Reproductive pharm Flashcards

Question

Hormonal IUD

Answer 1

all= Levonorgestrel Liletta= 8 yrs Mirena= 8 yrs Both are more likely to not have period Kyleena= 5 yrs Skyla= 3 yrs MOA: not fully demonstrated-> prob prevent fert by thickening cervical mucus to inhibit sperm or mobility or thin endometrium DOES NOT EFFECT FOLLICULAR DEVELOPMENT OR OVULATION SO RETURN TO FERTILE VERY QUICK-> NOT FOR PMS OR PMDD OR ENDOMETRIOSIS BC DOESNT STOP OVULATION Benefits: decreases dysmenorrhea (after 6 months), menorrhagia, 99% effective, higher dose IUD can cause amenorrhea SE: irregular bleeding (breakthrough), uterine perforation, expulsion, PID, ectopic prego Contrain: liver dz, leiomyoma, unexplained vag bleeding, active pelvic infxn

Answer 2

Etonogestrel- Nexplanon 3 yr effectiveness-> 99% effective MOA: SUPPRESS OVULATION-> increase viscosity of cervical mucus-> alterations in endometrium SE: HA, acne, mastalgia, weight gain, irregular menses Clinical pearl: third of women have no bleeding, third of women regular/irregular spotting, third of women have heavy persistent bleeding Contra: DVT, MI, CVA, liver dz, breast CA, unexplained vag bleeding

Answer 3

Ulipristal (Ella) and Levonorgestrel (Plan B) -up to 5 days after unprotected sex Copper or LNG IUD -w/in 5 days of unprotected sex w/ negative pregnancy test

Answer 4

average age= 52.54 Perimenopause= start 10 yrs prior to final Menstrual period (FMP) -early perimeno= irregular cycles, heavy -later perimeno= 2-13 months of amenorrhea Postmenopause= final menstrual period after 1 year of no menstrual bleeding-> from loss of ovarian follicular fxn-> due to aging or primary ovarian failure or surgical removal of ovaries Terminology: -early meno= FMP b4 age 45 -late meno= FMP after age 54 -Premenopause= reproductive stages btwn menarche and onset of perimenopause

Answer 5

repro aging= loss of oocytes by ovulation and atresia finite # of oocytes lost thru apoptosis-> ovulate about 400-500 eggs 20 wks gestation= 6-7 million Birth= 1-2 million Puberty= 300,000-500,00 meno= 300-400 remaining patho: FSH GOES UP AND ESTRADIOL GOES DOWN -FSH - very high= predicting meno but not to predict time of meno-> rises several years b4 meno and stabilizes 2 yrs after meno ESTRADIOL WILL VARY DRASTICALLY DURING PERIMENO-> decline 2 yrs b4 FMP

Answer 6

1. Genitourinary: changes in menstrual bleeding pattern, vulvovaginal symp (dry, dysuria), dyspareunia, constipation 2. Psychiatric/nervous sys: Insomnia, depression, anxiety, "brain fog", memory changes, hot flashes, night sweats 3. Cardiovascular: palpitations, increase in BP, changes in lipid panel 4. MSK: joint pain, myalgias 5. Other: changes in weight distribution, dry eyes PEARL: CRUCIAL TO IDENTIFY WHAT BOTHERSOME SYMPTOMS SHE HAS BC THIS IS GOING TO DICTATE WHAT TX YOU RECOMMEND

Answer 7

Hypothalamus= thermoregulatory center for the body= unknown MOA bothersome hot flashes= increased risk for CVD, OSTEOPOROSIS, BREAST CANCER UP TO 70% OF WOMEN WILL REMAIN UNTX WHI hormone therapy findings: use fo E+P hormone therapy after menopause = increased risk of heart disease, stroke, blood clots, breast cancer, dementia= NOT FOR USE IN POSTMENOPAUSAL WOMEN TO PREVENT HEART DISEASE OR LOWER CHOLESTEROL LEVELS basically: FOCUS OF TRIAL WAS TO ASSESS PREVENTION OF HEART DZ, BREAST CA, COLORECTAL CA, OSTEOPOROSIS IN POSTMENOPAUSAL WOMEN-> LOOKING AT CONJUGATED EQUINE ESTROGEN W/ OR W/OUT MEDROXYPROGESTERONE ACETATE-> no formal recommendation from USPSTF on HRT in sympt women

