Reproductive/GU Flashcards
Main groups of hormonal contraceptives (2 groups)
Estrogen-progestin contraceptives
Progestin-only contraceptive
Estrogen-progestin contraceptives Mechanism of Action
Estrogens: suppress FSH release, stabilize the endometrial lining, provide cycle control
Progestins: block the LH surge = no ovulation, thicken cervical mucus delay sperm transport, induce endometrial atrophy/inhibit endometrial proliferation
Estrogen-progestin contraceptives - indications
Abnormal bleeding (menorrhagia/ metrorrhagia/ amenorrhea) – assuming other causes have been excluded, Dysmenorrhea Endometriosis, PCOS Acne, PMS/PMDD
Estrogen-progestin contraceptives - cautions
breastfeeding - may decrease milk supply, HLD, DM with complications, prolonged immobility/long leg cast (clot), migraine without aura over the age of 35
Estrogen-progestin contraceptives - contraindications
Thromboembolic disease, CAD, Active liver disease, Breast cancer, Smoker over 35 yo, Migraine with aura, Uncontrolled HTN, Undiagnosed vaginal bleeding
Estrogen adverse effects (Excess and deficiency)
Progestin adverse effects (excess and deficiency)
High doses of estrogen-progestin contraceptives increases the risk of
Breast cancer, stroke, MI, DVT
Androgenic adverse effects
Acne
Weight gain
Hirsutism
Fatigue
Depression
Progestin only contraceptive options
Minipill
Nexplanon implant
DMPA injection - Depo-Provera
IUD - Mirena, Skyla, Lilletta
Continuous dosing of estrogen-progestin ocps is possible with which formulation?
monophasic
Transdermal contraceptive patch - adverse effects
Greater incidence of venous throboembolism (black box warning_
-60% more estrogen exposure than OC
Not indicated for weight > 198lbs
Depo Provera risks/side effects
Bleeding irregularities
Delayed return of fertility (up to 6-18 months)
-don’t use more than 2 yrs
Weight gain
Decrease in bone mineral density
Progestin-only contraceptives Mechanism of Action
Inhibition of ovulation- suppression of midcycle peaks of LH & FSH
Thickened, decreased cervical mucous
Thinner, atrophic endometrium
Progestin-only contraceptives - adverse effects
Spotting
Amenorrhea
Irregular menstruation
Ectopic pregnancy - increased risks
Paragard IUD Mechanism of Action
MOA: copper toxic to sperm, prevents implantation
Paragard benefits/side effects
Benefits: nonhormonal, use for up to 10 years
Side effects: increased menstrual flow and dysmenorrhea
Emergency Contraception Options
Plan B
Ella
Paragard
Emergency Contraception Mechanism of Action
Suppresses Ovulation (if taken prior to LH surge)
Prevent fertilization of an ovulated egg
Copper IUD: may also prevent implantation
No impact if already pregnant
Hormone Replacement Therapy (HRT) Indications
Menopausal vasomotor symptoms
Vaginal atrphy - vaginal preparations
Added benefits: –increased bone density however decreased bone density is not an indication to start HRT –decreases risk of colon cancer
Prescribing HRT
Use lowest dose for shortest duration possible
Less risky in younger women
Vaginal preparation less risky than oral/transdermal
In people with an intact uterus both estrogen and progesterone must be used - unopposed estrogen in those with a uterus increases risk for endometrial cancer
HRT contraindications
Breast cancer, CHD, VTE hx or high risk, liver disease, unexplained vaginal bleeding
Estrogen/progestin contraceptive counseling
How/when to start
Whether or not a back up method is needed
Common side effects and how to avoid Dangerous side effects
No protection against STIs
Follow-up visit
For pills: strategies to remember to take and what to do if a dose is missed
ACHES
Contraindications to IUD placement
Current PID/cervicitis or PID within the last 3 months
Nulliparity or remote hx of PID (>3 mos) is not a contraindication
Testosterone replacement indications
Primary – disorders of the testes, Low serum testosterone and elevated LH/FSH
Congenital: Klinefelter syndrome, cryptorchidism
Acquired: mumps, radiation, chemo, medications, trauma, testicular torsion
