Women's Health Flashcards
Define Chronic HTN
pre-existing HTN or new onset HTN before 20 weeks of gestation
Define gestational HTN
new onset HTN without proteinuria after 20 weeks of gestation
Define preeclampsia
new onset HTN after 20 weeks of gestation plus new onset of any of the following:
proteinuria,
signs of end-organ dysfunction,
uteroplacental dysfunction (fetal growth restriction)
Define chronic HTN w superimposed preeclampsia
new onset proteinuria in a woman with chronic HTN before 20 weeks gestation
What are the 3 signs for proteinuria in preeclampsia?
- 24h urinary protein (UTP) ≥ 300mg
- Dipstick protein ≥ 2+
- Urine protein : creatinine ratio (uPCR) > 0.3 mg/dL
What are the 5 signs of end-organ damage in preeclampsia?
- Platelet count <100
- LFTs > 2x ULN
- Doubling of SCr in the absence of other renal diseases
- Pulmonary edema
- Neurological complications such as seizures
What pharmaco therapy can be given for prevention of preeclampsia?
Aspirin 100mg OD (or more)
In which patient groups should aspirin be started for preeclampsia? (4)
- HTN w previous pregnancy
- Multifetal gestation
- Patients w autoimmune diseases
- Other related health complications (DM, CKD, etc)
When should low dose aspirin be started for preeclampsia
After 12 weeks, ideally before 16 weeks
What are the top 2 drugs that should be used in HTN in pregnancy and what should you watch out for
Labeltalol - look our for bronchoconstriction and bradycardia
Nifedipine ER - watch out for pedal edema
What is the third line drug for HTN in pregnancy?
Hydrochlorothiazide (interferes with blood volume expansion)
What BP should treatment be initiated for HTN in pregnancy?
140/90
What are the advantages, disadvantages and contraindications for female condoms?
A: can insert ahead of time, STD protection
D: high user failure rate, dislike ring hanging out
CI: TSS history, allergy to polyurethane
What are the advantages, disadvantages and contraindications for diaphragm with spermicide?
A: low cost, reusable
D: higher user failure rate, low protection against STDs, increased UTI risk, cervical irritation
CI: TSS history, recurrent UTI, allergy to latex or spermicide, abnormal gynecologic anatomy
Which hormones (luteinising and follicle stimulating) do progestins and estrogens help block?
Progestin blocks LH surge
Estrogens block FSH release
What are the effects of progestins and estrogen on the endometrium?
Estrogen builds it up
Progestin thins it out
What are the side effects of drosperinone? (3)
hyperkalemia, bone loss, thromboembolism
What are the side effects of cyproterone? (1)
High risk for thromboembolism
What are the two different ways to administer COCs?
Conventional cycle - 21 active + 7 placebo (newer ones 24+4)
Extended-cycle or continuous - 84 active + 7 placebo
or
no placebo at all
What are the three methods of initiating COCs?
First day (first day of menstrual cycle, no backup)
Sunday start (first sunday after cycle begins, 7 day backup)
Quick start (start now, 7 day backup, potentially until next cycle)
Which component of COCs increase VTE risk?
Estrogen
Which component of COCs increase stroke and MI risk?
Estrogen
What cardinal s/sx should you look out for in stroke and MI risk?
Migraine with aura
What are the 12 absolute contraindications to COCs?
- Current breast cancer or recent history of breast cancer within the last 5 years
- History of DVT or pulmonary embolism, and patients with DVT or PE currently on anticoagulant therapy
- Major surgery with prolonged immobility
- < 21 days postpartum (risk fo VTE)
- Thrombogenic mutations
- Migraine with aura
- SBP > 160 or DBP > 100 (uncontrolled and high CV risk)
- HTN with vascular disease
- Current or history of IHD
- Cardiomyopathy
- Smoking ≥ 15 sticks a day AND above 35 years old
- History of cerebrovascular disease
How to adjust if there is breakthrough bleeding?
If early or mid cycle, increase estrogen
If late cycle, increase progestin
How to adjust for bloating and n&v?
Reduce estrogen
For n&v, take at night
How to adjust COCs for headache?
