Rx only)

30 mg tablet x 1 dose within 120 hours

62
Q

Which EC has the lowest failure rate?

A 
Copper IUD (failure rate of 0.1%)
-also provides long term contraception (up to 10 years)
63
Q

Most common STI in the United States?

A

Human Papillomavirus (HPV)

64
Q

HPV serotypes associated with genital warts and cervical cancer

A

Genital warts: types 6 and 11

Cervical cancer: types 16 and 18

65
Q

What ages are indicated for the HPV vaccines?

A

Cervarix (2vHPV): females 9-25
Gardasil (4vHPV): females/males 9-26
Gardasil 9 (9vHPV): females/males 9-26
*recommended at age 11-12 (prior to exposure more effective)!

66
Q

What do PMS and PMDD stand for?

A

PMS: Premenstrual Syndrome
PMDD: Premenstrual Dysphoric Disorder

67
Q

When do PMS/PMDD occur in menstruation cycle?

A
  • occur during luteal phase (2nd half of cycle)

- resolve with menstruation (beginning of cycle)

68
Q

Pathophysiology of PMS/PMDD may be related to reduced levels of…?

A
  1. serotonin
  2. GABA
  3. allopregnanolone
69
Q

Classification of Normal, PMS, or PMDD according to quantity, time period of symptoms (days before menses), and number of cycles

A

Normal: 1 or more sx, 1-2 days before menses
PMS: 1 or more sx, 5 days, at least 3 consecutive cycles
PMDD: 5 or more sx, 7 days, at least 2 symptomatic cycles

70
Q

What non-pharmacologic treatment may reduce symptoms for PMS/PMDD?

A
  • aerobic exercise/relaxation
  • calcium carbonate 1200 mg daily
  • vitamin B6 50-100 mg daily
  • reduce caffeine, refined sugar, and sodium
71
Q

Which SSRIs are FDA-approved for PMDD treatment?

A
  1. fluoxetine 20 mg daily
  2. sertraline 50-150 mg daily
  3. paroxetine CR 12.5-25 mg daily
72
Q

What is the first line treatment recommendation for PMDD?

A

SSRI

-minimum requirement of 3 different SSRIs x 3 months (cycles) each before switching to different treatment

73
Q

Recommended pharmacologic treatment order of PMDD

A
  1. SSRI trial x 3
  2. COC
  3. Spironolactone
  4. Alprazolam (only if severe anxiety component)
  5. GnRH agonist
  6. Surgery- total hysterectomy with oophorectomy
74
Q

Which pharmacologic treatments for PMDD are dosed during the luteal phase only?

A
  1. Alprazolam (if anxiety component; NOT monotherapy)
  2. Spironolactone
    * SSRI can be dosed during luteal phase or continuously (patient preference)
75
Q

What are the treatment options for female sexual interest/arousal disorder?

A
  1. hormone therapy: estrogen or testosterone

2. flibanserin (Addyi): mixed serotonin agonist/antagonist

76
Q

How many weeks to be classified as:

viable, excellent survival, term, and full gestation?

A

Viable = 24 weeks
Excellent survival = 34 weeks
Term = 37-42 weeks
Full gestation = 40 weeks

77
Q

What is the recommended frequency for prenatal visits?

A

Initial visit at 8-10 weeks, then:

  • every 4 weeks until 24 weeks
  • every 2 weeks until 36 weeks
  • every 1 week until delivery
78
Q

What is the timeline differentiating an embryo from a fetus?

A

Embryonic development = weeks 4-8

Fetal development = weeks 9-38

79
Q

What weeks are associated with each trimester?

A

1st: weeks 1-12
2nd: weeks 13-26
3rd: weeks 27-40

80
Q

What prenatal supplements are needed and at what dose?

A
  1. Folate 0.4 mg daily (4 mg daily if high risk of NTD); begin at least 1 month prior to conception
  2. Iron 27-30 mg daily
  3. Calcium 1000 mg daily (1300 mg if 14-18 yo)
  4. Omega-3 fatty acids: 12 oz seafood/week
81
Q

What is the recommended limitation for caffeine in the prenatal diet?

A

less than 200 mg daily

1 cup of coffee = 100-200 mg

82
Q

What is included in third trimester testing (5)?

A
  1. glucose tolerance test
  2. CBC
  3. HIV
  4. Syphilis
  5. Group B Beta Strep*
83
Q

Which agents are first line for Group B Beta Strep prophylaxis?

A
  • Penicillin G, 5 million units IV, then 2.5-3 q 4 hrs
  • Ampicillin 2 g IV, then 1 q 4 hrs
  • during labor until delivery
84
Q

Which vaccine should women receive during each pregnancy?

