Thrp: Exam 7 (Gender Specific Issues) Flashcards
Ethinyl Estradiol
Estrogen
Estradiol Valerate
Newest estrogen *Natazia only
Mestranol
Estrogen: Not used
Progestin MOA in Contraception
Mimic Luteal phase: (-)feedback = No ovulation Hostile Cervical Mucus Inhospitable endometrium Dec fallopian tube movement (can do 1 or all at anytime)
*NOT CLEAN
Progestin, estrogen, androgen, endometrial activity
Desogestrel
Progestin: High progestin and low estrogen activity
Norgestimate
Progestin: Zero Estrogenic activity
Levonorgestrel
Progestin: Most androgenic activity w/ no estrogenic activity
Norethindrone Acetate
Progestin:
Norgestrel
Progestin: Zero Estrogenic activity
Norethindrone
Progestin:
Ethynodiol Diacetate
Progestin:
Drospirenone
Progestin: Spirinolactone anolog w/ ANTI-Androgenic activity
=Tx Acne, facial hair, PCOS
*Regular K+ Monitoring (~Potassium Sparing Diuretic)
(Yasmin and Yaz)
Dienogest
Progestin: Synthetic Progestin (no real advantage over others)
Anti-androgenic and zero estrogenic activity
(Natazia)
Nor-QD
Progestin only Minipill: Norethindrone 0.35mg
Ovrette
Progestin only Mini pill: *Norgestrel (0 estrogenic activity)
Medroxyprogesterone Depot
Contraception
150mg IM q12w
104mg SQ q12w
(3 month duration)
Back up needed for 1st week for the 1st time shot
OR if 1 wk late for next shot
CI: overweight (wt gain SE) Ab bleeding
Reversible dec in BMD due to no estrogen and (-) feedback (=Hypoestrogenic state)
- worse if start early or >5yrs
- dont use if other BMD risk factors (ex smoke, low Ca++)
Ortho-Evera
Patch: norelegestromin + EE 3wk on (Δ q7d) 1wk off
Missed Dose = 2 Days
If wk 1 = Apply ASAR, back up X7D; new day 1
If wk2 = <2days Apply ASAR; OK
≥ 2days = new cycle; back up X7D
if wk 4: remove when remember/cont wear ok
Nuvaring
Vaginal Ring: Etnogestral + EE
3wk in 1 wk out
Removal >3hr = back up tell cont. 7 day use
or if > 1wk extra wear: new ring, back up X7D, rule out pregnancy
Nexplanon
Progestin rod implant
Effective 3 yrs w/ immediate return to fertility w removal
SE: (progestin only Rx)
Irregular bleeding that does NOT resolve
Yuzpe Regimen
EC: High dose EE 100 mcg + high dose progestin (levnorgestrel 1mg)
W/IN 72 hrs then repeat 12 hrs later (efficacy 75%)
(any OC X 2 dose - FDA Approved = Ovral (#2), Alesse (#5), Nordette (#4), LoOvral (#4))
if already conceived does NOT harm
SE: N/V **Can take antiemetic IF vomit w/in 2hrs REPEAT dose (high dose estrogen), heavy menses/breast tenderness
CI: known preg (not harmful but waist of $$), any OC CI, Hx of clots, cancer (only 1Xdose)
EC Levonorgestrel Only
Plan B= levonorgestrel 0.75mg take w/in 72hrs then repeat 12 hrs after 1st dose
OR take both w/in 72 hr = Plan B One Step (1.5mg)
**Acceptable efficacy up to 120 hrs after sex BUT loner the wain lower the efficacy
SE: Some N/V**Can take antiemetic IF vomit w/in 2hrs REPEAT dose , breast tenderness, HA, Dizziness
If not period w/in 3 wks need prego test
EC Copper IUD
EC up to 5 days AFTER ovulation
Mifepristone
EC: OFF LABEL use up to 5 days after sex (Abortifacient)
Ulipristal acetate
RX only EC: “SPRM” MOA: progesterone antagonist to prevent implantation (effective even if LH surge has begun)
*Suppression of dominant follicle growth, delay endometrial growth, postpone ovulation
DOSE: 30mg up to *120hrs post sex
(efficacy similar to (but better than) PlanB)
(Ella)
Mirena
Levornorgestrel IUD: Rel 20mcg/day
Effective 5 years w/ <1% failure
Local delivery = MOA: inhospitable endometrium, thick cervical mucus, changes in tubal motility (less ovulation effect/ (-) feedback)
AE: inc unexpected spotting/bleeding (dec over time; after 1yr many amennorheic)
SERIOUS but rare = uterine perforation
P.A.I.N.Sx: Period late/abnormal spotting, Abdominal pain/pain with intercourse, Infection exposure (STD)/abnormal vaginal discharge, Not feeling well (fever/chills), String mission/shorter or longer.
