Week 12: OB/GYN & Genitourinary - Contraception, HRT, Erectile disorders, Incontinence/BPH Flashcards

1
Q

Pathophysiology of female reproductive system

A
  • Hypothalamus controls pituitary gland via GnRH (released in pulsate manner to maintain cycle)
  • Pituitary gland then releases LH and FSH which stimulates ovaries to release progesterone and estrogen
  • Menstrual cycle and pregnancy are tightly controlled by both positive and negative feedback loops between hypothalamus, pituitary, ovaries, eggs and uterus
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2
Q

Hormones of the female reproductive system

A

FSH

  • Stimulates maturation of follicle in ovary
  • Causes release of estrogen which peak right before ovulation

LH

  • Stimulate luteal phase of ovulation and promote thickening of endometrium
  • Cause release of progesterone which peaks just before mestruation

Progesterone

  • Responsible for preparing endometrium for pregnancy
  • Thickens in preparation for implantation
  • If egg implants it keeps rising to keep endometrium thick
  • If fertilization does not occur, drops rapidly which results in shedding of endometrium

See menstrual cycle diagram

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3
Q

Contraception

  • Options (All)
  • Options of hormonal contraception
A

Options

  • Hormonal contraception
  • Barrier methods
  • Withdrawal
  • Rhythm or fertility awareness methods
  • Copper IUD
  • Spermicide

Option of hormonal contraception

  • Progestin only (POP)
  • Combined oral contraception (COC)
  • Levonorgestrel IUD
  • Vaginal ring
  • Medroxyprogesterone injection (depot)
  • Etonogestrel implant
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4
Q

Hormonal contraception: POP/Minipill

  • MOA
  • Benefits
  • Risks
A

MOA

  • Thicken cervical mucus to stop sperm from entering cervix preventing fertilization
  • Changes the endometrium to mimic non fertile points of menstrual cycle preventing implantation
  • May suppress ovulation by stopping LH surge

Benefits

  • Can be taken by those who cannot have estrogen
  • Lower risk of blood clot than COC
  • Relatively inexpensive

Risks

  • Harder compliance
  • Slightly less effective than COC
  • Oral - affected by N&V and malabsorption disorders
  • Higher risk of ectopic pregnancy vs COC
  • Can be androgenic (acne, weight gain)
  • Higher incidence of breakthrough bleeding than COC
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5
Q

Hormonal contraception: COC

  • MOA
  • Contraindications
  • Benefits
  • Risks
A

MOA

  • Has progesterone and estrogen to give broad contraceptive coverage
  • Inhibit ovulation (more effective than POP)
  • Reduce receptivity of endometrium to implantation
  • Thicken cervical mucus

Contraindication

  • Breastfeeding
  • Higher risk of clots/stroke/MI if smoker, overweight, high BP, valvular disease, history of clots/VTE/MI/stroke, >40/50
  • History of breast or cervical cancer
  • Patients suffering from migraine with aura

Benefits

  • Higher efficacy that POP
  • Easier compliance
  • Progesterone used are less androgenic than POP
  • Inexpensive

Risk

  • Higher risk blood clots than POP
  • Common causes headache and nausea
  • Oral - affected by nausea and vomiting
  • Taken every day
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6
Q

Hormonal contraception: Hormonal IUD

- MOA

A

MOA

  • Contains only a progesterone
  • Small device inserted into uterus
  • Local effect - releases levonorgastrel in order to change endometrium to prevent implantation and thickened cervical mucus
  • In some women it suppresses ovulation
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7
Q

Hormonal contraception: Vaginal ring

- MOA

A

MOA

  • Contains estrogen and progesterone
  • Thickens cervical mucus forming barrier to sperm passing through cervix
  • Inhibits ovulation through negative feedback loop of both LH and FSH
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8
Q

Hormonal contraception: Depot injection

- MOA

A

MOA

  • Contains progesterone
  • Injected by doctor and creates depot of progesterone that is slowly released over 12 weeks
  • Thickens cervical mucus to create barrier to sperm
  • Change endometrium to prevent implantation
  • Reliably suppresses ovulation (compared to POP)
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9
Q

Hormonal contraception: Contraceptive implant

- MOA

A

MOA

  • Contains only progesterone
  • Inserted subdermally in inner, upper arm every 3 yrs
  • Thickens cervical mucus to prevent sperm entering through cervix
  • Change endometrium to prevent implantation
  • Reliably suppresses ovulation by suppressing LH surge
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10
Q