Answer 8

1. Vasomotor sympt 2. Prevention of bone loss 3. Premature hypoestrogenism- caused by hypogonadism, castration, or premature ovarian insuff 4. Genitourinary synd of menopause NO INDICATIONS FOR PREVENTION OF HEART DISEASE, MOOD AUGMENTATION, DEMENTIA PREVENTION

Answer 9

undiag abn gental bleeding known, suspected, hx of Breast ca suspected estrogen-dependent neoplasia= endometrial cancer not cervical cancer active/hx of DVT OR PE thromboembolic dz liver dysfxn pregnancy hypersens to estrogen therapy porphyria cutanea tardis hypertriglyceridemia

Answer 10

1. Conjugated equine estrogens (CEE)-> most research about efficacy and safety 2. 17 beta Estradiol-> mc used estrogen in europe= BIOIDENTICAL FORMULA 3. Ethinyl estradiol-> MC in combo contraceptives and some HRT prep IF SHE HAS AN INTACT UTERUS= ESTROGEN MUST ALSO HAVE PROGESTERONE THERAPY TO PREVENT ENDOMETRIAL HYPERPLASIA AND ENDOMETRIAL CANCER

Answer 11

1. Micronized progesterone -bioidentical -sedating effect bc 1st pass metab makes a GABA agonistic effect= SEDATING Contraind: PEANUT ALLERGY BC PEANUT OIL USED IN IT 2. Medrozyprogestrone acetate (MPA)= MC USED/STUDIED 3. Norethindrone acetate- not in US by itself for HRT but is in combo pills no patches available, only oral or IUD (endometrial protection)

Answer 12

1. Continuous combined -MC bc dont have to remember timing -> estrogen and progestin-> highest rates of amenorrhea and lowest of endometrial hyperplasia 2. Continuous- cyclic -daily estrogen plus Progestin cyclically for 12-14 days each month-> can cause bleeding w/ progestin w/drawal 3. Continuous-cyclic long cycle -not recommended-> daily estrogen + progestin for 14 days every 2-6 months= heavier/longer bleeding but less frequent -REQUIRES ENDOMETRIAL MONITORING AND BIOPSY

Answer 13

start lowest of estrogen and titrate up-> notice in 2 wks but say 6-8 weeks BEFORE WE KNOW IF WORKING all combined HRT have Progestin for Endometrial protection

Answer 14

NOT FOR CONTRACEPTION TOO - - ONLY FOR SYMPTOMS 1. Within 10 years of FMP (final menstrual period)-> DO NOT HAVE TO WAIT UNTIL THEY ARE OFFICIALLY 1 YEAR POST MENOPAUSAL can take 2-4 wks b4 noticing -> follow up in 6 weeks any vaginal bleeding is CA until proven otherwise= biopsy WINDOW OF OPPORTUNITY OR TIMING HYPOTHESIS

Answer 15

BASED ON SYMPTOMS-> if controlled= CONTINUE CURRENT DOSE uncontrolled? titrate up Estrogen component + sleep effects Efficacy 2 weeks-> re eval 6-12 wks-> reval annually if on steady dose or if AE assessment is clinical 6-12 months and dont need lab values

Answer 16

Age 65= START TO TAPER and MUST ATLEAST ATTEMPT TO TAPER some will not be able to get off HRT w/out RESUMPTION OF SIGNIFICANT HOT FLASHES-> but okay to ongo if started b4 65 risks: DEMENTIA, MI, CEREBROVASCULAR ACCIDENTS AFTER AGE 65 DONT START HRT AFTER 65 OR OVER 10 YRS BC OF RISKS

Answer 17

Estradiol, estrone, and micronized progesterone demand increased after Womens Health Initiative said women felt safer with them some may go to compounding pharmacies to get bioidentical hormones or biodient hormones non fda approved pellets inserted SQ COMPOUNDED BIOIDENT= UNTESTED AND MAY OR MAY NOT CONTAIN % OF HORMONE Pros: for individuals sensitive to different vehicles in meds Cons: no FDA approval process, not covered by insurance...efficacy...safety?

