Therapeutics Exam 4 (Women's Health) Flashcards
Definition of Oligomenorrhea
menstrual cycle > 35 days
Definition of Polymenorrhea
menstrual cycle < 21 days
what things are seen as abnormal bleeding?
bleeding b/w periods after sex spotting at any point of menstrual cycle heavier bleeding than normal longer/shorter bleeding than normal bleeding after menopause
what is secondary dysmenorrhea:
onset in ______
poor response to _________
_______ and vaginal _____
onset in 20 - 30s
poor response to NSAIDs/oral contraceptive pills
dyspareunia/ discharge
Risk factors for Dysmenorrhea
< 20 y.o wt loss attempts depression/anxiety heavy menses nulliparity smoking family hx
Nonpharm options for dysmenorrhea?
heating pad
exercise
omega 3 fatty acids and vit B (???)
smoking cessation
drugs for dysmenorrhea treatment?
danazol (an androgen)
leuprolide
NSAIDs (use only during symptoms!!)
oral contraceptives
how to treat oligomenorrhea or polymenorrhea and metorrhagia?
treat underlying cause..
hormonal contraception!
possible causes for oligomenorrhea
anovulation heavy exercise eating disorders thyroid disease prolactinoma adolescent age perimenopause medications (antipsychotics and antiepileptics)
what is menorrhagia?
heavy menstrual bleeding (> 80 mL)
causes of menorrhagia?
hormonal imbalance
infection
fibroids
coaglupathy
How to treat menorrhagia?
iron supplementation
NSAIDs
Hormonal contraceptive
Target underlying cause
How to treat acute menorrhagia treatment
tranexmic acid (TID x5 days) Medroxyprogesterone (TID x 1 wk) HD estrogen (IV q4H until bleeding slows; OR
monophasic OC TID x 1 wk!! (like a whole pack of sprintec in a week!!)
definition of metorrhagia?
bleeding b/w periods
what can cause metorrhagia
IUD infections meds hormone imbalance fibroids, polyps, endometriosis
what is the billings ovulation method
monitoring cervical mucous (clear and thin = ovulation)
Review of Menstrual Cycle:
______ stimulates FSH and LH
estradiol/estrogen
Review of Menstrual Cycle:
Two phases?
folicular phase then Luteal phase
Review of Menstrual Cycle:
what hormone is higher during follicular phase?
vs
what hormone is higher during luteal phase?
follicular: estradiol
luteal: progesterone
Review of Menstrual Cycle:
what is Day 1?
start of the menstruation
Review of Menstrual Cycle:
_______ surge –> ovulation
FSH and LH surge
Changes in a Women’s Body:
Menstrual Cycle, Pregnancy or Elderly Women?
will have increased gastric pH
pregnancy and elderly
Changes in a Women’s Body:
Menstrual Cycle, Pregnancy or Elderly Women?
decreased creatinine clearance
elderly
Changes in a Women’s Body:
Menstrual Cycle, Pregnancy or Elderly Women?
increase blood volume and decrease albumin
pregnancy
Changes in a Women’s Body:
Menstrual Cycle, Pregnancy or Elderly Women?
decreased Vd for hydrophilic and increased Vd for lipophilic
elderly
what age are women supposed to start get cervical screenings?
age 21
how often are women to get a cervical screening
every 3 years
roles of estrogen in contraception
suppress FSH
increase SHBG
why is estrogen increase SHBG good
more SHBG = increase binding of free androgens = acne is better!
roles of progestin in contraception
prevent LH surge
thicken cervical mucus
change motility of fallopian tubes
atrophy of endometrium
why is estrogen suppress FSH good
it prevents a dominant follicle
why is progestin preventing the LH surge good
inhibit ovulation
why is progestin thickening the cervical mucus good
inhibit sperm/penetration/transport
why is progestin changing the motility of fallopian tubes good
impair transport of sperm/ova
why is progestin causing atrophy of endometrium good
impair implantation
what are side effects from estrogen that mean there is not enough estrogen
breakthrough bleeding early in cycle light menses vaginal dryness spotting (no withdrawl bleeding??)