Emergency contraception

- Options

A

Used to prevent pregnancy after unprotected intercourse or failed contraception

Options

  • Levonorgestrel tablet within 72 hrs (contains progesterone high dose)
  • Ulipristal tablet within 120 hrs (contains progesterone receptor modulator)
  • Copper IUD within 5 days
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11
Q

Pathophysiology of menopause

- Two stages

A
  • Cease to ovulate
  • Occurs naturally with age
  • Produce lower amounts of progesterone and estrogen

Stages

  • Peri menopause (start to decline in hormone levels)
  • Menopause (menstruation stops)
  • Post menopause (all eggs gone)
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12
Q

Causes of menopause

A
  • Naturally with age
  • Drug induced in some chemotherapy agents
  • Hysterectomy/oophorectomy
  • Primary ovarian insufficiency
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13
Q

Clinical presentation of menopause caused by drop in hormone levels of

  • Estrogen
  • Progesterone
  • Testosterone
A

Estrogen

  • Hot flush/tingling
  • Loss of BMD
  • Vaginal dryness/atrophy
  • Fatigue
  • Breast pain/tenderness
  • Headache
  • Weight gain/fat redistribution

Progesterone

  • Hot flushes/tingling
  • Vaginal dryness/atrophy
  • Spotting
  • Fatigue
  • Breast pain/tenderness
  • Headache

Testosterone

  • Hair loss/thinning
  • Altered mood
  • Low libido
  • Forgetfulness
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14
Q

Menopause hormone replacement therapy options

A
  • Tablets - estrogen and progesterone available separately or as combined
  • Patches - estrogen available separately or as combined
  • Gel - Estrogen only
  • Cream and tablets - inserted into vagina
  • IUD - progesterone only
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15
Q

Menopause HRT: Tibolone

  • MOA
  • ADR
A

MOA

  • Estrogenic activity on vagina, bone, thermoregulator centers in brain
  • Progesterone activity on breast tissue and endometrium

ADR

  • Abdominal pain/bloating/weight gain
  • Vaginal bleeding/discharge
  • Dizziness/migraine/nausea
  • Stroke
  • Possible increase in breast cancer and endometrial cancer
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16
Q

Menopause HRT: Tibolone

- Contraindications and cautions

A

Hepatic impairment
- Contra in severe impairment

Renal impairment
- No precautions

Contraindicated

  • Hormone dependent tumor
  • CVD
  • Cease 4 weeks before surgery
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17
Q

Erectile dysfunction

  • Primary
  • Secondary
A

Primary (rare)
- Psychological factors (guilt, depression, anxiety)

Secondary

  • Organic etiology (vascular, hormonal, neurological, structural)
  • Psychological (anxiety, stress, mood disorder)
  • Situational (place, partner, time)
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18
Q

Physiology of an erection

A
  • Cavernosal arteries dilate, engorging corporal tissue with blood
  • Engorging causes corporal tissue to swell, erecting penis
  • Engorged corporal tissue compresses penile veins and venules, maintaining erection
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19
Q

Erectile dysfunction - Non pharmacological treatment

A
  • Remove causative factors
  • CBT/councelling
  • Treat causative factors
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20
Q

Erectile dysfunction - Pharmacological treatment options

A

1st line
- Oral PDE-5 inhibitor

2nd live
- Intracavernosal alprostadil/vacuum device

3rd line
- Intracavernosal combination

4th line
- Penile implant

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21
Q

Erectile dysfunction: PDE-5 inhibitor

  • MOA
  • Examples
A

MOA

  • Inhibit breakdown of cGMP to inactive GMP by PDE-5
  • Allow increased vasodilation and relaxation of corpus cavernosum to increase blood flow during sexual stimulation

Example

  • Sildenafil (Viagra)
  • Tadalafil
22
Q

Erectile dysfunction: PDE-5 inhibitor

- Contraindications and cautions

A

Elderly

  • Risk of hypotension
  • Require low dose - assess exercise tolerance
  • Half life is increased

Hepatic impairment

  • Low dose in mild/mod
  • Do not use in severe

Renal impairment
- Low dose in moderate impairment

Contraindications

  • Migraine
  • NO donors
  • CVD
  • Leukaemia
  • Sickle cell anaemia
23
Q

Erectile dysfunction: Alprosadil

  • MOA
  • ADR
A

MOA

  • Local injection
  • Prostaglandin E1 analogue - dilates arteries in corpus cavernosum
  • Relax smooth muscle of corpus cavernosum and spongiosum

ADR

  • Penile pain
  • Priapism
  • Brusing/injection site reaction
  • Fibrotic changes
  • Hypotension/fainting/dizziness
24
Q