Answer 18

Patho: decrease ovarian reserve and follicles-> reduction in Inhibin B and AMH -> increases FSH= 1. faster growth of remaining follicles 2. Increased follicular atresia 3. maybe Luteal Out of Phase event LOOP= excess estradiol produciton as new follicles start growing explains symp: mastalgia, worsening migraine, fibroid growth, irregular bleeding, risk of endometrial hyperplasia Early perimenopause: irregular cycle, skipped cycles, worsening PMS Late perimenopause: ovulation more sporadic, follicular development goes way down leads to estradiol deficiency

Answer 19

1. Oral BC pills -Continuous COC or 24/4 form to cut down on prolonged bleeding -> keep on till 55 yo then switch to HRT bc 90% women will have menopause at 55 20MCG OR LESS to control symp and CONTRACEPTIVE BC MOST LIKELY TO HAVE TWINS DURING THIS LAST CALL 2. IUD for HEAVY bleeding 3. Serotonin reuptake inhibitors- GREAT FOR IRRITABILTY but decrease libido 4. Conservative management -diet= complex carbs can stabilize mood, cravings, insulin -exercise= healthy endorphins-> low impact -Relaxation and meditation practice

Answer 20

aka vulvovaginal atrophy VVA estrogen deficiency can lead to changes in labia, introitus, vagina, clitoris, bladder, urethra-> lose elasticity, shorten vaginal vault, narrow introitus, loss rugae, thin vaginal tissue-> dryness, irritation, burning, soreness, tightness= all bc of decreased Estrogen and Testosterone Not only caused by menopause-> caused by any condition = low estrogen state (hypothalamic amenorrhea, prolonged lactation, pelvic radiation, tx w/ aromatase inhibitors->>> most will say they have a UTI OR A YEAST INFECTION but post meno rarely get yeast infxns PE: -vaginal pH will be elevated -UA, wet prep, STI, -biopsy unusual lesion Tx: -lube for sex -topical estrogen -nonhormonal options

Answer 21

1. Low dose vaginal estrogen -No progestin needed bc local -> full effic 2-3 months and notice diff in 2-4 wks -cream (Estrace or Premarin), inserts (Imvexxy or Vagifem), ring (Estring or Femring)= 17 Beta estradiol 2. Vaginal DHEA Prasterone= FOR PAINFUL INTERCOURSE-> for mod to severe dyspareunia secondary to atrophy MOA: dehydroepiandrosterone converted to androgens and sestrogens AE: vaginal discharge and abnormal pap ~2% 3. Oral ospemifene for severe dyspareunia assoc w/ GUSM MOA: selective estrogen receptor modulator (SERM) Agonistic effects on endometrium and vaginal tissue but Antagonistic effects on Breast 4. Systemic estrogen therapy doesnt always work for GUFM bc doesnt penetrate well PEARL: IF HAVING HOT FLASHES AND PO IS WORKING FOR THAT, CAN STILL ADD VAGINAL PREP TO HELP W/ GUSM

Answer 22

only non hormonal option w/ FDA to tx hot flashes is Paroxetine salt (Brisdelle) Off label: venlafaxine gabapentin clonidine other SSRI

Answer 23

HRT started w/in 10 yrs of menopause or less than 60 yo= lower all cause mortality and not increase risk of coronary events, stroke risk not increased both heart dz and stroke risk increases in HRT AFTER AGE 60 BUT NOT NECESSARILY IF CONTINUED AFTER 60

Answer 24

70-91% report painful periods and 25% experiencing menstrual disturbances 58% use BC for something other than prevent prego Disorders: 1. Premenstrual syndrome 2. Premenstrual dysphoric disorder 3. Heavy menstrual bleeding & abnormal uterine bleeding 4. Polycystic Ovarian syndrome (PCOS) 5. Endometriosis/adenomyosis

Answer 25

Recurrent variable cluster of PHYSICAL and Emotional symptoms during the 5 days b4 the onset of menses and ends 4 days after menstruation 40% of all premenopausal women from 25-40 Symp: bloating, breast pain, ankle swelling, sense of increased weight, irritability, aggressiveness, depression, libido change, lethargy, food cravings

Answer 26

EMOTIONAL OR MOOD SYMPTOMS during luteal phase plus some physical symp COMPLETELY RESOLVES W/ ONSET OF MENSES CLEAR FUNCTIONAL IMPAIRMENT W/ WORK OR PERSONAL RELATIONSHIPS -possible abn/fault building of progesterone in the brain= sedating -abn serotonergic response in relation to sex hormones track mood w/ cycle for 2 months

Answer 27

1. Exercise 2. Reduce caffeine, salt, alcohol intake 3. Increase dietary calcium, Vitamin D3, magnesium, complex carbohydrates

