Women's Health Flashcards
1
Q
Menstrual hormone review
A
- menstruation typically occurs on 1-7 days, avg. about 5 days
- Follicular phase: the first 13-14 days; main hormones are FSH, estrogen & LH
- Ovulatory phase: ovulation occurs mid-cycle with the surge in LH
- Luteal phase: days 14-28; main hormones are estrogen & progesterone (prepares uterus for implantation)
2
Q
Benefits of hormonal contraceptives
A
- pregnancy prevention
- cycle regulation: decrease blood loss (anemia), irregular cycle regulation
- dysmenorrhea –> painful menstrual cramps
- menorrhagia –> abnormally heavy or prolonged bleeding
- menometrorrhagia –> heavy bleeding occurs more frequently or irregularly
- decrease ovarian cysts
- improve PMS & pre-menstrual dysphoric disorder
- treatment of endometriosis
- prevention of ovarian & endometrial cancer
3
Q
Estrogen contraceptive
A
Ethanol estradiol (EE) -helps stabilize the endometrium & control the menstrual cycle
4
Q
Progesterone (Progestin) contraceptive
A
1st generation: Norethindrone, Norethindrone acetate & ethynodiol diacetate
2nd generation: levonorgestrel
3rd generation: Desogestrel, Norgestimate & drospirenone
5
Q
Combined hormonal methods
A
- combined oral contraceptives
- ortho evra patch
- nuva ring
6
Q
MOA of combined hormonal contraceptives
A
Estrogen & Progesterone work synergistically (estrogen regulates the cycle, progesterone stops conception)
- continuous levels of estrogen & progesterone suppress FSH & LH
- progesterone suppresses LH to prevent the mid-cycle surge & stop ovulation
- progesterone thickens cervical mucus to impair sperm travel
- estrogen suppresses FSH to prevent the selection & emergence of a dominant follicle
7
Q
Progesterone portion of combined hormonal methods
A
All forms of progesterone can exhibit some estrogenic, androgenic & anabolic activity
- estrogenic: increases estrogen
- androgenic: produces male characteristics (Desogestrel & norgestimate are less androgenic)
- anabolic: testosterone effects
8
Q
Monophonic combined oral contraceptives
A
- provides the same amount of hormones every day for 21 days (days 22-28 are placebos)
- modified mono-phasic provides very low dose estrogen on days 24-28
9
Q
Biphasic & triphasic combined oral contraceptives
A
- biphasic switches hormone level once through a pack
- triphasic changes hormone levels every week
- both have varying levels of estrogen & progesterone every week
- less progesterone in general than monophasics
10
Q
Withdrawal bleeding
A
pseudomenstruation
- 28 day oral contraception pills: provide medication during the 7-day hormone free period (ie. some have iron to alleviate anemia)
- a monthly episode of withdrawal bleeding is not necessary to maintain a healthy uterus
11
Q
Extended & continuous cycle combined oral contraceptives
A
Extended: shorten the length of bleeding time to decrease mood swings & acne; contains 24 or 26 pills
Continuous: pack contained 84 active pills; 12 weeks of pills, pseudo menstruation the 13th week (bleed 3x per year)
12
Q
Missed combined oral contraceptives
A
1 missed pill –> take pill as soon as realized, take next tablet as scheduled, backup protection not required
2 or less missed pills –> take 2 a day until caught up, use backup method through the rest of the pack or until pseudomenstruation occurs
3 or more pills –> discontinue present pack & allow for withdrawal bleeding, start new pack 7 days after last pill taken, use backup until new set of pills have been taken for at least 7 consecutive days
13
Q
ortho-evra transdermal patch
A
- patch is placed once a week for 3 weeks in a row (need to rotate sites to prevent skin irritation)
- 4th week is path free to allow for withdrawal bleeding
- patch works similar to COC by inhibiting ovulation, thickening cervical mucus to prevent sperm penetration & preventing a fertilized egg from implanting in the uterus
14
Q
NuvaRing transvaginal contraceptive
A
- 2 inch diameter flexible indwelling ring inserted into the vagina
- non-biodegradable, transparent & colorless
- put 1 ring in, last 3 weeks. Take it out week 4 & have psuedomenstruation
