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women's health Flashcards

1
Q

ethinyl estradiol - MOA

A
  • estrogen receptor agonist
  • stabilise endometrial lining -> inhibit FSH from anterior pituitary -> suppress development of ovarian follicle -> make endometrium unsuitable for implantation of ovum -> reduce pregnancy
  • cycle control
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2
Q

ethinyl estradiol - PK

A

1) absorption

  • well absorbed orally (OD)
  • onset 30-60 mins
  • IV, IM, topical

2) distribution

  • highly protein bound

3) metabolism

  • by liver
    ** phase I: CYP3A4 hydroxylation
    ** phase IIL conjugation w glucuronide & sulfation -> hormonally inert ethinylestradiol glucuornide & ethinylestradiol sulfate (enterohepatic circulation)

4) elimination: faeces & urine

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3
Q

ethinyl estradiol - AE

A

1) breast tenderness
2) headache
3) fluid retention (bloating)
4) N, dizziness, weight gain
5) VTE
6) MI, stroke
7) liver damage

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4
Q

ethinyl estradiol - CI

A

1) history/susceptibility to arterial/venous thrombosis
2) advanced diabetes w vascular disease
3) HTN ≥ 160/100
4) avoid in breastfeeding (< 21 days postpartum) & breast cancer in women

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5
Q

norethindrone (progestin) - types

A

drosperinone (4th gen)

  • diuretic, anti-androgenic, anti-mineralocorticoid
  • can cause hyperkelaemia, thromboembolism, bone loss
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6
Q

norethindrone (progestin) - MOA

A
  • progestin receptor agonist
  • thicken cervical mucous -> prevent sperm penetration
  • slow tubal motility -> delay sperm support
  • induce endometrial atrophy
  • inhibit LH release = prevent ovulation = make endometrium unsuitable for implantation of ovum
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7
Q

norethindrone (progestin) - PK

A

1) absorption

  • well absorbed orally (OD)

2) distribution

  • highly protein bound

3) metabolism

  • liver
  • reduction -> glucuronidation & sulfation
  • some into ethinylestradiol

4) Excretion

  • pee & shit
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8
Q

norethindrone (progestin) - AE

A

headache, dizziness, bloating, weight gain, unpredictable spotting & bleeding, amenorrhea, androgenic (Acne, oily skin, hirsutism)

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9
Q

norethindrone (progestin) - additional info

A
  • ovulation suppression up to 1.5 yrs so X good if planning pregnancy
  • potential ethinylestradiol AE
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10
Q

definition of HTN in pregnancy

A
  • > 1 measurement at least 4 hrs apart of SBP > 140 DP > 90
  • severe: 2 measurement of SBP > 160 +/- DBP > 110
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11
Q

categories of pregnancy HTN

A

1) < 20 wks gestation
2) ≥ 20 wks gestation

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12
Q

< 20 wks gestation for pregnancy HTN - chronic HTN

A
  • pre-existing HTN or new onset of HTN before 20 wks gestation
  • X proteinuria
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13
Q

< 20 wks gestation for pregnancy HTN - chronic HTN w superimposed preclampsia

A

new onset proteinuria

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14
Q

≥ 20 wks gestation for pregnancy HTN - gestational HTN

A

1) new onset HTN
2) X proteinuria

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15
Q

≥ 20 wks gestation for pregnancy HTN - preeclampsia - definition

A
  • new onset HTN
  • any new onset of

1) proteinuria
2) signs of end-organ dysfunction
3) uteroplacental dysfunction
** fetal growth restriction (IUGR)
** abnormal umbilical artery dopplers
** stillbirth/fetal demise

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16
Q

≥ 20 wks gestation for pregnancy HTN - preeclampsia - progression into eclampsia

A
  • new onset of tonic-clonic, focal or multifocal seizure superimposed on preeclampsia
  • complications
    1) maternal: placental abruption, intracranial haemorrhage, DIVS, acute renal failure, neurologic sequlae, pulmonary odema, aspiration pneumonia, cardiopulmonary arrest
    2) Fetal/neofetal: fetal bradycardia, preterm birth, fetal/neonatal death, perinatal depression/asphyxia
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17
Q