A

Tdap

-live vaccines generally contraindicated

85
Q

Nausea and Vomiting of Pregnancy (NVP) risk factors

A

History of:

  1. motion sickness
  2. migraine headaches
  3. nausea with COCs
86
Q

NVP treatment

A
  1. pyridoxine (vitamin B6) 10-25mg q8h
  2. doxylamine 10mg/pyridoxine 10mg (Diclegis) 2 tabs at bedtime - titrate up to 4 tabs/day if sx uncontrolled
  3. ginger extract 125-250mg q6h
87
Q

Heartburn treatment during pregnancy

A
  1. antacids (calcium containing ONLY)
  2. H2RAs
  3. PPIs
    * heartburn peaks in 3rd trimester
88
Q

What three physiologic factors lead to UTI during pregnancy?

A
  1. dilated ureters
  2. increased bladder volume
  3. decreased bladder tone
89
Q

What are the 3 stages of UTI in pregnancy if left untreated?

A
  1. asymptomatic bacteriuria
  2. acute cystitis
  3. pyelonephritis
90
Q

Treatment of UTI in pregnancy

A

most common:
Cephalexin 250mg BID-QID
Nitrofurantoin 50-100mg QID

*avoid fluoroquinolones, tetracyclines, and Bactrim

91
Q

When is a DVT / PE most common in pregnancy?

A

DVT: equal frequency among 3 trimesters and postpartum
PE: more common during postpartum

92
Q

What are the symptoms of DVT / PE and tests of choice in pregnancy?

A

DVT sx: unilateral leg pain and swelling
DVT test: venous ultrasound
PE sx: dyspnea and tachypnea
PE test: spiral CT

93
Q

Pharmacologic treatment of TE in pregnancy

A
  • LMWH (enoxaparin, dalteparin)
  • UFH
  • DOAC (apixaban, category B)
  • Category X: warfarin
94
Q

Management of TE during delivery

A
  1. Scheduled induction or C-section at 37 weeks (stop anticoagulant 24 hours prior)
  2. Switch to UFH at 36-37 weeks (shorter half life; protamine reversal agent available)
95
Q

When to restart anticoagulation postpartum?

A

6 hours after natural delivery
12 hours after epidural removal
24 hours after C-section
*continue at least 6 weeks postpartum, total duration at least 6 months

96
Q

Medications indicated for preterm labor without membrane rupture

A
  1. Mag sulfate (fetal neuroprotection)
  2. CS (speed fetal maturation)
  3. Group B Strep Prophylaxis
  4. Tocolytics (delay delivery)
97
Q

Corticosteroid dosing in preterm labor

A

**1 course between 24-34 weeks (48 hours only)
Betamethasone 12mg IM q24h x 2 doses
Dexamethasone 6mg IM q12h x 4 doses

98
Q

Group B Strep Prophylaxis dosing in preterm labor

A

Penicillin G: 5 million units IV, then 2.5 million units IV q4h until delivery

99
Q

Tocoloytics used in preterm labor

A
  1. Nifedipine (preferred, safest)
  2. Indomethacin
  3. Terbutaline
  4. Magnesium
    * used short term x 2-5 days to allow time for steroids (if between 24-34 weeks)
100
Q

Magnesium sulfate dosing in preterm labor

A

Fetal protection:
4-6 g IV load, then 1 g/hr x 12 hours
Tocolytic:
4-6 g IV load, then 2 g/hr

101
Q

Medications indicated for preterm membrane rupture

A
  1. Mag sulfate
  2. Corticosteroids
  3. Latency antibiotics
    * not tocolytics b/c not in labor
102
Q

Latency antibiotic dosing for preterm membrane rupture

A

IV q6h x 48 hours:
Ampicillin 2g and Erythromycin 250mg

PO q8h x 5 days:
Amoxicillin 250mg and Erythromycin 333mg

103
Q

Diagnosis of chronic HTN vs gestational HTN vs preeclampsia

A
  1. Chronic HTN: elevated BP (>140/90) before 20 weeks, or pre-existing HTN
  2. Gestational HTN: elevated BP after 20 weeks
  3. Preeclampsia: new onset BP >140/90 and proteinuria of >300mg/24 hrs
104
Q

Treatment of chronic HTN vs gestational HTN vs preeclampsia

A

Chronic HTN: BBs and CCBs
Gestational HTN: no tx if less than 160/110
Preeclampsia: monitor until 37 weeks unless severe sx (seizure prophylaxis with MgSO4)

105
Q

HELLP Syndrome

A

Hemolysis
Elevated Liver enzymes
Low Platelets
*symptoms: RUQ or epigastric pain, N/V

106
Q

Treatment of HELLP Syndrome

A

variant of severe preeclampsia

-immediate delivery after prenatal corticosteroids

107
Q

Eclampsia definition

A

Seizure caused by elevated BP in pregnancy; usually last 60-90 seconds

108
Q

Treatment of eclampsia

A

-delivery ASAP after occurrence
-Magnesium sulfate to prevent additional seizures:
if not on infusion, 6g IV loading dose then 2g/hr infusion
if on infusion, additional 2g IV

109
Q

BG goals for preexisting DM?

A

FBG less than 95
2-hr PPG less than 120
*SMBG 4 times daily

110
Q

Diagnosis of Gestational Diabetes

A

Glucose screening at 24-28 weeks:

BG > 130-140 (OGTT)

111
Q

What does the RID tell us?