- can be taken out for 2 hours at a time and still be effective); can be left in during sex
- added side effects: foreign body sensation, expulsion, possible vaginal discomfort
15
Q
How to start combined hormonal methods
A
- 1st day start method: initiated on first day of menstruation; no backup needed
- Sunday start: initiated on the Sunday after the first day of menstruation (won’t have psuedomenstruation on the weekend); backup needed for 7 days
- Quick start: initiated the day the patient receives the contraception; need backup for at least 7 days (recommended through 1st cycle)
16
Q
Combined hormonal contraceptive medication interactions
A
Use backup method for the duration of treatment plus 7 extra days (if med is long term, new form of contraception is needed)
- anticonvulsants: patients need 2 different types of birth control or longer acting method (ie. IUD)
- anticoagulants: estrogen cancels out the effect
- antituberculin
- antibiotics: need to use a backup method (for sure with Rifampin & Doxycycline)
17
Q
Excess estrogen side effects
A
Most common: fluid retention, breast tenderness
-nausea (the more estrogen, the higher nausea), vomiting, dizziness, edema, breast enlargement chloasma, leg cramps, headaches, HTN
18
Q
Estrogen deficiency side effects
A
Most common: breakthrough bleeding
-oligomenorrhea, dyspareunia (painful intercourse-low estrogen causes vaginal atrophy & dryness)
19
Q
Excess progesterone side effects
A
Most common: vaginitis, excess hair growth, decreased breast size
-increased appetite, weight gain, oily skin, acne, depression, amenorrhea
20
Q
Progesterone deficiency side effects
A
dysmenorrhea, bleeding late in the cycle, heavy menstrual flow, amenorrhea
21
Q
Contraindications for combined hormonal contraceptives
A
- smokers over age 35
- HRN
- coronary artery disease/CHF/strong family hx of heart disease
- clotting disorders/hx of thromboembolism
- breastfeeding
- known or suspected endometrial cancer
- diagnosis of breast cancer current or past
- migranes with or without aura
22
Q
Medical risks associated with combined hormone contraceptives
A
- thromboembolism
- stroke
- MI
- HTN
- hepatic neoplasia
- gallbladder disease
23
Q
Patient education for combined hormonal contraceptives
A
A - severe abdominal pain C -chest pain H - headaches E - eye problems (vision changes) S - severe leg pain
If experiencing any of these, come to the clinic. Method will be stopped immediately & changed
24
Q
Progestin only & LARC methods
A
- progestin only pills - “mini pills”
- Depo-provera
- long acting reversible contraception (LARCs)
- IUDs: hormonal (levonorgestrel) & non-hormonal (copper)
- Nexplanon
25
Good candidates for progesterone & LARC methods
- patients who can't take combined methods because of co-morbidities or chronic disease
- active viral hepatitis or cirrhosis
- breastfeeding patients
- hypertensive patients
- patients over 35 that smoke
26
Progesterone only pill
- works by thickening the cervical mucus & thinning the endometrium to make the uterus inhospitable for fertilization/implantation (don't suppress LH & FSH)
- each pill = 24 hours of protection
- must be taken at the exact same time each day (within 30 minutes); if > 3 hrs late, need backup contraceptive method for 48 hours
- irregular unscheduled bleeding can occur
27
Depo-provera
MOA: suppresses ovulation & changes cervical mucus; inhibits secretion of LH & FSH; suppresses estradiol levels (which can lead to decreased bone mass)
- should be given every 12 weeks (-2 or +1 week cushion)
- IM injection
- document weight & BP at visits (depo can increase both)
28
Long-Acting reversible contraception (LARCs)
Hormonal methods:
-IUD: intrauterine device
-Nexplanon: implantable devices
Non-hormonal methods: Paragaurd (IUD)
29
IUD Mechanism of Action
- inflammatory reaction (especially with copper IUD)
- thickens cervical mucus
- inhibits sperm: sterile inflammatory response is toxic to sperm & egg
- thins the uterine lining
- doesn't always suppress ovulation
30
IUD contraindications
- pregnancy
- unexplained vaginal bleeding
- cervical cancer
- abnormal uterine anatomy
- ongoing pelvic infection
31
Hormonal LARCs
- inserted in clinic
