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424 Pharmacology > Reproductive health > Flashcards

Reproductive health Flashcards

1
Q

What are the available formulations for testosterone?

A
  • Gel: 50-100mg daily, stable concentrations, well tolerated, risk of secondary exposure to others is low as long as the pt washes their hands, waits until gel is dry, avoids getting it wet for 5 hours
  • Transdermal (not available in the US)
  • Injectable: 50-100mg weekly or 100-200mg every 2 weeks; most cost effective
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2
Q

What is testosterone used to treat?

A
  • Primary hypogonadism
  • hypogonadotropic hypogonadism
  • male climacteric
  • transgender masculine patients
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3
Q

Contraindications to testosterone therapy (6)

A
  • Prostate cancer
  • Male breast cancer
  • Severe urinary tract symptoms
  • Erythrocytosis, do not use if HCT over 50
  • Severe, untreated sleep apnea
  • Uncontrolled CHF
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4
Q

Drug interactions with testosterone

A
  • Anticoagulants (warfarin): increased r/f bleed
  • Diabetic agents: increased r/s hypoglycemia
  • Corticosteroids: increased fluid retention
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5
Q

Monitoring with testosterone therapy

A
  • Check level 2-3 months after starting treatment and after any dose change; once stable, change to every 6-12 months
  • Re-evaluation for prostate cancer 3 months and one year after starting treatment - PSA and digital exam
  • Hct 3-6 months after starting treatment, then annually
  • Check lipids, liver function and CBC
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6
Q

Adverse fx of testosterone (8, 5 specific to men; 2 specific to women)

A
  • Acne
  • Sleep apnea
  • Erythrocytosis
  • Liver disorders: Hepatitis, hepatic neoplasm, cholestatic hepatitis, jaundice, hepatocellular carcinoma
  • Men: gynecomastia, reduced sperm levels, decreased libido at high levels, depression, prostate disorders
  • Women: menstrual irregularities, virilization
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7
Q

What medication can NOT be taken in combination with phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil)?

A

Alpha-blockers

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8
Q

Antiandrogens

5-alpha reductase inhibitor: Finasteride (Proscar, propecia)

Indications, MOA & Monitoring

A
  • Indications: treats BPH and male pattern baldness
  • MOA: inhibits enzymes that converts testosterone to DHT (dihydrotestosterone)
  • Monitoring: prostate evaluation required for any increase in PSA while on medication
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9
Q

Antiandrogens

GnRH Analogues: Leuprolide (Leupron)

Indications & MOA

A
  • Indications: advanced prostate and breast cancers, management of endometriosis and uterine fibroids, precocious puberty, pubertal suppression in transgender adolescents
  • MOA: blocks LH release hormone antagonists; Creates reversible chemical orchiectomy or oophorectomy state
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10
Q

Antiandrogens

Aldosterone antagonist: Spironolactone

Dosing, indications, MOA

A
  • 50-200mg orally daily
  • PCOS, acne, hirsutism
  • aldosterone antagonist and inhibits the 5-alpha reductase enzyme
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11
Q

Antiandrogens

Aldosterone antagonist: Spironolactone

Pregnancy considerations, adverse fx

A
  • Contraindicated in pregnancy
  • Adverse fx: GI upset, gynecomastia
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12
Q

Estrogen

What are the different forumlations available for the indications? (contraception, menopause, vaginal atrophy/dryness)

A
  • contraception: pill, transdermal, vaginal ring
  • Menopausal symptoms: oral, transdermal, topical gels, emulsions, lotions, intravaginal creams, tablets, rings
    • Conjugated equine estrogens (premarin): derived from pregnant mare’s urine, mostly comprised of estrone
    • Synthetic conjugated estrogens: derived from plant source (soy, yams)
    • Many women prefer plant based
    • Micronized 17-beta estradiol: bioidentical to main product of premenopausal ovary
    • Esterified estrogens: comparable to serum estradiol/estrone levels to conjugated estrogen
    • Ethinyl estradiol: more potent than others for MHT, used in low doses
  • Vaginal atrophy and dryness: vaginal cream, tablets or ring
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13
Q

What are the advantages of combined oral contraceptives?

A
  • Highly effective
  • Rapidly reversible
  • Regulate menstrual bleeding
  • Decreased menstrual blood loss and dysmenorrhea
  • Reduction in risk of ovarian and endometrial cancers
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14
Q

What are prescribing considerations for estrogen replacement therapy in menopause?

