Women's Health

Question 1

COC CI

Answer 1

cancer, heart disease, VTE, diabetes with micro complications, <6w postpartum if breastfeeding, migraines w aura, BP>160/100, liver tumor/cirrhosis, smoker >35yo (>15cig/day)

Question 2

older progesterones

Answer 2

levonorgestrel, norethindrone, norethindronacetate
some testosterone activity

Question 3

newer progesterones

Answer 3

desorgestrel, norgestimate
greater VTE risk

Question 4

antiandrogenic progesterones

Answer 4

drosperinone, cyproterone
good for acne, bloating, but inc VTE risk

Question 5

How to start COC

Answer 5

Sunday start +7d backup
quick start +7d backup
1st day menses no backup

Question 6

Missed pills

Answer 6

1st 7d then need EC +7d backup
w2-3 1 missed pill is ok but 2-3 missed start new pack and skip PFI and use EC + 7d backup

Question 7

COC AE

Answer 7

spotting in 1st 3m normal
E: nausea, breast tenderness
P: wt gain, mood swings
ACHES: abdominal pain, chest pain, headaches, eye problems, severe leg pain

Question 8

What are leuprolide, goserelin and nafarelin?

Answer 8

Gonadotropin-releasing hormone (GnRH) agonists which suppress FSH, preventing proliferation of the endometrium and causing amenorrhea. May be used to shrink fibroids and manage heavy bleeding. AE: bone loss (if >6mth), hot flashes, vaginal dryness, decreased libido.

Question 9

What is tranexamic acid?

Answer 9

An antifibrinolytic, used for heavy bleeding. AE: n/v/d. CI: history of thrombosis, hemorrhage, hematuria.

Question 10

Plan B Counselling

Answer 10

Indicated within 3 days (70% effective at day 5)
AE: Nausea, vomiting (repeat dose if <1h) take Gravol, spotting. Take pregnancy test if don’t get period at usual time. Decreased efficacy if >80kg, consider Ulipristal (rx, $).

Question 11

Mifegymiso Counselling

Answer 11

Mifepristone PO (antiprogestin terminates pregnancy) + Misoprostol buccal (prostaglandin induces contractions within hours, taken 24-48h after). CI: asthma, adrenal failure, ectopic pregnancy. AE: n/v/d, bleeding may last 2 weeks. Red Flags: soaking 2 maxi pads in 2h, fainting, fever, flu-like sx, severe pain uncontrolled by NSAID. May start COC next day. Must follow-up w Dr after.

Question 12

Supplements recommended pre-pregnancy

Answer 12

Supplement:
Folic acid 0.4-1.0mg/day
Vit D 600IU/day
Iron 27mg elemental iron daily

Diet & Supplement:
Calcium 1000mg/day
Essential fatty acids omega-3,6
Vit B12 2.6mcg/day

Question 13

Pregvit Dosing

Answer 13

Morning pink has iron, take on empty stomach

Night blue has folic acid 1.1-5mg and calcium

If n/v from iron can flip timings or use low iron in T1. Note both should be separated from levothyroxine.

Question 14

Gestational diabetes tx and targets.

Answer 14

Insulin is the therapy of choice. Metformin and Glyburide safe until insulin initiated.
Target A1C<6.5, FBG<5.3, PPBG<7.8

Question 15

How do levothyroxine doses change during pregnancy?

Answer 15

Doses increase 20-30% as soon as pregnancy suspected, then monitor TSH q4w until week 20. Post-partum doses return to pre-pregnancy and monitor TSH 6wk post.

Question 16

PO med for ovulation induction

Answer 16

Aromatase inhibitor letrozole start on days 3-7 or 5-9 of cycle, stimulates ovulation in 7days. AE: hot flushes, headaches, mood swings, n/v, bloating, breast tenderness, increased risk of multiples.

Question 17

Injectable meds for ovulation induction

Answer 17

Injectable gonadotropins (FSH, hMG, LH) stimulates ovaries directly- start on day 2 of cycle and continued 7-12 days usually. AE: n/v/d, bloating, breast tenderness, injection site irritation, malaise, multiples.

Question 18

meds to trigger ovulation + maturation

Answer 18

hCG injection (ex. Ovidrel) triggers ovulation in 36h, used after letrozole or gonadotropin, may cause false + pregnancy test

Question 19

misc. meds used in infertility tx

Answer 19

progesterone, glucocorticoids, sildenafil, ASA

Question 20

Meds used to boost milk flow

Answer 20

Domperidone -3-4 day onset, doesn’t need to be empty stomach (that’s for stomach motility)
or
Metoclopramide - CNS AE (not commonly used)
or
NHPs: fenugreek, blessed thistle, milk thistle, alfalfa, brewer’s yeast

Question 21

Counselling antifungal for thrush during breastfeeding

Answer 21

Miconazole 2% cream applied after each feed for 2w, wipe away visible cream before next weed
+/-
Fluconazole 150mg po then 50-100mg ID F10D

Question 22

Mastitis non-pharms, tx recommendations

Answer 22

continue feeding q2h and massage while feeding, warm compress before feeds and cold compress between feeds for pain/inflammation. If sx don’t improve within 12-24h consider antibiotics f10-14days.

Question 23

Tx for N/V during pregnancy?

Answer 23

Pyridoxine (B6) q8h prn

Diclectin (pyridoxine+doxylamine) B6+antihistamine - delayed release tab takes 4-6h, commonly used 2 tabs hs for morning sx + 1am and 1 mid afternoon (max 8/day) -CI in glaucoma, PUD, MAOI -AE: drowsiness, vertigo, headache, diarrhea

Dimenhydrinate or diphenhydramine

Last lines: metoclopramide, phenothiazines, ondansetron (controversial)

Question 24

Prometrium counselling

Answer 24

Contains soy/peanut (ask allergies)
Causes drowsiness use QHS
Insert at least 1 inch
Pregnant May use up to 36w

Question 25

Role of estrogen in menstrual cycle

Answer 25

“The builder”
Causes proliferation of the endometrial lining

Question 26

Role of progestin in the menstrual cycle

Answer 26

“The mover/decorator”
Prevents over-proliferation and changes proliferative lining into secretory lining. Fall in P triggers menstruation.

Question 27

How estrogen and progesterone in contraceptives acts as birth control

Answer 27

E: HPOA axis suppression (tricks hypothalamus into not sending LH FSH which cause ovulation)
P: thins lining, thickens mucus, slows motility. Plan B prevents fertilization and implantation and (controversial) ovulation. Depo provera stops ovulation for sure since high dose.

Question 28

Non-hormonal treatments for menopause

Answer 28

Gabapentin
SSRI/SNRI
Reduce vasomotor sx (hot flashes) by ~50%