Erectile dysfunction: Alprosadil

- Contraindications and cautions

A

Elderly

  • Assess exercise tolerance
  • Higher risk of orthostatic hypotension

Hepatic and Renal impairment
- No precautions

Caution
- Men with HIV/HepB/C

Contraindication

  • Penile implant
  • Anatomical deformities of penis
25
Priapism - Definition - Treatment
Definition - Prolonged painful erection Treatment - 2 hrs = hot shower and pseudoephedrine 120mg (cold and flu vasoconstrictor) - 2-4 hrs = repeat previous treatment and phone doctor - >6 hrs = hospital to aspirate and drain corpora cavernosa, infusion of adrenergic drug to contract smooth muscle If aspirate not successful a surgical stunt required
26
Types of urinary incontinence
1. Urge incontinence - Bladder over sensitivity from infection or neurological disorders 2. Stress incontinence - Reduce pelvic floor - Increased abdominal pressure (pregnancy) 3. Overflow incontinence - Urethral blockage - Bladder unable to empty properly
27
Urinary incontinence - risk factors
- UTI - Menopause - Obesity - Constipation - Neurological/ musculoskeletal conditions - Diabetes - BPH - Pregnancy/vaginal delivery - Medication - Advanced age
28
Urinary incontinence - management | - Non pharmacological options
- Bladder diary - Manage underlying contributing factors - Pelvic floor exercises/bladder training - Schedual voiding - Incontinence pads
29
``` Urinary incontinence - management - Pharmacological options 1st line = anticholinergics - MOA - Example - ADR ```
1st line = Anticholinergics MOA - Block cholinergic receptors on bladder to reduce contractility and increase bladder capacity Example - Oxybutynin - Solifenacin ADR - Confusion - Constipation - Dry mouth - Blurred vision - Urinary retention - Drowsiness - Dizziness
30
Urinary incontinence - management - Pharmacological options 1st line = anticholinergics - Contraindications and cautions
Elderly - More likely to experience ADR - Start low and go slow Hepatic impairment - Reduce dose Children - Prefer oxybutynin - Can be used from age 5 Pregnancy and breastfeeding - Limited data - See specialist Renal impairment - Reduce dose Caution - Those with urinary overflow secondary to urinary retention - Bladder outlet obstruction - Avoid combination with other drugs that have anticholinergic effects
31
``` Urinary incontinence - management - Pharmacological options 2nd line = Desopressin - Indication - MOA - ADR ```
Indication - Nocturnal enuresis in children 5 and over - Available as oral spray and wafer MOA - Bind to V2 receptor in collecting duct of nephron - Increases amount of water reabsorbed from urine back into kidney ADR - Hyponatremia/fainting/seizure/coma - Nasal irritation/nausea
32
Urinary incontinence - management - Pharmacological options 2nd line = Desopressin - Contraindications and caution
Elderly - Not indicated for Children - Oral tablets and wafers preferred to spray due to increased risk of hyponatremia with spray Caution in children who cannot comply with fluid restrictions
33
``` Urinary incontinence - management - Pharmacological options 2nd line = Mirobegron - MOA - ADR ```
For adults and can take up to 8 weeks to see effect MOA - Beta3 receptor agonist on bladder muscle - Relax bladder muscle as it fills and increases bladder capacity ADR - Increased BP - UTI - Headache - Tachycardia
34
Urinary incontinence - management - Pharmacological options 2nd line = Mirobegron - Contraindications and caution
Elderly - More likely to see hepatic/renal/HT/arrhythmia effect - Start low and go slow Hepatic impairment - Low dose for mode impairment - Avoid in severe impairment Children - Not indicated Pregnancy and breastfeeding - No data; avoid if possible Renal impairment - Reduce dose - Do not use in severe impairment Caution - Hypertension - Severe uncontrolled HT or arrhythmia
35
Benign Prostatic hyperplasia/hypertrophy | - Size of prostate
- Prostate generally gets larger over time - Exact cause of BPH is unknown - Size of prostate directly linked to testosterone - As it enlarges it narrows urethra and puts pressure on bladder
36
BPH symptoms and presentations
Lower urinary tract symptoms (Voiding or obstructive) - Hesitancy - Weak and poorly directed stream - Straining to urinate - Dribbling after urination has finished or irregular stream - Urinary retention - Overflow or paradoxical incontinence Lower urinary tract symptoms (storage or irritative) - Urgency - Frequency - Nocturnal Other symptoms - Perineal pain - Dysuria - Haemoturia
37
BPH - Diagnosis - Treatment options