Counseling: check string qmo
Tx: Endometriosis
Skyla
New Levornorgestrel IUD: Rel 14mcg/day
Effective 3 years
Local delivery = MOA: inhospitable endometrium, thick cervical mucus, changes in tubal motility (less ovulation effect/ (-) feedback)
P.A.I.N.Sx: Period late/abnormal spotting, Abdominal pain/pain with intercourse, Infection exposure (STD)/abnormal vaginal discharge, Not feeling well (fever/chills), String mission/shorter or longer.
AE: inc unexpected spotting/bleeding (dec over time; after 1yr many amennorheic)
SERIOUS but rare = uterine perforation
ParaGard
Copper IUD Contraception MOA: Spermacide
Effectiveness for 10 years (failure rate 2.1 - 2.8%)
w/Copper IUD Always have period
CI: List*
P.A.I.N.Sx: Period late/abnormal spotting, Abdominal pain/pain with intercourse, Infection exposure (STD)/abnormal vaginal discharge, Not feeling well (fever/chills), String mission/shorter or longer.
AE: inc unexpected spotting/bleeding w/ reg cycle bleeding q.mo, heavy bleed w/cramping
SERIOUS but rare = uterine perforation
Ca++ for PMS
1200mg/day (women should get this much anyway)
Dec mood sx, fluid retention, pain (48%) VS. 30% Px
Low risk/cost intervention
Tx: PMS Bloating
Salt restriction: powerful (EDEMA too)
Spironalactone 25mg up to QID x 10d prior to menses
Tx: PMS Breast Pain
Vit E 400 IU QDay OR “Evening Primrose Oil” 500mg - 3g qd
Bromocriptine (DA Receptor Ag) if due to hyperprolactinemia
Tx: PMS Insomnia
Sleep Hygiene
Low dose Trazodone
intermittent diphenhydramine
Tx: PMS Anxiety
Buspirone: Cont or luteal phase only
(20-30mg/day in 2-3divided doses)
Avoid BDZ (Alprazolam)
Mifepristone
Medical Abortion: MOA: antiprogestin that blocks progestin activity resulting in changes the uterine lining and inc sensitivity to prostaglandins: -> cervical so feting and uterine contractions (i.e. medical abortion)
1 Dose followed by Misoprostol
Not available in pharmacies
Used UP TO 7wks (49days) from last period
*need three office visits, consent signed, agree to undergo surgical abortion if doesn’t work
CI: IUD, chronic steroid therapy, ectopic preg, **Hemorrhagic disorder or anticoag therapy (AE = bleeding for up to 30 days)
AE: bleeding up to 30 days (Heavy bleeding may mean incomplete abortion), uterine cramping, N/D, dizziness
Clostridium sordelli Toxic Shock Syndrome
Misoprostol
Prostaglandin: MOA: Augment uterine contractions
Medical abortion: 400-800 mcg vag or PO given after Mifepristone
OTHER USES:
Dec GI effects of NSAIDS and PUD (200mcg QID)
Induce contraction at delivery
Miscarriage POST-Tx (can see at retail setting)
Insertion of IUD (little evidence for this but done)
PMDD Tx
1° Tx = Education, support, diet, regular exercise
Ca++
2nd line = SSRI: Sertraline or fluoxetine: Dose during luteal phase OR continuos
SSRI’s Tx MOOD Sx
Yaz has approved indication for Tx of PMDD
Spironolactone
MOA: Aldosterone Receptor Antagonist, K+ sparring diuretic
Tx: hirsutism & Acne in PCOS
50-100mg BID for 6-12 mo (may take 6-9mo for improvement)
Monitor K+ and renal fn
AE: Polymenorrhea, mastodynia, HA mood swings, fatigue, GI
Clomiphene Citrate
MOA: antiestrogenic effect on hypothalamus. initiates hormonal cascade to produce ovulation and restore normal gonadotropin secretion
Dose: 50mg/day X 5 D started on cycle day 5. can inc by 50mg up to MAX: 200-250mg/day TOTAL of 6 cycles
*once dose attained to cz ovulation, little gained w/inc dose and more SE
AE: GI, vasomotor, sleep disturbances, ovarian hyperstim hepatotoxic (rare)
Metformin
Insulin-senstizine agent:
(For PCOS: sensitizers can induce ovulation by dec serum LH and testosterone via improvement in insulin sensitivity
MOA: inhib hepatic glucose production and improve peripheral glucose uptake (improves insulin sensitivity)
Dose: 500 mg TID OR 850 - 1000mg BID
TITRATE UP if effective cont for 6mo-1yr
AE: N/D! big time D but transient. lactic acidosis (rare but fatal)
*not concerned about Hypoglycemia Rx does NOT inc insulin
Monitor: renal fn, LFT
CI: Cr >1.4, hepatic disease, pulmonary compromise->septic shock and lactic acidosis
Pioglitazone
Thiazolidinediones insulin-senstitizing agent:
class being pulled
MOA: improve insulit sensitivity in muscle and adipose tissue and CAN induce ovulation too.