Secondary – disorders of the hypothalamus/pituitary Low serum testosterone and normal or low LH/FSH
Congenital syndromes causing GnRH deficiency
Acquired: Tumors, eating disorders, post-androgen abuse, DM, Infiltrative diseases, head trauma, Drug use (marijuana, anabolic steroids, opioids)
Testosterone Replacement Adverse Effects
Acne, Gynecomastia, Edema, Increased risk of CV disease, Increased risk of prostate cancer, Lower HDL, elevated triglycerides, Increased homocysteine, Male pattern baldness, Mood changes, Increased risk of sleep apnea
Men on testosterone replacement should be screened for
prostate cancer
Non-estrogen medications used in treatment of menopausal vasomotor symptoms
Antidepressants
Black Cohosh
Soy
Mechanism of action for Mirena
Progestin releasing IUD
- Impairs sperm motility and function
- Inhibits conception
- Thickens cervical mucus
- Endometrium atrophy
- Impaired tubal motility
Progestin IUD benefits and adverse effects
Benefits:
Acts locally (systemic effects rare), lighter periods, no weight gain
Adverse effects:
Irregular cycle 3-6 months
Yuzpe Method
Can be used with any combined or progestin only OC
Not as effect as other EC methods
Can have significant nausea
Plan B
Available OTC
Effective until LH surge
-Best within 3 days, can be used up to 5 days
Effectiveness decreases with BMI>25
Ella
Effective until LH peak
-Effective up to 5 days after unprotected sex
Prescription only
Decrease efficacy in BMI>30
Copper IUD as Emergency Contraceptive
Effective at anytime in cycle
Not impacted by BMI
Insert up to 5 days after unprotected sex
Black box warning for testosterone replacement therapy
Risk for MI, CVA, HF, depression, hostility, liver toxicity
BPH non-pharm management
Fluid restriction (prior to bedtime especially)
Limit caffeine and ETOH
Double voiding
Seated voiding
Avoid diuretics when possible
Classes of drugs used to treat BPH
Alpha 1 blockers
5 alpha reductase inhibitors
Anticholinergic agents
PDE-5 inhibitors
Alpha 1 Blockers Mechanism of Action and Examples
Block alpha1 receptors in the vasculature resulting in arterial and venous vasodilation. This causes smooth muscle relaxation and decreases urethral resistance.
Doxazosin and Terazosin are older and need more titrating
Alfuzosin, Tamsulosin, and Silodosin are newer, and more uroselective – less risk for hypotension and no need to titrate
Alpha 1 blockers side effects
Hypotension is major side effect
Headache, dizziness, nasal congestion, fluid retention, impotence, palpitations, drowsines
Tamsulosin: intraoperative floppy iris syndrome
5 Alpha Reductase Inhibitors Mechanism of Action and Examples
Inhibits 5-alpha reductase converstion of testosterone to dihydrotestosterone (DHT) which is responsible for prostate cell proliferation and inhibits apoptosis (cell death) of prostate cells
Finasteride (Proscar)
Dutasteride (Avodart)
5 Alpha Reductase Inhibitor Side Effects
Decreased libido, impotence, decreased semen quantity
Decreases PSA by up to 50%, get a baseline prior to intiating if monitoring for change
Medications that can exacerbate BPH
PDE-5 Inhibitor Mechanism of Action and Examples
PDE-5 converts cGMP to GMP resulting in increased levels of cGMP (necessary for erection to occur).
Sildenafil (Viagra)
Tadalafil (Cialis)
Vardenafil (Levitra)
Avanafil (Stendra)
PDE-5 Inhibitor Contraindication
On nitrate therapy
MI/stroke or life threatening arrhythmia in past 6 months
Caution with HF, uncontrolled hypo/hypertension, unstable angina, prolonged QT and alpha blocker use
PDE-5 Inhibitor Side Effects
Priapism, visual disturbances, hearing loss
Anticholinergic indications and side effects
1st line for the treatment of overactive bladder
- Urinary retention, dry mouth, constipation, dizziness, blurry vision, tachycardia, drowsiness
- Increase dementia risk
Use extended release formulations to decrease side effects
Anticholinergic contraindications
Contraindicated in narrow angle closure glaucoma and uncontrolled tachycardia