what are the 3 different characteristics of progesterone components
progestational
androgenic
estrogenic
what are the side effects of androgenic progestin
acne
hirsutism
(want low androgenic activity!!)
why is it good to have estrogenic components of progestin
it is there to oppose the androgenic side effects!
what specific progestins are 3rd/4th gen aka they will have the fewest side effects
norgestimate
desogestrel/etonogestrel
drosperinone
Implant: what hormone(s)? good for how long? return on fertility effect?
progestin only
3 years
may be delayed
Levonorgestrel IUD: what hormone(s)? good for how long? return on fertility effect?
progestin only
3 - 5 years (depends on IUD)
immediate fertility
Serious side effects of IUD?
expulsion
uterine perforation
infection
Copper IUD: what hormone(s)? good for how long? return on fertility effect?
no hormone, duh!
10+ years!!!!
immediate fertility
Birth Control Shot: what hormone(s)? good for how long? return on fertility effect?
progestin only
shot given every 3 months
delayed return of fertility
Birth Control Shot:
given every 3 months (____ - ____ weeks)
considered late after _____ weeks
11 - 13
15 weeks = late = use back up for a week!
serious ADEs of the Birth Control Shot?
lower bone desnity
heavy bleeding
potential benefits of IUDs?
lower risk of uterine cancer
safe to breastfeed
long term protection
(lighter periods with hormonal IUD but NOT copper)
potential benefits of the Birth Control Shot?
lower risk of uterine cancer
safe to breastfeed
(lighter periods with hormonal IUD but NOT copper)
(aka just like IUD but no longer term protection..)
The combined pill: what strengths are very low dose, low dose, and high dose
very low: 20 - 25 mcg
low: 30 - 35 mcg
high: 50 mcg
Mini Pill:
hormone?
must be taken within hour many hours everyday?
progestin only
3 hours
Nuvaring:
hormones?
if left out for _____ hours use backup for 7 days
progestin and estrogen
> 3 hours
Patch:
hormones?
if off for more than ____ or if on for more than ____ - use back up for 7 days
progestin and estrogen
off more 24 hours
on more than 9 days
serious side effects from combined methods
(ACHES) Abdominal pain (liver or gallbladder or clot) Chest pain (PE or MI) headache (HTN or stroke) eye problems (bc HTN or stroke) severe leg pain (DVT)
potential mechanisms of antibiotics and COC
altered intestinal flora
increased N/V/D from abx
altered metabolism
main contraindication for progestin only contraception
current breast cancer
what are the 3 emergency contraception options
copper IUD
Ulipristal acetate
Levonorgestrel pill
what is usually 1st line recommendation for all women for contraception?
LARCs! (IUD and implants!!)
Emergency Contraception:
Must take within _____ of unprotected sex
5 days!
package will say 72 but up to 5 days is ok!
Emergency Contraception:
Wait 5 days to restart hormonal birth control if _____ is used
ulipristal (Ella)
Side effects of Emergency Contraception?
N/V
headache/dizziness
breast or stomach pain
next period may start early/spotting
HPV non-cancer risks?
Anogenital warts
Recurrent respirator papillomatosis
Cervical Cell Abnormalities
HPV cancer risks?
anal
head and neck
CERVICAL!
Ideal vaccination time/age?
before onset of sexual activity/ age 11 - 12
what HPV vaccine is currently available? (others have been withdrawn)
Gardasil 9
Gardasil vaccine:
if < 15 y.o – get how many vaccines
if > 15 y.o – get how many vaccines
< 15: 2 vaccines
> 15: 3 vaccines
current ages approved by FDA for gardasil
9 - 45 now!!!
used to be years 9 - 26.. just approved for 27 - 45!
HPV Vaccine logistics: Shake it or dont shake it before giving solution will look like \_\_\_\_\_\_\_\_ given (SQ or IM) (Live or non-live) vaccine?
shake it!!
soln is white/CLOUDY
IM
non-live!
Contraindications to HPV vaccine
hypersensitivity..