AE: edema, wt gain, hepatotoxic
(Actos)
OC for Tx of Endometriosis
Continuos is KEY
Depot Medroxyprogesterone
Levonnorgestrel IUD - very effective
Letrozole
Aromatase Inhibitor
Tx: endometriosis, only tx that decreases formation of estrogens by the endometrial implants themselves
MOA: inhibits estrogen syn
NOT FDA Aproved
Anastrozole
Aromatase Inhibitor
Tx: endometriosis, only tx that decreases formation of estrogens by the endometrial implants themselves
MOA: inhibits estrogen syn
NOT FDA Aproved
Danazol
inhibits ovarian steroid production and inc metabolism of estrogen
-> Pseudomenopause to Tx Endometriosis
NOT USED* tons of SE LAST LINE ONLY
Leuprolide
GnRH Agonist: Tx: endometriosis
MOA: induce a hypoestrogenic state via negative feedback on ovarian steroid production
Takes 2 weeks
Daily SQ injection; Monthly depot inj
AE (=Menopause: hot flashes, vag dryness, dysparenunia, dec BMD)
TO avoid bone loss “Add Back Therapy”: add back predestine/estrogen - not OC need more use HRT regimes
Used for 6mo, effect retained for 6-12 mo After d/c
Nafarelin
GnRH Agonist: Tx: endometriosis
MOA: induce a hypoestrogenic state via negative feedback on ovarian steroid production
Takes 2 weeks
Nasal Spray
AE (=Menopause: hot flashes, vag dryness, dysparenunia, dec BMD)
TO avoid bone loss “Add Back Therapy”: add back predestine/estrogen - not OC need more use HRT regimes
Used for 6mo, effect retained for 6-12 mo After d/c
Goserelin
GnRH Agonist: Tx: endometriosis
MOA: induce a hypoestrogenic state via negative feedback on ovarian steroid production
Takes 2 weeks
Monthly SQ implant
AE (=Menopause: hot flashes, vag dryness, dysparenunia, dec BMD)
TO avoid bone loss “Add Back Therapy”: add back predestine/estrogen - not OC need more use HRT regimes
Used for 6mo, effect retained for 6-12 mo After d/c
Estrace
19β estradiol:
PO - Standard dose 1-2mg; low dose 0.5mg
Vaginal cream 0.1mg/gm: 1g 1-3X/wk for maintenance (DO not need progestin at this dose) **IF QDAY then need progestin if pt has uterus
Prempro
Continous combined estrogen+progestin
Climera
Estradiol Patch: once weekly
Climera Pro
Estradiol + levonorgestrel Once weekly patch
Estring
Vaginal estrogen: 17β estradiol 7.5mcg/day replace q 3 mo.
=NOT systemic - no progestin needed
FOR urogenital Sx only
Femring
vaginal ring: 0.05-0.1mg/day replace q 3 mo
Tx: hot flashes
THIS IS FOR SYSTEMIC SX: NEED PROGESTIN (if uterus)
Topical estrogen for Systemic Sx
Many- need progestin if uterus
transfer risk
Follow exact directions: if 1 pump then *1PUMP
Provera
Medroxyprogesterone (Progestin HRT products)
2.5, 5, 10mg
Hot flashes Alternative Tx
Tx: hotflashes
Gabapentin 300mg TID: Start low and go slow
Limited efficacy but option
Other options
Venlafaxine, fluoxetine, paroxetine, citalopram, clonidine
- *Raloxifene for postmenopausal osteoporosis can CZ hot flashes
- Tamoxifen induced hotflashes: Estrogen Tx is CI** - use citalopram NOT other Alt.