≥ 20 wks gestation for pregnancy HTN - preeclampsia - prevention of eclampsia

A

low dose aspirin

  • recommend for high risk pt
    ** HTN on previous pregnancy, multifetal gestation (twins/>), autoimmune disease, DM, CKD
  • MOA: improve uroplacental blood flow by inhibiting thromboxane A2 -> reduce thromboxane-prostacyclin imbalance
  • dose: 100mg or more daily
  • regimen: after 12 wks, ideally before 16 wks, until delivery
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18
Q

monitoring parameters for pregnancy HTN

A

1) proteinuria

  • UTP > 300mg
  • dipstick > 2+
  • uPCR > 0.3 mg/dL

2) signs of end organ damage

  • platelet count < 100
  • LFT > 2x ULN
  • double SCr but absence renal disease
  • pulmonary oedema
  • neuropsych probs

3) albumin-creatinine ratio (ACR)

  • > 8 mg/mmol
  • alternative to uPCR for women w chronic HTN
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19
Q

drug choice for pregnant HTN

A

1) methyldopa

  • low potency, increased AE
  • safety in pregnancy

2) labetalol

  • monitor bronchoconstrictive effect, bradycardia

3) nifedipine ER

  • monitor pedal odema, flushing, headache

4) hydrochlorothiazide

  • 2nd/3rd line
  • potential interference w normal blood volume expansion w pregnancy

5) hydralazine

  • AE mimic severe preeclampsia & imminent preeclampsia
  • N/V, palpitation, flushing, headache, tremor
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20
Q

aims of treatment for pregnancy HTN

A

BP < 140/90

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21
Q

types of barrier technique categories

A

1) condom
2) diaphragm w spermicide & cervical cap

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22
Q

types of condoms

A

1) External (male)

  • CI: rubber/latex allergy
  • advantage: STI protection
  • disadvantage: high user failure rate, possible breakage

2) internal (Female)

  • absolute CI: allergy to polyurethane, history of TSS
  • advantage: inserted earlier, STI protection
  • disadvantage: very high user failure rate, dislike ring hanging outside vagina
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23
Q

diaphragm w spermicide & cervical cap

A
  • absolute CI: allergy to latex/rubber, recurrent UTI, history of TSS, abnormal gynecologic anatomy
  • advantage: low cost, reusable
  • disadvantage: high user failure rate, low protection against STI, increased risk for UTI, cervical irritation
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24
Q

combined oral contraceptives (COC) - components

A

1) progestin
2) estrogen

  • ethinyl estradiol (EE)
  • high dose ≥ 50 microgram
  • moderate/standard dose 30-35 microgram
  • low dose 15-20 microgram
  • lower dose indication: young, underweight (< 50), age > 35, peri-menopausal, fewer side effect
  • higher dose indication: obesity, early-mid cycle breakthrough bleeding/spotting, tendency to be non adherent
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25
Q

types of COC

A

1) monophasic

  • same estrogen progestin every pill
  • advantages: less confusing, less complicated instructions

2) multiphasic

  • variable estrogen & progestin
  • advantages: lower progestin = lower SE

3) conventional

  • old: 21 days active + 7 days placebo = 28 days
  • new: 24 days active + 4 days placebo = 28 days
    ** 3 additional active pill to shorten pill free interval -> reduce hormonal fluctuation -> lower SE

4) extended cycle/continuous COC

  • 84 days -> 7 days placebo
  • continuous X placebo
  • advantages: convenient, lesser periods
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26
Q

initiation of COC

A

1) first day method

  • start on first day of menstrual cycle
  • no backup contraceptive required on first day

2) sunday start

  • first sunday after menstrual cycle begin
  • backup contraceptive for at least 7 days
  • provide weekends free of menstrual period

3) quick start

  • start now
  • require backup contraceptive for at least 7 days & potentially till next menstrual cycle begin
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27
Q

factors affecting COC selection

A

1) hormonal content required
2) convenience
3) adherence level
4) tendency for oily skin, acne, hirsutism
5) medical condition: premenstrual syndrome, dysmenorrhoea

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28
Q

benefit of extra contraceptive

A

1) relief menstrual related problems
2) improve menstrual regularity
3) better for acne
4) premenstural dysphoric disorder
5) iron-deficient aneamia
6) PCOS
7) reduced risk from ovarian & endometrial cancer
8) reduced risk of ovarian cyst, ectopic pregnancy, pelvic inflam disease, endoemtriosis, uterine fibroids, benign breast disease