A

Relative Infant Dose (RID): quick estimate of how much of a mother’s dose will transfer to breastmilk and risk of effect on infant
>10% = large amount of transfer, risk of effect exists

112
Q

Hale’s Lactation Risk Category

A 
L1: safest
L2: safer
L3: moderately safe
L4: possibly hazardous
L5: contraindicated
113
Q

Preferred pain medications in breastfeeding women

A

Preferred non-narcotics: APAP** or ibuprofen
Aspirin: low dose only may be acceptable
Opioids: morphine preferred (poor bioavailability in infant)

114
Q

Postpartum Hemorrhage definition

A

> 500 mL of blood loss after delivery

*treat early: risks of orthostatic hypotension, anemia, hemorrhagic shock, death

115
Q

4 causes/types of postpartum hemhorrhage

A
  1. tone (of uterus)
  2. trauma
  3. tissue
  4. thrombin (coagulopathy)
116
Q

Treatment of postpartum hemorrhage

A
  1. Uterine Tone: oxytocin, carboprost, misoprostol, methylergonovine
  2. Trauma: sutures, drain hematomas, etc.
  3. Tissue: removal of placenta (manually or methotrexate)
  4. Thrombin: replenish blood supply (FFP, pts, factors)
117
Q

Normal menstrual cycle:

total days, days of flow, flow volume

A

22-35 days total
3-7 days flow
35 mL volume (5-6 pads or tampons/day)

118
Q

Dysmenorrhea definition

A

painful menstruation; lower abdominal pain

119
Q

Dysmenorrhea pathophysiology

A

Inflammatory response from PG/LT cascade in uterus causes symptoms
(uterine contractions decrease uterine blood flow causing tissue ischemia and pain)

120
Q

Dysmenorrhea treatment

A
  • *NSAIDs (taken when pain expected)
  • hormonal contraceptives
  • androgen (danazol)
  • GnrH antagonist (leuprolide) - severe refractory cases
121
Q

Amenorrhea definition

A

Absence of menstruation > 6 months

*rule out pregnancy!

122
Q

Oligomenorrhea vs Polymenorrhea vs Menorrhagia vs Metrorrhagia

A

Oligomenorrhea: menstrual cycle > 35 days
Polymenorrhea: cycle less than 21 days
Menorrhagia: heavy menstrual bleeding >80mL
Metrorrhagia: bleeding between periods

123
Q

Acute Menorrhagia Treatment

A
  1. Tranexemic acid 1300 mg PO TID x 5 days
  2. Medroxyprogesterone 20 mg PO TID x 1 week
  3. High dose estrogen 25 mg IV q4h until bleeding slows, then monophasic OC (30-35 mcg EE) TID x 1 week
124
Q

Menorrhagia Treatment

A
  • iron supplementation
  • NSAIDs
  • hormonal contraception
  • target underlying cause (hormonal imbalance, infection, fibroids, coagulopathy)
125
Q

What does anovulation (failure of ovary to release ova) indicate?

A

unopposed estrogen

need progesterone in some form

126
Q

Overflow incontinence

A

Urethral blockage; outlet obstruction
-bladder unable to empty properly
-pressure builds > contents released
(more common in males; BPH)

127
Q

Stress incontinence

A

-relaxed pelvic floor; increased abdominal pressure
-outlet incompetence
-small volume
(more common in females)

128
Q

Urge incontinence

A 
OAB: overactive bladder
-detrusor muscle oversensitivity
-large volume
-urgency and frequency
(most common type of incontinence)
129
Q

Urge incontinence treatment

A

Muscarinic antagonists (oxybutynin, tolterodine, trospium, solfenacin, darfenisin, fesoterodine)

130
Q

Beta-agonist used to treat incontinence

A

mirabegron (Myrbetriq) 25 mg PO daily

-titrate to 50 mg at 8 weeks if needed

131
Q

Adverse effects of anticholinergics

A 
dry mouth (common)
constipation
delirium/confusion
dry eyes
132
Q

Formulations of oxybutynin

A
  • Ditropan (XL) - tablet
  • Oxytrol - OTC patch
  • Gelnique - gel
  • all used to treat OAB (antimuscarinic)
133
Q

Which dopamine agonists are approved for RLS?

A
  • pramipexole (2-3 hrs before bed)
  • ropinorole (1-3 hrs before bed; titration schedule)
  • rotigotine (24h patch; if sx all day)
134
Q

First line therapy in RLS with pain

A

alpha-2-delta calcium channel ligands

gabapentin, pregablin

135
Q

Preferred agents for RLS in pregnant patients?

A

Opioids

136
Q

Iron supplementation goals in RLS with iron deficiency

A

Serum ferritin > 50 mcg/L

Iron saturation > 20%

137
Q

First line therapy for RLS in younger and healthier patients

A

Dopaminergic agents (CD/LD, pramipexole, ropinorole, rotigotine)

138
Q

Hospice care definition

A

Provision/continuation of palliative care once life expectancy of 6 months or less

Therapeutics Fall 2016 (4 decks)

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