Ospemifene
SERM: Tx- dyspareunia due to vulvar/vaginal atrophy
Dose 60mg/day WITH FOOD
AE: Cz endometrial cancer VTE/stroke
RISK VS BENIFIT
Vit D2
Ergocalciferol (Diet)
Vit D3
Cholecalciferol (sun/skin)
Activated Vit D3
Calcitriol
0.25mcg/day for renal impairment pts ONLY
Calcium
Tx and Prevent Osteoporosis
DNE: 500-600mg/dose
Take w/meals (except Ca++ Citrate - Pretreated with acid)
Dose = (DIET + supplement) >65yo = 1500mg/day 51-64 = 1200mg /day 19-50yo = 1000mg (1 dairy serving = 300mg)
AE: constipation, nausea
DDI:
Thiazide good DDI: dec renal Ca++ excretion
Loopers Bad DDI: inc renal Ca++ excretion
Calcium Citrate
24% Elemental
Best Ca++ supp for elderly
Does not need acid for absorption
Food does still enhance ab
(Citrical)
Calcium Carbonate
40% Elemental
Need to take w/food: ok supp for younger adults
(Tums)
Vitamin D Tx
800 IU /day
Benifits are dose related: 800 IU (min) - 2000 IU MAX
Is Fat soluble -> will store can get toxicity
DDI: cholestyramine, mineral oil, phenytoin, barbiturates
Recheck levels for insufficient/deficiency its 3-4 mo after starting
(50K IU/wk usually 3 mo = OK; not long term)
Raloxifene
Tx: osteoporosis: LAST LINE ONLY and C.I. in men
MOA: SERM - estrogen-like effect on bone w/o breast/endometrial cancer liability
Not great efficacy
Dose: 60mg Qday
AE: **Raloxifene for postmenopausal osteoporosis can CZ hot flashes, leg cramps, DVT/PE - Hx = CI
Calcitonin
Tx Osteoporosis related fractures (NOT LONG TERM)
RISK OF CANCER = FDA: DO not use for osteoporosis
Alendronate
(Fosamax) Tx: Osteoporosis
MOA: Bind bone and disrupt respiration (similar to estrogen MOA)
COUNSELING POINTS
AE:
Oral - GI* esophageal ulceration, ab pain, bone pain/body pain** DLT switch to other med**
IV - FIRST DOSE EFFECT=flu like Sx, bone pain; rare = jaw osteoporosis
- atypical femur fractures: w/ >5yr use, low trauma fractures -
CI in pts w/ CrCl<35***
- DOSE: b/c its cheap
- prevention: 5mg qday or 35mg q week
- Tx: 10mg Qday or 70 mg q week
Risedronate
Tx: Osteoporosis
MOA: Bind bone and disrupt respiration (similar to estrogen MOA)
COUNSELING POINTS
AE:
Oral - GI* esophageal ulceration, ab pain, bone pain/body pain** DLT switch to other med**
IV - FIRST DOSE EFFECT=flu like Sx, bone pain; rare = jaw osteoporosis
- atypical femur fractures: w/ >5yr use, low trauma fractures -
CI in pts w/ CrCl<35***
Ibandronate
Tx: Osteoporosis
MOA: Bind bone and disrupt respiration (similar to estrogen MOA)
COUNSELING POINTS
AE:
Oral - GI* esophageal ulceration, ab pain, bone pain/body pain** DLT switch to other med**
IV - FIRST DOSE EFFECT=flu like Sx, bone pain; rare = jaw osteoporosis
- atypical femur fractures: w/ >5yr use, low trauma fractures -
CI in pts w/ CrCl<35***
Zolendronic Acid
Tx: Osteoporosis
MOA: Bind bone and disrupt respiration (similar to estrogen MOA)
COUNSELING POINTS
AE:
Oral - GI* esophageal ulceration, ab pain, bone pain/body pain** DLT switch to other med**
IV - FIRST DOSE EFFECT=flu like Sx, bone pain; rare = jaw osteoporosis
- atypical femur fractures: w/ >5yr use, low trauma fractures -
CI in pts w/ CrCl<35***
DOSE: 5mg IV infused over not less than 15min ONCE YEARLY (or q2yr for prevention)
Indication = cant swallow or severe GI w/ oral
Denosumab
Tx: osteoporosis (failed bis-P)
MOA: Anti-resorptive RANK-L inhibitor
Dose: 60mg SQ q6mo
AND 1000mg Ca+ and min of 400 IU Vit D
NO Renal adjustment but inc risk of hypocalcemia: CI in hypocalcemia pts