Exclude migraine w aura, then switch to extended or continuous cycle as HA usually occurs in pill free week
What 3 drugs can COCs interact with?
Rifampin, anticonvulsants, HIV antiretrovirals
What to do if one dose is missed (less than 48h)
Take missed dose and continue the rest as normal, no backup required
What to do if two or more consecutive doses are missed (more than 48h)
Take missed dose and discard the rest, continue the rest as usual, backup required for 7 days
What to do if the pills were missed during the last week of hormonal tablets (ie. day 15-21)
Finish remaining pills in active pack, skip hormone-free and start new pack, require backup for 7 days
How to start taking POPs? (2)
Within 5 days of starting cycle with no backup
or
Any other day with 2 day backup
What is the timing adherence issue for POPs?
If late by more than 3h, backup required for 2 days
How should be vaginal rings be used?
They are to be used for 3 weeks then discarded (precise placement not an issue)
What do transdermal patches and vaginal rings come with? (risk)
Increased risk of VTE
How are progestin injections given?
Depot administered IM every 12 weeks (3 months)
What are the side effects of progestin injection (3)
Weight gain, short term bone loss, amenorrhea
avoid in elderly, avoid using for more than 2 years
Which IUDs should be used for heavy flow and no flow? How long can they be used for?
Heavy flow use Levonorgestrel IUD 5 years
No flow use copper IUD 10 years
What are the 3 broad categories causing amenorrhea?
Anatomical causes (pregnancy, anatomical abnormalities)
Endocrine disturbances
Ovarian insufficiency or failure
What are the pharm (4) and non pharm (3) treatment options for amenorrhea?
COCs, estrogen only, POP or copper IUD
Weight gain, reduction of exercise intensity, stress management
What are the pharm (6) and nonpharm (2) treatment options for menorrhagia?
NSAIDs/tranexamic acid, cyclic progesterone (14/21 days), COCs, progestin IUDs, POPs, progestin injections
Endometrial ablation, hysterectomy
What are the pharmacological options for dysmenorrhea? (3)
NSAIDs (first line), COCs (second line), progestin injection or IUD (third line)
What are the 4 presentations of menopause?
- VMS (due to estrogen)
- GSM (due to estrogen)
- Psychological or cognitive impairment
- Bone fragility
What are the 5 counselling points for VMS management?
- Layered clothing that can be removed or added as necessary
- Lower room temperature
- Less spicy food, caffeine and hot drinks
- More exercise
- Dietary supplements (isoflavones and black cohosh)
What is the 1 counselling point for mild vulvovaginal symptoms?
Nonhormonal vaginal lubricants and moisturisers
What are the 2 kinds of HRT for menopause and when should they be given
Estrogen only or Estrogen+Progestin
(Estrogen only for patients who do not have uterus function due to risk of endometrial cancer)
What are the two administrative ways that HRT can be given?
- Continuous-cyclic: estrogen continuous while progestin on 1st/15th of the month for 10-14 days (bleeding when progestin is stopped)
- Continuous combined: both E and P given daily, no withdrawal bleeding
What are the patient counselling points for HRT? (3)
- May take up to 2-3 months before seeing improvements in menpausal sx
- Undergo annual mammography and endometrial surveillance
- If they spot abnormal symptoms, see doctor
What are abnormal bleeding patterns for estrogen only, continuous-cyclic and continuous-combined HRT?
estrogen only: any bleeding
continuous-cyclic: bleeding when progestin is still on
continuous-combined: prolonged or heavier bleeding > 10 months after initiation
What are other pharmacological treatment options for VMS? (4)
- SSRIs
- SNRIs
- gabapentin
- tibolone (risk of stroke)
Which metabolised form of EE undergoes enterohepatic recirculation?
EE sulfate
What are the side effects of EE?
Breast tenderness, headache, fluid retention (bloating), nausea, dizziness, weight gain, venous thromboembolism (VTE), myocardial infarction and stroke, liver damage
In which patient groups are EEs contraindicated? (3)
Patients with a known history of susceptibility of arterial or venous thrombosis
Patients with advanced diabetes with vascular disease
Hypertension ≥ 160/100