Severe allergic rxns to YEAST (it is a vaccine component)
Allergic rxn to previous dose
Warnings/Precautions to HPV vaccine?
syncope!
have appropriate medical treatment available in case if anaphylactic rxn
what is CRPS or POTS
CRPS: complex regional pain syndrome
POTS: postural orthostatic tachycardia syndrome
– possible HPV vaccine reactions!!
PMS and PMDD: Recurrent moderate \_\_\_\_\_ and \_\_\_\_\_ symptoms Occur during the \_\_\_\_ phase Should resolve with \_\_\_\_\_ Over 200 symptoms!!
moderate psychological and physical symptoms
during the luteal phase
resolve w/ menstruation
PMS and PMDD:
Pathophys is not super well understood — what are some possible casuses tho
serotonin GABA allopregnanolone estrogen progesterone
PMS Definition/Diagnosis:
at least one symptom associated with __________
___ days before onset of menses
Present for at least __#__ consecutive menstrual cycles
assoc. w/ economic or social dysfunction
5 days before
3 cycles
PMDD Definition/Diagnosis: \_\_\_\_ symptoms final week before menses Improves within a few days of onset of menses Present in majority of cycles Starts \_\_\_\_\_ days before menses
5 symptoms!!!
7 days
Non-Pharm options for PMS and PMDD?
AEROBIC exercise (2 - 3 x/wk) Relaxation Techniques Calcium Carb Vit. B6 Reduced CAFFEINE, Refined SUGARS, and SODIUM
Pharm Treatment of PMS/PMDD?
1st/2nd line: SSRI 3rd line: Alprazolam 4th: GnRH agonists (Oral contraceptives or spironolactone could be good) Surgery if insanely bad
T or F: For PMS/PMDD treatment alprazolam is typically used to replace SSRIs
false!! never to REPLACE only to augment!!! used when pt has hella anxiety symptoms – NOT for any physical sxs
GnRH analogs for PMS/PMDD:
Must add _____ therapy after ____ months because of ________
add back hormone thearpy!
6 - 9 months
b/c reductions in bone mass
GnRH analogs for PMS/PMDD:
effective in pschyoemotional sxs, physical sxs, or both?
both!!
but used hella last line
Oral Contraceptives for PMS/PMDD:
Good for/effective in pschyoemotional sxs, physical sxs, or both?
only physical sxs!!
Oral contraceptives: doing a shortened _____ interval = greater reduction in symptoms
shortened pill free*
Spironolactone for PMS/PMDD:
take doses during ______ of cycle
Will work to decrease what things?
during luteal phase
decreases weight gain, somatic symptoms (breast tenderness or bloating) and negative mood
Treatment options for Female orgasmic disorder?
CBT EROS-CTD (like vacuum device for the clitoris) NON FDA approved Meds: Bupropion Apomorphine SL...?
Female Sexual Interest/arousal disorder treatment options?
estrogen or testosterone..
Addyi(filbanserin)
MOA of Addyi?
Mixed 5HT1a agonist/ 5HT2a antagonist
Contraindications for Addyi?
Alcohol use
Strong/moderate CYP3A4 inhibitors
Hepatic impairment
T or F: Addyi has a REMS program
True
ADEs of Addyi?
dizziness
nausea
fatigue
Pre-Natal Diet: what things are needed for sure to be adequate?
folate iron calcium omega 3 fatty acids calories!
All women of childbearing age should have ____ folic acid daily
If high risk or hx of NTD: women should have ____ folic acid daily
0.4 mg
4 mg
Food sources for folic acid?
fortified foods green leafy veggies citrus fruits liver legumes whole wheat bread
Pregnancy: Iron recommendations:
_____ mg of iron
27 - 30 mg QD
Food sources of iron?
lean red meat fish poultry dried fruits iron fortified cereals
Adequate calcium intake for pregnant women may decrease risk of _____ and ____
HTN and preeclampsia
what fish should be avoided in pregnant women?
king mackerel shark swordfish tilefisk raw rish (refrigerated smoked seafood?)
what fish CAN pregnant women have
shrimp canned light tuna salmon pollock catfish
prenatal diet:
Caffeine: recommended = < _____ mg/day
200 mg/day
Prenatal genetic screenings?