AE: Sim to bis-P but less common
Must monitor Ca++
Teriparatide
Recombinant PTH
MOA: Only Tx to build bone
Pulsatile dosing: PTH Paradox
Dose: 20ug/day SQ
short term use 2yr MAX to form new bone: **Must follow up Tx w/ antiresorbtive agent to maintain newly formed bone
AE: dose dependent: N HA Dizzi leg cramps
Mild hypercalcemia
(Forteo)$$$$
Sildenafil
Specific PDE-5 inhibitor: inhibits breakdown of cGMP -> potentiating smooth muscle relaxation and erection
Dose: 25-100mg PO 30min-4hr before sex MAX=One dose/day
t1/2=4hrs,
Fatty meals delay onset by one hour*
AE: nasal congestion, changes in color vision (loss of blue/green - transient), sudden vision loss, priapism/prolonged erection
DDI: alpha blocker (tamsulosin less of an issue), 3A4 inhibitors (HIV, ery/clarithromycin, -azole), Alcohol (increased vasodilatation, dec ability to achieve erection)
(Viagra (25, 50,100mg Tx ED), Revatio (20mg, 10mg/12.5ml inj Tx: PAH))
Vardenafil
Specific PDE-5 inhibitor: inhibits breakdown of cGMP -> potentiating smooth muscle relaxation and erection
t1/2=4-5hrs
MAX 1 dose / day
AUC dec if taken w/ fatty meal
AE: nasal congestion, changes in color vision (loss of blue/green - transient), sudden vision loss, priapism/prolonged erection
(Levitra)
Tadalafil
Specific PDE-5 inhibitor: inhibits breakdown of cGMP -> potentiating smooth muscle relaxation and erection
*t1/2=17.5 hrs (may cont to work up to 36hrs and still in system at 96hrs after single 20mg dose **NOT GOOD FOR CVD PTS)
Can take daily OR prn
Taken w/ or w/o food = OK
AE: nasal congestion, **NO changes in color vision (loss of blue/green - transient), sudden vision loss, priapism/prolonged erection
*Back pain/muscle ache (PDE11)
(Cialis)
Avanafil
Specific PDE-5 inhibitor: inhibits breakdown of cGMP -> potentiating smooth muscle relaxation and erection
t1/2 = 5hr
w/ w/o food
one dose/day only (typ 100mg 30min prior to sex)
AE: nasal congestion, changes in color vision (loss of blue/green - transient), sudden vision loss, priapism/prolonged erection
(Stendra)
Papaverine
Non-specific PDE inhibitor Intracavernosal injection
SE: Priapism, corporeal fibrosis, Hypotension
Combined with phentolamine +/- alprostadil
()
Phentolamine
alpha antagonist that reduced peripheral adrenergic tone
Enhances cholinergic tone: improves cavernosal filling
INJECTION: used with papaverine
Yohimbine
Herbal Prescription: central alpha blcoker
5.4mg TID (in most OTC products for ED)
Poor efficacy
AE: palpitation, anxiety, tremor, HTN
Avoid use in paitents with DM CAD anxiety levier/renal dysfn
IM Testosterone
Tx: Hypogonadism ONLY
Goal: normal range, Sx resolution
IM 200-300mg enanthate or cypionate q 2-4 wks (NOT QDAY)
get “see-saw” effect but cheap
Monitor: baseline, 3mo, 6mo, yrly
PSA, DRE, Hematocrti
Voiding assessment
Breast exam
Transdermal Testosterone
Tx: Hypogonadism ONLY
Goal: normal range, Sx resolution
Androderm Patch: 2mg/24hr or 4mg/24hrs MAX 6mg/day
Androgel/testim: 5gm applied qd in am MAX=10g/day)
Get physiologic levels that are constant
Monitor: baseline, 3mo, 6mo, yrly
PSA, DRE, Hematocrti
Voiding assessment
Breast exam
TURP
Transurethral resection of the prostate
Tamsulosin
selective alpha 1a inhibitor: relax smooth muscle of the prostate to improve urine flow rate and red BPH Sx
0.4mg PO Qday
Sex dysfn, orthostasis (less than non-selective Rxs), SJS, intraoperative flobby iris syndrome