Diagnosis - Blood test for PSA - Physical exam for DRE ``` Treatment options - No treatment - Oral medicines > Alpha blockers > PDE-5 inhibitors > 5-alpha reductase inhibitors - Surgery > Transurethral resection of prostate > Transurethral incision of prostate > Open or retropubic prostatectomy - Laser treatment ```
38
BPH pharmacological treatment - 5-alpha reductase inhibitor - MOA - Example
MOA - 5-alpha reductase is enzyme which converts testosterone to dihydrotestosterone (more potent and stimulates prostate growth) - Results in reduced size of prostate allowing better urinary flow Example - Dutasteride - Finasterise
39
BPH pharmacological treatment - 5-alpha reductase inhibitor | - Contraindications and cautions
Elderly - Caution with fixed combination dutasteride and tamsulosin due to increased risk of hypotention Children - Not indicated Pregnancy - Caution - should not handle capsules or tablets
40
BPH pharmacological treatment - Selective alpha blockers - MOA - Examples
MOA - Selectively block alpha 1 receptor - Relaxes smooth muscle of bladder neck and prostate which results in decrease in resistance to urinary flow Example - Tamsulosin - Prazosin
41
BPH pharmacological treatment - Selective alpha blockers | - Contraindications and cautions
Elderly - Avoid prazosin - Use other options with caution - More susceptable to orthostatic hypotension Hepatic impairment - Contraindicated with alfozosin - Caution with use of other options Children - Not indicated Renal impairment - Worsened first dose hypotension; begin treatment cautiously Caution - Patients already on anti hypertensives due to risk of hypotension
42
UTI classification - Types - Uncomplicated - Complicated
Types - Cystitis = infection of bladder - Urethritis = infection of urethra - Epididymitis = infection of epididymis - Pyelonephritis = infection of kidney/upper urinary tract Uncomplicated - Premenopausal - Non-pregnant - Adult women with no structural/functional abnormality - Recurrence = within 2 weeks of 1st infection - Reinfection = > 2 weeks from 1st infection Complicated - Not uncomplicated - Chronic recurring - Children - Pregnancy - Anatomical/functional abnormality - Comorbidities
43
UTI risk factors
- Female - Sexual activity - Age - Immunosuppresant - Genetic - Catheter use - Dehydration - Pregnancy - Diabetes - Antibiotic use - Inability to completely void bladder (paralysis or stroke)
44
UTI Pathophysiology
- Upper urinary tract and bladder are normally sterile > Opening to these tracts are not > Bladder normally clears itself by completely voiding urine > Acidity of urine helps kill bacteria Infection of upper urinary tract - kidney causes easy hematogenous spread to surrounding tissue and sepsis and shock can occur quickly
45
UTI presentation/symptoms - Common/uncomplicated adult - Pyeloephritis - Elderly - Children under 2
Common/uncomplicated adult - Dysuria - Increased frequency - Urgency - Suprapubic pain - Hematuria Pyelonephritis - Fever/chills - Pain in back/lower abdomen Elderly - Often asymptomatic - Confusion - Loss of appetite - Flu like symptoms Children under 2 - Often non specific - Fever - General unhappiness/failure to thrive - Loss of appetite - Abdominal pain - Vomiting
46
UTI complications if untreated
- Recurrent infection - Permanent kidney damage - Pregnancy - low birth weight or premature birth - Urethral stricture (male) - Sepsis - death (common in elderly)
47
UTI diagnosis
- Urine sample - CT/MRI (if anatomical abnormality suspected) - Cytoscopy (visualize tract and bladder)
48
UTI treatment - Non pharmacological - OTC/Herbal
Non pharmacological - Drink fluid - Avoid acidic drink and caffeine - Heating pads OTC/Herbal - Urinary alkaliniser - symptomatic relief - Cranberry - Hexamine hippurate
49
UTI treatment | - Antibiotics (general info)
Antibiotic resistance is growing - Keep course short as possible If asymptomatic only treat children and pregnant women
50
UTI treatment Uncomplicated UTI - Antibiotics > Examples
Antibiotics - Short term - Oral Example - Trimethoprim (3days) - Cephalexin (5days) - Amoxycillin + clavulanate (5 days)
51
``` UTI treatment Complicated UTI - Pregnant - Men - Pyelonephritis (mild) - Pyelonephritis (severe) ```
Pregnant - Same as uncomplicated but no trimethoprim Men - Same as uncomplicated but all for 7 days Pyelonephritis (mild) - Same as uncomplicated but for 10-14 days Pyelonephritis (severe) - IV antibiotics
52
UTI treatment for recurrent UTI
Long term treatment - Trimethoprim oral daily for 3-6 months OR - Cephalexin oral daily doe 3-6 months If sexual intercourse is cause can use antibiotic when sex occurs rather than daily