- check strings
- might have no cycle/bleeding
- removal = immediate return to fertility
- progesterone only; localized distribution of hormones, not systemic
Types: (Levonorgestrel)
- Mirena, Kyleena & Liletta: 5 years
- Skyla: 3 years
32
Non-hormonal LARCs
Paraguard
- great option for people who can't use hormonal methods
- can be used for up to 10 years
- side effects: heavier menstrual bleeding & cramping
33
Implantable hormonal LARCs - Nexplanon
MOA: low levels of circulating progesterone suppresses ovulation & thickens cervical mucus
-implanted into the non-dominant arm & left in place for up to 3 years
Common side effects: menstrual irregularities, weight gain, headaches, vaginitis
Contraindications: pregnancy, active liver disease or active venous thromboembolism
34
Hormonal LARC comparison
Hormonal IUDs: 3 or 5 years, in the uterus, irregularities in menstrual bleeding, doesn't protect against STIs, few contraindications
Nexplanon: 3 years, in the arm, irregularities in menstrual bleeding, contraindicated in active liver disease & active venous thromboembolism
35
Emergency contraception
- works by disrupting the timing of ovulation or preventing fertilization
- oral EC methods
- copper IUD: most effective form; inserted within 5 days of unprotected intercourse
36
Oral emergency contraceptive methods
- Ulipristal Acetate (UPA): can be used up to 120 hours after; anti-progesterone
- Levonorgestrel (LNG): can be used up to 72 hours; includes OTC Plan B
- combined oral estrogen & LNG contraceptive pills
37
Mifepristone (abortifacient)
Indications: pregnancy termination of intrauterine pregnancy through 70 days gestation (given with misoprostol)
MOA: stimulates uterine contractions & blocks the effects of progesterone
Admin: buccal or vaginal administration (could take effect in 2-24 hours)
Side effects: abdominal cramping, uterine cramping, nausea, headache, HTN, angioedema
Caution: concurrent use with any blood thinners could lead to increased risk of severe uterine bleeding
38
Mifepristone black box warning
- risk for serious bleeding & fatal infections
- atypical presentation of infections
- sepsis
- prolonged heavy bleeding (ie. fill 2 large pads per hour, clots common)
- signs of incomplete abortion
39
Mifepristone patient education
- be at an appropriate location within the window of pregnancy termination (up to 70 days/10 weeks)
- misoprostol given 24-48 hours after mifepristone
40
Mifepristone nursing implications
- monitor for abnormal bleeding
- monitor vital signs (BP, HR, signs of HTN, signs of hemorrhagic shock with continued bleeding)
- symptom management (N/V, pain)
41
Goals of caring for transgender women
- reduce hormonally induced male secondary sex characteristics
- induce secondary sex characteristics to match gender identity
- achieve balance with hormonal medications & patient desired outcomes
42
Hormone regimes for transgender women
Antiandrogens: block the effects of testosterone, affect androgen receptor blockers
Progesterones: involved in maturation of mammary structures
GnRH agonists: suppresses testicular production; can be used to suppress puberty in young teens
Estrogen: works directly on body tissue, indirectly suppresses testosterone
43
Monitoring of transgender women on hormone therapy
- evaluate every 3 months in 1st year, then 1-2 times per year after that for appropriate signs of feminization & for adverse reactions
- measure serum testosterone & estradiol every 3 months
- for individuals on spironolactone, monitor serum electrolytes (K+) q4 months for the 1st year & then annually
- routines cancer screening is recommended
- consider bone mass density at baseline & then follow-up as needed
44
Serum testosterone & estradiol levels during hormone therapy
Serum testosterone: <50 ng/dL
| Serum estradiol: shouldn't exceed the peak physiologic range; 100-200 pg/mL
45
Specific screening for transgender women
- breast cancer
- cervical cancer (no screening)
- prostate cancer
- cardiovascular disease
- DM
- hyperlipidemia
- osteoporosis
46
Hormone therapy adverse events
- VTE
- cardiovascular disease
- elevated triglycerides
- hyperprolactinemia