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29
Q

precautions for hormonal contraceptive - conditions

A

1) breast cancer
2) VTE
3) ischaemic stroke/MI

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30
Q

precautions for hormonal contraceptive- breast cancer

A
  • healthy & young: benefit > risk
  • age > 40: avoid
  • fam history/risk factor: avoid
  • current/recent Hx of breast cancer within past 5 yr: stop
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31
Q

precaution for hormonal contraceptive- VTE

A
  • estrogen enter liver = increase hepatic production of clotting factors
  • new generation progestin increase protein C resistance & higher risk of clots
  • risk factors: > 35 yo, obesity, smoker, immobilisation, cancer, hereditary thrombophilia
  • consider low dose estrogen w older progestin, progestin only contraceptive, barrier method
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32
Q

contraindication for hormonal contraceptive

A

1) current/history breast cancer past 5 yrs
2) DVT/PE (and anticoagulant)
3) major surgery w prolonged immobilisation
4) < 21 days postpartum w other risk factor
5) < 6 wk postpartum if breastfeeding
6) thrombogenic mutation
7) SLE + unknown APLA
8) migrane w aura
9) SBP > 160, DP > 100
10) HTN w vascular disease
11) current/history of ischaemia heart disease
12) cardiomyopathy
13) smoking ≥ 15 sticks/day + age ≥ 35 yo
14) history of cerebrovascular disease
15) DM > 20 yrs or w complications

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33
Q

adverse effects of hormonal contraceptive- general

A
  • occur with early use, improve 3-4th cycle after adjusting to hormone levels
  • need counselling
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34
Q

adverse effect of hormonal contraceptive- conditions

A

1) breakthrough bleeding

  • early/mid cycle: increase estrogen
  • late cycle: increase progestin

2) acne

  • change to less androgenic progestin
  • consider increase estrogen
  • if on Progesterone only pills (POP) then change to COC

3) bloating

  • reduce estrogen
  • change to progestin w mild diuretic effect (drosperinone)

4) N/V

  • reduce estrogen
  • take pills at night/change to POP

5) headache

  • if occur in pill-free wk then switch to extended cycle/continuous/shorter pill interval

6) menstrual cramp

  • increase progestin/switch to extended cycle/continuous

7) breast tenderness/weight gain

  • keep both estrogen/progestin as low as possible
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35
Q

DDI for hormonal contraceptive

A

1) rifampicin

  • Abx alter gut flora -> alter metabolism -> less active drug
  • additional contraception until rifampicin stop for at least 7 days

2) anticonvulsant

  • reduce free serum concentration
  • phenytoin, carbamazepine, barbiturate, topiramate, oxcarbazepine, lamotrigine

3) HIV ART

  • reduce effectiveness
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36
Q

counselling for missed doses of hormonal therapy

A

1) miss 1 dose < 48 hrs

  • take missed dose immediately, continue the rest as per usual
  • maybe 2 pills per day
  • X need additional contraceptive

2) miss 2/> dose > 48 hrs

  • take last missed dose immediately, discard missed doses
  • continue rest as per normal (maybe 2 pills/day)
  • backup contraceptive 1 wk

3) missed during last wk of hormonal tablet (day 15-21)

  • finish remaining active pills in current stack
  • skip hormone free interval, start new pack next day
  • backup contraceptive at least 7 days
37
Q

progesterone only pill (POP) - indication

A

breast feeding, intolerant to estrogen, condition that preclude estrogen

38
Q

progesterone only pill (POP) - types

A

1) norethindrone
2) levonorgestrel: 28 active pills (continuous)
3) drospirenone: 24 active, 4 inactive

39
Q

progesterone only pill (POP) - regimen

A

1) within 5 days of menstrual cycle/bleeding: X back up

2) any other day: back up for 2 days(drosperinone 7 days)

40
Q

progesterone only pill (POP) - missed doses

A
  • N/L: late by > 3 dose then take exra & continue, backup 2 days
  • D: < 24 h take extra & continue, ≥ 2 active pills missed: backup for 7 days
41
Q

transdermal contraceptive

A
  • estrogen + progestin
  • X effective if > 90kg
  • once weekly for 3 wks + 1 patch free wk
  • tissue irritation
42
Q

vaginal ring

A
  • estrogen + progestin
  • use 3 wks then discard
  • tissue irritation, risk of expulsion
43
Q

progestin injection

A
  • IM injection every 12 wks
  • good for adherence
  • delayed return to fertility
  • variable breakthrough bleeding esp within first 9 months (amenorrheic)
  • weight gain, short term bone loss = reduced bone mineral desnity
44
Q

long acting reversible contraception (LARC)

A
  • hormonal + non hormonal that includes IUD
  • very effective
  • reversible upon removal
45
Q

intrauterine device (IUD) - MOA

A

inhibit sperm migration, damage ovum, damage/disrupt transport of fertilised ovum