Answer 28

1. meds that PREVENT OVULATION= COC, patch, vaginal ring 2. SSRIs for MOOD DISORDERS 3. Magnesium + Vitamin B6 -mag citrate= diarrhea so use Magnesium Glycinate

Answer 29

Goal: decrease bleeding and decrease risk of endometrial hyperplasia or CA ALERT: ALL AUB IN >35 YO IS CA UNTIL PROVEN OTHERWISE definition of heavy menstrual bleeding 1. bleeding for >7 days 2. changing tampon/pad after less than 2 hours or 3. passing clots quarter size or larger Ddx: PALM-COEIN Polyp Adenomyosis Leiomyoma Malignancy Coagulopathy Ovulary dysfxn Endometrial hyperplasia Iatrogenic Not yet classified tx: 1st line: COC Progestin therapy= medroxyprogesterone acetate MPA, Prometrium OMP, Norethindrone (Aygestin) Mirena IUD Other: NSAIDS to reduce blood loss by decline in protaglandin synth= VC = less effective than IUD or tranexamic acid cant take hormone? = tranexamic acid

Answer 30

indication: HEAVY MENSTRUAL BLEEDING class: antifibrinolytic agent MOA: competitively blocks the conversion of plasminogen to plasmin-> reduction in fibrinolysis taken only during menses Contraind: prior DVT/PE, coagulopathy

Answer 31

Endometriosis= condition in which the type of tissue that forms the lining of the uterus is found outside the uterus-> plaques can breakdown and cause scar tissue= increase pelvic/abd pain Adenomyosis: endometrium grows into the wall of the uterus symp: heavy bleeding, painful periods, pelvic pain Gold standard: DIAGNOSTIC LAPAOSCOPY AMOUNT OF VISUAL DZ DOES NOT CORRELATE TO THE PAIN PT EXPERIENCES TX: not a cure or decrease tissue= for pain only 1. NSAIDS= low cost, easily available-> celecoxib in pts desiring to get prego Progestin only- good for those who cant have estrogen 1.COC= STOPS OVULATION bc ovulation feeds endometriotic plaques Gonadotropin releasing hormone agonist or antagonist Severe: tx causes long term bone loss GNRH agonist= Lupron (leuprolide acetate) GNRH antagonist= Orilissa (elagolix) Aromatase inhibitors surgery

Answer 32

Clinical diagnosis Rotterdam criteria: need 2 of the 3 1. Oligomenorrhea 2. Hyperandrogenism 3. Polycystic ovaries symp: Hyperandrogenism, hirsutism nestrual dysfxn tx: 1st line: COC for 6 months-> if hyperandrogenic symp then add -Spironolactone- antiandrogen and diuretic -finasteride- 5 alpha reductase type 2 inhibitor -dutasteride- inhibits both 5-alpha reductase types 1 and 2 if insulin resistance -metformin -lifestyle = exercise, diet, adequate sleep, stress reduction

Answer 33

MOA of tx: 1. increase # of mature eggs -Clomid=Selective estrogen receptor modulator (SERM) -Femara= aromatase inhib= production of fewer follicles= less risk of multiple gestation 2. Induce ovulation -GNRH releasing hormone analogs and antag 3. Acting directly of ovary to stimulate development of mature eggs -human menopausal gonadotropin or hMG -FSH Metformin= for hyperinsulinemia can lead to increase in mestrual cyclicity

Answer 34

inflammatorry vs infectious symp: discharge, bleeding, dysuria, dyspareunia, irritation, edema must do physical exam and approp swabs/testing to diag DOWNLOAD CDC STI Tx app

Answer 35

EDUCATION: TX PT AND PARTNER= ABSTAIN FROM SEX DURING TX AND 7 DAYS AFTER TX= EXPEDIATED PARTNER THERAPY (EPT) 1. Chlamydia trachomatis- Doxycycline 2. Neisseria gonorrhea- Ceftriaxone 3. Mycoplasma genitalium- do Mgen resistance testing or Doxy followed by Moxifloxacin if resistance testing: -Macrolide sens: Doxy followed by Azithromycin -Macrolide resistant: Doxy followed by moxiflozacin 4. Trichomonas vaginalis -Men: Metronidazole 2 g -Women- Metronidazole 500 mg 5. Herpes simplex virus-> look it up 6. Candida -OTC: Clotrimazole, Miconazole -script: diflucan 7. Bacterial Vaginosis (BV)- Metronidazole