Sickle cell
Cystic fibrosis
aneuploidy
what are some third trimester/late pregnancy testing?
glucose tolerance test CBC HIV Syphilis Group B Beta Strep
Vaccination in Pregnancy?
what can they not get?
which ones should they get during pregnancy?
NO LIVE VACCINES!!
should get flu and TDaP
Pregnancy PK Changes:
Absorption: ______ gastric emptying
slower
Pregnancy PK Changes:
Distribution: _____ blood volume;
change in protein binding;
_____ ratio of lean muscle to adipose tissue
large blood volume
lower ratio
Pregnancy PK Changes:
Elimination: ________ renal and hepatic blood flow
increased
Pregnancy PK Changes:
Metabolism:
Changes in ________ metabolism enzymes
phase 1 and phase 2 metabolism
Pregnancy and Timing of Medication Exposure:
First 2 weeks after conception — all or nothing
Weeks 3 - 10: ______genesis – critical if exposed to a teratogen
organogenesis
3 major teratogens that were listed in lecture?
Thalidomide
ACE Inhibitors
Warfarin
Prescription drug labeling sections: what are the 3 sections
pregnancy
lactation
female/male reproductive potential
what are the 3 common pregnancy complaints we might have to recommend things for?
N/V
Heartburn
Constipation
Non-Pharm options for NVP?
Start prenatals 3 months before conception Avoid triggers (smells, foods, motion) Eat small, frequent, low-fat meals drink chilled beverages Ginger
FIRST line NVP pharm treatment option?
1st line: Pyridoxine +/- doxylamine
SECOND line NVP pharm treatment option?
antihistamines phenothiazines anticholinergics Dopamine antagonists serotonin inhibitors
LAST line NVP pharm treatment option?
glucocorticoids
main safety concerns of serotonin inhibitors in pregnancy?
QT prolongation (for mom)
cleft palate
fetal cardiac abnormalities
heartburn for pregnant women is worst in what trimester?
third
causes of heartburn in pregnant women?
increased progesterone
enlarged uterus
non pharm options for heartburn - pregnancy lecture
diet - avoid trigger foods
eat small, well balanced meals
raise head of bed 6 - 8 inches
chewing gum
causes of constipation in pregnancy?
dietary changes decreased physical activity iron containing vitamins mechanical factors progesterone
Non pharm options for pregnant women with constipation
increased fiber and fluid avoid constipating foods... regular exercise limit stress avoid constipating meds...
what are some acute issues in pregnancy?
UTI
pain/fever/HA
VTE
may concern of UTIs in pregnancy being left untreated?
pyelonephritis
Non-pharm options for treating UTI in pregnancy?
hydration wipe from front to back void before/after sex avoid scented feminine products wear cotton underwear avoid tight fitting clothes
what antibiotics should HELLA not be used for UTI in pregnancy treatment
fluroquinolones (cipro and levo)
tetracyclines
bactrim (sulfa-TMP)
what antibiotics are ok to use in tx of UTI in pregnancy
cephalexin
nitrofurantoin
ampicillin
sulfisoxazole
avoid what antibiotics for UTI in pregnancy?
fluoroquinolones (Cipro and levofloxacin)
tetracyclines
SMZ-TMP
Acute issues in pregnancy:
If fever unresolved in _____ - go see OB
if headache persists and women is over ____ weeks - go see OB
fever: 24 - 36 hours
HA: over 20 weeks (bc worried about preeclampsia)
what is the DOC for pain/fever in pregnancy
APAP
Pregnancy -Pain/HA
NSAIDs: avoid use after ______ weeks (premature ductal closure)
32 weeks
risk factors for thromboembolism in pregnancy?
> 35 yo Obesity (BMI > 30) grand multiparity personal/family hx of VTE bed rest immobility > 4 days hyperemesis dehydration preeclampsia surgery/trauma
Managing thromboembolism in pregnancy:
Postpartum —- Restart anticoag….
___ hours after natural delivery
6 hours
Managing thromboembolism in pregnancy:
Postpartum —- Restart anticoag….
______ hours after epidural removal
12 hours
Managing thromboembolism in pregnancy:
Postpartum —- Restart anticoag….