46
Q

intrauterine device (IUD) - precautions

A

X use if

  • pregnant
  • current STI
  • undiagnosed vaginal bleeding
  • malignancy of genital tract
  • uterine anomalies
  • uterine fibroids
47
Q

intrauterine device (IUD) - types

A

1) levonorgestrel IUD

  • reduce menstrual flow
  • ideal if concomitant menorrhagia
  • 5 yrs

2) copper IUD

  • heavier bleeding
  • ideal if concomitant amenorrhea
  • 10 yrs
48
Q

amenorrhoea definition

A

X menstrual bleeding in 90 day period

49
Q

amenorrhoea - categories

A

1) primary/functional

  • X menses by age 15 in females who never menstruated
  • rare

2) secondary

  • absence for 3 cycles in previously menstruating
  • more freq in < 25 yo w past history, competitive athlete, massive weight loss
50
Q

amenorrhoea - aetiology

A

1) anatomical

  • pregnancy, uterine structural abnormalities, X shedding of endometrial lining

2) X ovulation = X proper sequence of estrogen production -> progesterone production -> estrogen/progesterone withdrawal

  • endocrine disturbances = chronic anovulation
  • ovarian insufficiency/failure
  • affect GnRH, FSH, LH (low body fat, weight loss)
51
Q

amenorrhoea - treatment

A

non pharmaco

  • weight gain, reduce exercise intensity, stress management

pharmaco

  • COC
52
Q

menorrhagia - definition

A
  • menstrual blood loss > 80ml per cycle
  • bleed > 7 days per cycle
  • basically heavy flow
53
Q

menorrhagia - pathophysiology

A

1) uterine related factors

  • fibroids
  • adenomyosis
  • endometrial polpys
  • gynaecologic cancer
  • alteration in HPO axis

2) coagulopathy factor

  • cirrhosis
  • Von willebrand disease
  • idiopathy thrombocytopenic purpura
54
Q

menorrhagia - treatment

A

non pharmaco: endometrial ablation to hysterectomy

pharmaco

  • want contraceptive: COC
  • X contraceptive: NSAID, tranexamic acid (help clot), cyclic progesterone
55
Q

dysmenorrhea - definition

A

crampy pelvic pain w/just before menses

56
Q

dysmenorrhea - categories

A

1) primary

  • X find cause
  • release prostaglandin & leukotriene -> vasoconstriction -> cramp

2) secondary

  • underlying anatomic/physiologic cause
  • endometriosis
57
Q

dysmenorrhea - treatment

A

1) nonpharmaco

  • topical heat therapy
  • exercise
  • acupuncture
  • low fat vegetarian diet

2) pharmaco

  • 1st line: NSAID
  • 2nd line: COC
  • 3rd line: progestin injection/progestin IUD
58
Q

premenstrual syndrome (PMS) - symptoms

A

1) somatic/physical

  • bloating, headache, weight gain, fatigue, dizziness, nausea, appetite change

2) affective/mood

  • anxiety, depression, angry outburst, social withdrawal, forgetfulness, tearful, restlessness
59
Q

premenstrual syndrome (PMS) - premenstrual dysphoric disorder (PMDD)

A

severe mood symptoms, psychiatric disorder

60
Q

premenstrual syndrome (PMS) - pharmacological therapy

A

SSRIs, COC for physical

61
Q

premenstrual syndrome (PMS) - non pharmaco

A

increase exercise, vitamins, reduce caffeine & refined sugar & sodium

62
Q

polycystic ovary syndrome (PCOS) - presentation

A

1) menstrual irregularities
2) androgen excess

  • acne, hirsutism, obesity
  • metabolic disorder/insulin resistance
63
Q

PCOS treatment

A

1) COC
2) metformin

64
Q

menopause definition

A

permanent cessation of menses following loss of ovarian follicular activity

65
Q

menopause aetiology

A

1) natural

  • occur in stages: perimenopause, menopause, postmenopause

2) induced

  • any time before natural menopause w removal of both ovaries/iatrogenic ablation of ovarian function
66
Q

categories of menopause symptoms

A

1) vasomotor symptoms (VMS): hot flush/night sweat
2) genitourinary syndrome of menopause (GSM)
3) psychological/cognitive
4) bone fragility
5) others