- cancer
- infertility
47
Menopause Overview
-the permanent cessation of menses
3 stages during the transitional process:
-perimenopause: occurs up to 10 years prior to menopause (avg. age is 42-55)
-menopause: year without menses (median age: 51)
-postmenopause: time afterwards
48
Menopause increases the risk of:
- stroke
- heart disease
- fractures (especially hip)
- colorectal cancer
- endometrial cancer
49
Hormone replacement therapy (HRT/MHT)
- estrogen-progestin therapy (EPT) for patients who have an intact uterus
- estrogen therapy (ET) for use with patients who've had a hysterectomy; cannot be used in patient with a uterus (causes endometrial cancer)
- goal: relieve menopausal symptoms
50
Forms of HRT
oral, transdermal, rings, creams, gels
51
Premarin (oral estrogen)
MOA: maintain female genital system
Therapeutic effect: Tx of moderate to severe vasomotor symptoms
Side effects: N/V, breast tenderness, fluid retention, leg cramps
-has a greater effect on the liver due to 1st pass effect
-admin increases hepatic production of triglycerides, HDL & clotting factors
52
Transdermal estrogen
- contain 17-beta estradiol
- patch applied once or twice a week (most common side effect: skin irritation at site)
- do not apply to breast or waistline
- equally effective in preserving bone density & treating menopausal symptoms
- associated with lower risk of venous thrombosis & stroke, and has less effect on serum lipids
53
Estrogen vaginal rings
can be used to provide low-dose estrogen for vaginal atrophy but not as good for other symptoms
54
Estrogen vaginal creams
have low systemic absorption & are good for vaginal complaints & atrophy
55
Estrogen topic gels/lotions/mists
- gels/lotions come in individual packets that are applied from wrist to shoulder or to the thighs or calves
- topic spray is sprayed between the elbow & wrist on the inside of the forearm
56
Progesterone
- most common: Medroxyprogesterone acetate
- usually used in combination with estrogen
- IUDs (mirena) have been used off-label for HRT
57
Estrogen & Progesterone combo HRT
- used in patients with a uterus
- meant to be used < 5 years because of an increased risk of breast cancer associated with combination treatments
- progestin given to decrease risk of hyperplasia
- Forms: tablets, transdermal patches
58
Estrogen & Testosterone combo HRT
- decrease in testosterone accompanies menopause; this can lead to loss of libido
- ONLY indication: severe vasomotor symptoms & loss of libido
- longterm use is associated with hepatocellular neoplasm, increased edema & elevation of cholesterol level
- can lead to hirsutism, voice changes & a decrease in HDL
- testosterone can be added to HRT in doses of 1.25 to 2.5 mg
59
HRT side effects
- nausea/vomiting
- breakthrough bleeding
- fluid retention
- breast tenderness
- leg cramps
- headahces
- mood changes
- cholasma
60
Risks of combined HRT
- coronary heart disease
- invasive breast cancer
- stroke
- pulmonary embolism
61
Risks of estrogen only HRT
- pulmonary embolism
| - hip fracture
62
Bioidentical hormone replacement therapy
- estrogen-like compounds that have been derived from plants
- custom-made for the patient
- Tri-est, Bi-est, straight estriol, micronized progesterone
63
Contraindications to HRT
- pregnancy
- hx of endometrial cancer
- personal hx of breast cancer
- hx of thromboembolic disorders
- acute liver disease or chronic impaired liver function
- active gallbladder or pancreatic disease
- coronary artery disease
- undiagnosed vaginal bleeding
- transient ischemic attack (TIA)
64
Other meds used for menopausal symptoms
-SSRIs
-SNRIs
-Methyldopa
-Clonodine
-Gabapentin
Alternative choice: natural soy/soy derivatives, red clover extract, vitamin E, evening primrose oil, St. John's wort, ginseng, valerian, melatonin
65
Recommended order of HRT
1. short term treatment of symptoms at the lowest possible dose for the shortest possible period
2. if vasomotor symptoms not controlled, higher estrogen dose used for a short period
3. if there is a contraindication to HRT or the decision has been made not to use these methods, consider SSRI or alternative therapies