A
  • benefits outweigh the risk for healthy, symptomatic women who are within 10 years of menopause or younger than 60 years old and do not have contraindications
  • Long-term use no longer recommended
  • Oral has greater fx on liver due to first-pass effect which can increase production of clotting factors, lipids and thyroid hormones
  • Transdermal associated with lower r/f venous thrombosis and stroke - less fx on serum lipids and equally effective for preserving bone density; also preferred formulation in women with migraine with aura
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15
Q

Contraindications of combined oral contraceptives

A
  • Age over 35 and smoking
  • Uncontrolled HTN
  • Venous thromboembolism
  • Current breast cancer
  • History of stroke
  • Cirrhosis
  • Migraine with aura
  • Ischemic heart disease or multiple risk factors
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16
Q

Contraindications of estrogen therapy for menopause

A
  • History of breast cancer
  • Coronary heart disease
  • Venous thromboembolic event
  • Stroke/TIA
  • Active liver disease
  • Unexplained vaginal bleeding
  • High risk endometrial cancer
17
Q

When is estrogen contraindicated?

A
  • Estrogen only products in women with an intact uterus
  • Pregnancy (unless specialist directed low hormone level)
  • Breast cancer
  • Estrogen-dependent neoplasia
  • Active deep vein thrombosis or pulmonary embolism
  • History in past year of stroke or myocardial infarction
  • Liver dysfunction
  • Smokers
18
Q

Interactions with combined oral contraceptives

A
  • Anticonvulsants (except gabapentin, levetiracetam, valproate, zonisamide)
  • Rifampin
  • Griseofulvin
19
Q

Adverse fx of estrogen replacement therapy for menopause (7)

A
  • Breast soreness
  • Headaches
  • Elevated BP
  • Exacerbation of DM
  • Cholestasis
  • Thromboembolic event
  • Endometrial hyperplasia
20
Q

Selective estrogen receptor modulators

Raloxifene (Evista),Bazedoxifene (Duavee)

MOA

A
  • estrogen agonist in bone - prevents bone loss, improves bone mineral density, decreases vertebral fracture risk
  • Estrogen antagonist in breast - reduces risk for breast cancer
21
Q

Selective estrogen receptor modulators

Raloxifene (Evista),Bazedoxifene (Duavee)

Prescribing considerations

A
  • Raloxifene (evista) = used for women with an increased risk for breast cancer and decreased bone density
  • Bazedoxifene (Duavee) = combination estrogen derivative with SERM
  • rule out other disorders that may cause further low bone density: Hyperparathyroidsim, Vitamin D deficiency, hyperthyroidism, renal disease
22
Q

Selective estrogen receptor modulators

Raloxifene (Evista),Bazedoxifene (Duavee)

Patient education

A
  • Role of diet, caffeine, alcohol, and smoking on risk for developing osteoporosis
  • Role of other medications that contribute ( i.e., thyroid hormones)
  • Importance of adequate calcium and vitamin D regardless of treatment
23
Q

Selective estrogen receptor modulators

Raloxifene (Evista),Bazedoxifene (Duavee)

Monitoring, adverse fx (2)

A
  • Bone density
  • Increased risk for thromboembolism and hot flashses
24
Q

Selective estrogen receptor modulators

Ospemifene (Osphena)

Dosage, indications, MOA, adverse fx

A
  • 60mg once daily
  • Indicated in dyspareunia and vaginal dryness in postmenopausal women
  • MOA: Estrogen agonist in endometrium, increases thickness and moisture of vaginal mucosa
  • Adverse fx: Potential increased risk for endometrial cancer if intact uterus, increased risk of stroke and DVT
25
Q

What forumlations of progesterone are available?

A
  • Progestin-only pills (norethindrone)
  • Medroxyprogesterone acetate (Depo-Provera)
  • IUD (Mirena, Skyla)
  • Etonogesterol implant (nexplanon)
26
Q

Progesterone

Indications & MOA

A
  • Postmenopausal hormone replacement, contraception
  • thickens cervical mucus, suppresses ovulation, lowers mid-cycle peak of FSH and LH, slows egg movement through the fallopian tube, thins the endometrium
27
Q

Progesterone

Contraindications

A
  • Known or suspected pregnancy
  • Breast cancer
  • Undiagnosed abnormal uterine bleeding
  • Hepatic dysfunction
  • Thromboembolic disease
  • Depression
  • Disorders that worsen with fluid retention
28
Q

Progesterone

Interactions & Monitoring

A
  • Interactions: Rifampin
  • Monitoring
    • Depression
    • Seizures
    • Blood glucose for patients with DM
29
Q

Progeesterone

Adverse fx (5)

A
  • Irregular breakthrough bleeding
  • Amenorrhea
  • Acne
  • Weight gain
  • osteoporosis
30
Q

What are the different forms of contraception available? And their special considerations?