67
Q

menopause symptoms - vasomotor sypmtoms

A
  • hypothalamus level estrogen withdrawal -> thermoregulation dysfunction
    1) intense feeling of heat on face
    2) rapid/irregular HR
    3) flushing/redden face
    4) perspiration
    5) cold sweat
    6) Sleep disturbances
    7) feeling of anxiety
68
Q

menopause symptoms - genitourinary syndrome

A
  • cause: decreased estrogen -> changes to anatomy
  • symptoms
    1) genital dryness
    2) burning, irritation, pain
    3) Sexual symptoms of lubrication difficulty
    4) impaired sexual function/libido/painful intercourse
    5) urinary urgency
    6) dysuria
    7) recurrent UTI
69
Q

menopause symptoms - psychological/cognitive

A
  • cause: stress + hormonal fluctuation
  • symptoms

1) depression/anxiety
2) poor concentration/memory
3) mood swing

70
Q

menopause symptoms - bone fragility

A
  • decreased oestrogen = more bone loss
  • increase risk of osteoporosis & fracture
  • increase joint pain
71
Q

menopause symptoms - others

A

hair loss, breast pain, digestive problem, frequent urination, urinary pain, brittle nails, fatigue, dizziness, weight gain, memory lapses

72
Q

menopause nonpharmaco - vasomotor

A
  • layered clothing that can be removed/added when necessary
  • lower room temp
  • less spicy/caffeine/hot drinks
  • more exercise
  • dietary supplements (isoflavones, black cohosh)
73
Q

menopause nonpharmaco - vulvovaginal

A

nonhormonal vaginal lubricant/moisturiser

74
Q

indications for monopausal hormonal therapy (MHT)

A
  • moderate/severe symptoms
  • insufficient response to non pharmaco
  • treat symptoms affecting QoL
75
Q

Types of MHT - categories

A

1) estrogen only
2) estrogen + progestin

76
Q

MHT - estrogen - dosage forms (list)

A

1) oral
2) systemic topical
3) local vaginal

77
Q

MHT - estrogen - oral dosage form

A
  • start new pack once old finish
  • advantages: cheap
  • disadvantages
    1) dose dependent SE
    2) potential for missed dose = irregular bleeding
78
Q

MHT - estrogen - systemic topical - formulations

A

1) patches

  • replaced twice a wk
  • site rotation to prevent irritation (lower back -> abdomen -> butt)

2) Gel

  • packaging has ruler to measure dose
  • site rotate: arm/thigh daily
79
Q

MHT - estrogen - systemic topical - advantages & disadvantages

A

1) Advantages

  • lower systemic dose
  • convenient
  • continuous release

2) disadvantage

  • more expensive
  • skin irritation
  • gel more variability in absorption
80
Q

MHT - estrogen - local vaginal - general

A
  • pessary, cream
  • inserted twice/wk
  • insert tablet before bedtime to reduce movement
81
Q

MHT - estrogen - local vaginal - advantage & disadvantage

A

1) Advantage

  • lowest estrogen dose
  • continuous release

2) disadvantage

  • inconvenient/uncomfortable
  • vaginal discharge
  • only for localised urogenital atrophy (X systemic absorption)
82
Q

MHT - estrogen + progestin - requirement

A

intact uterus

83
Q

MHT - estrogen + progestin - types of regimen

A

1) continuous cyclic

  • progestin added on either 1st or 15th of month for 10-14 days
  • withdrawal bleeding when progestin stopped
  • regulate menses = more regular bleeding

2) continuous combined

  • both daily
  • X withdrawal bleeding
  • chance of amenorrhoea
84
Q

MHT - estrogen + progestin - role of progestin

A

1) Reduce risk of endometrial cancer
2) maybe improve VMS

85
Q

MHT vs COC

A

1) physiologic goal

  • MHT: replace/supplement endogenous estrogen to relieve S&s of lower estrogen production
  • COC: suppress HPO axis to avoid ovulation

2) amt of ethinylestradiol equivalent

  • MHT: 10-15 mcg
  • COC: 20-50 mcg
86
Q

MHT precaution/CI

A

1) breast cancer
2) VTE

  • surgery, cardiovascular disease, uncontrolled BP, stroke, heavy smoking, endometrial cancer
87
Q

MHT monitoring

A

1) Annual mammogram (breast cancer)
2) endometrial surveillance

  • unopposed estrogen: vaginal bleeding
  • continuous cyclic: bleeding occur when progestin on
  • continuous combine: bleeding prolonged, heavier than normal, frequent, persist > 10 month after treatment start
88
Q

other pharmaco therapy for VMS

A

1) antidepressant

  • SNIR: venlafaxine
  • SSRIs: paroxetine

2) gabapentin

  • night sweat, sleep disturbances
89
Q

other pharmaco therapy for PMS

A

tubolone

  • improve mood, libido, menopause symptom, vaginal atrophy
  • protect against bone loss
  • indication: postmenopausal ≥ 12 months since last natural period
  • EXPENSIVE

endo (8 decks)

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