_____ horus after C -section
24 hours
Managing thromboembolism in pregnancy:
Postpartum:
Continue anticoag for at least _____ postpartum
6 weeks
Managing thromboembolism in pregnancy:
Postpartum:
want to do a TOTAL duration for at least ______
6 months
Managing thromboembolism in pregnancy - delivery:
scheduled induction or C-section at ____ weeks
- stop LMWH ____ prior
- stop Factor Xa/direct thrombin inhibitor ______ prior
at 37 weeks
stop LMWH: 24 hours prior
other 2: 24 - 48 hours…. (so 24 hrs for all!)
Managing thromboembolism in pregnancy - delivery:
switch to _____ at 36-37 weeks gestation b/c shorter half life
UFH
Preterm birth is known as before ______ weeks gestation
37 weeks
What are some MATERNAL risk factors for premature birth?
hispanic race < 6 mos b/w pregnancies physically strenuous work pre-pregnancy BMI < 19 (aka underweight) Medical conditions (DM, HTN, thyroid disease)
What are some PREGNANCY characteristics risk factors for premature birth?
infections cocaine/heroin use multiple gestation -- twins/triplets shortened cervix tobacco use uterine abnormalities placental abruption
Preventing Preterm Birth:
if hx of preterm birth: ______ q week (weeks 6 - 36)
if no hx of preterm birth _______ daily as early has 18 weeks based on cervix
if hx: hydroxyprogesterone IM
no hx of preterm = vaginal progesterone suppository
if Preterm labor and contractions: what drugs are used?
- magnesium sulfate (fetal neuroprotection)
- corticosteroids (betamethasone and dexamethasone)
- Penicillin (Group B strep prophylaxis) — do if not tested before
- tocolytics
what drugs are tocolytics
nifedipine
indomethacin
terbutaline
magnesium sulfate
Pre-Term labor & contractions - Magnesium sulfate: prevent _______ and is for ________ protection
prevent cerebal palsy
fetal neuroprotection
Pre-Term labor & contractions
Corticosteroids used in weeks 24 - 34 for developing _______
lungs
Pre-Term labor & contractions
Tocolytics are used in weeks 24 - 34 to ________
stop contractions
Pre-Term Membrane rupture:
use what drugs?
corticosteroids and magnesium sulfate and “latency abx”
common meds for HTN in pregnancy
labetalol amlodpine nifedipine HCTZ hydralazine methyldopa
gestational HTN:
elevated BP after ____ weeks
generally do not treat if BP is < ______
20 weeks
160/110 mmHg
risk factors fro gestational HTN
gestational diabetes
hx of preeclampsia
obesity
age
Preeclampsia = new onset BP of > _______ and proteinuria > _________
140/90
300 mg / 24 hrs
risk factors for preeclampsia
microvascular disease (diabetes, HTN, vascular diseases) nephropathy Age < 20 y.o or > 35 y.o Family/personal hx or preeclampsia first pregnancy
Preeclampsia:
_______ is only cure
delivery
Preeclampsia:
what are severe symptoms?
neurologic: headache and blurry vision
end organ damage (kidney and liver and placental function)
may deliver at 34 weeks or earlier…
Goals of managing preeclampsia?
prevent seizures
lower Blood pressure
avoid maternal end organ damage
Preeclampsia seizure prophylaxis agents?
magnesium sulfate;
phenytoin
benzo
what is HELLP syndrome and what does it stand for?
it is a variant of severe pre-eclampsia
Hemolysis, Elevated, Liver enzymes, Low Platelets
if pregnant lady has pre-existing diabetes: Patient should do SMBG \_\_\_\_\_ times a day Has more (strict or relaxed) blood glucose goals?
4 x/day
more strict!!
which antidepressant should be avoided for sure in pregnancy
paroxetine
what ___% for RID range means a large amount of drug is transferred to milk/risk to infant exists
10%
______ lactation risk category:
what values/what represents - what is safest and what is contraindicated?
Hale’s
L1 = safest –> 2, 3, 4, L5 = contraindicated
what does RID do and what does it stand for?
Relative infant dose:
can be used to calculate potential exposure