A
  • Ortho Evra patch: 20mcg estrogen and 150mcg norelgestromin - apply for 3 weeks then 1 week off
    • increased failure rate with women weighing more than 198lbs
  • NuvaRing: 15mcg estrogen, 120mcg etonogestrel - apply for 3 weeks then 1 week off
    • Better cycle control and decreased breakthrough bleeding
    • Systemic exposure to estrogen lower
  • Progestin only pills
    • Used when estrogen is contraindicated
    • Dose needs to be taken at the same time each day - if a few hours late, back up method recommended for 48 hours
  • Depot medroxyprogesterone acetate (Depo-provera)
    • One injection effective in suppressing ovulation for 12-13 weeks
  • Mirena IUD: releases 20mcg levonorgestrel daily
    • Can be left in place for 5 years
    • Small levels of systemic ciruclating hormone and minimal systemic side effects
  • Implanon: implantable rod contains 68mg of etonogestrel
    • Contraception for 3 years
31
Q

Progesterone antagonist: mifepristone (mifeprex, korlym)

Indication and risks?

A
  • Indication: termination of intrauterine pregnancy, cushing syndrome
  • Risk of serious complications including bleeding and bacterial infections
  • Only available through restricted access program
32
Q

What methods of emergency contraception are available? When does it need to be used to be effective?

A
  • Should be implemented as soon as possible (less than 72 hours) after unprotected intercourse, may be initiated up to 120 hours after
  • Methods of emergency contraception
    • Combined OCs
    • Progestin only (Plan B and Next Choice)
    • Copper IUD
33
Q

What are the different starting methods for oral contraceptives?

A
  • First-day start
    • Pills started on first day of menstrual cycle
    • No backup method needed
  • Sunday start
    • First pill taken on the Sunday following the start of menses
    • Back up method for first 7 days
    • Menses only occur during the week
  • Quick or “same-day” start
    • First pill taken on the day of the office visit
    • Back up method for first 7 days
34
Q

What is the difference between monophasic, biphasic and triphasic oral contraceptives?

A
  • Monophasic: same dose of estrogen and progestin for full cycle
  • Biphasic: vary the dose of progestin
  • Triphasic: vary the dose of estrogen, progestin, or both
35
Q

What is the normal role of estrogen and progesterone?

A
  • Estrogen
    • Increases bone density
    • Results in normal skin and blood vessel structure
    • Affects lipid levels
    • Reduces bowel motility
    • Enhances coagulability of blood
    • Causes edema because of its action on the renin–angiotensin system
    • Maintains stability of the thermoregulatory center
  • Progesterone
    • Thicken and stabilize endometrium
    • Thicken cervical mucous
    • Relaxes smooth muscle of the uterus
    • Thins vaginal mucosa
36
Q

Noncontraceptive benefits of oral contraceptives

A
  • Decreased dysmenorrhea, menstrual irregularities, and menstrual blood loss
  • Lessening of acne and hirsutism
  • Fewer ovarian cysts
  • Significantly reduced endometrial and ovarian cancer risk
  • Lower incidence of benign breast conditions, such as fibrocystic changes and fibroadenoma
  • Reduced risk of hospitalization for gonorrheal pelvic inflammatory disease
  • Suppression of endometriosis in women who do not currently desire pregnancy
37
Q

Hormonal contraceptives

Patient education & interactions

A
  • Patient education
    • What to do if doses are missed
    • 50% of women discontinue because of side effects
  • Interactions: Tuberculosis drugs, antiepileptic drugs, St. John’s Wort
38
Q

What are some adverse fx of hormonal contraceptives?

A
  • Venous thromboembolism risk increases three to five times with OC use
  • cholestatic jaundice
  • benign hepatic neoplasms
  • myocardial infarction
  • Stroke
  • neurological migraineS
39
Q

What are some adverse fx of depo-provera? Black box warning?

A
  • Adverse fx:
    • Spotting, followed by amenorrhea
    • Weight gain
    • Depression
  • BBW: decreased bone density with long term use

424 Pharmacology (12 decks)

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