Women's health (including Pharmacology) Flashcards
What is the definition of hypertension in pregnancy?
Either SBP > 140mmHg or DBP > 90mmHg based upon >1 measurements at least 4 hours apart
What is the definiton of severe hypertension in pregnancy?
SBP > 160 mmHg and/or DBP > 110 mmHg based upon > 1 measurements
What is the definition of chronic HTN?
Pre-existing HTN or new onset HTN before 20 weeks gestation
What is the definition of gestational HTN?
New onset HTN without proteinuria after 20 weeks gestation
What is the definition of chronic HTN with superimposed preeclampsia?
New onset proteinuria in a woman with chronic HTN but no proteinuria, before 20 weeks’ gestation
What is the definition of Preeclampsia?
New onset HTN after 20 weeks gestation PLUS any one of following:
1) Proteinuria or
2) signs of end organ damage or
3) Uteroplacental dysfunction
What is used for prevention of preeclampsia and when should it be started?
Low dose aspirin
Start after 12 weeks (ideally before 16 wk) and continued till delivery
Which of the following can be used to treat HTN in pregnancy?
a) Labetalol
b) Diltiazem
c) Lisinopril
d) Spironolactone
e) Nifedipine ER
Labetalol and Nifedipine ER
Which of the following can be used to treat HTN in pregnancy?
a) Levodopa
b) Methyldopa
c) Lorsartan
d) Hydrochlorothiazide
e) Hydralazine
Methyldopa, Hydrochlorothiazide, Hydralazine
State the contraindications for use of condoms (both male and female)
Male condom: allergy to latex
Female condom: Hist of toxic shock syndrome, Allergy to polyurethane
What is the only advantage that condoms provide that other forms of contraception do not?
STD protection
What are the contraindications for using Diaphragms with spermicide and cervical caps? (4 total)
1) Allergy
2) History of toxic shock syndrome
3) Abnormal gynecological anatomy
4) recurrent UTI
Which barrier technique is reusuable?
Diaphragm and cervical cap
What are the disadvantages of using cervical caps/diaphragm other than high user failure rate?
1) Increase risk of UTI
2) Cervical irritation
3) Low/no protection against STD
State the MOA/role of estrogen in birth control pills
1) inhibits FSH release, preventing follicle maturation and hence prevent ovulation.
2) Helps to stabilise endometrial lining and provide cycle control
State MOA of progestins in birth control
1) Thicken cervical mucus to prevent sperm penetration
2) Slows tubal motility (delay sperm transport)
3) Induces endometrial atrophy
4) blocks LH surge, hence preventing ovulation
When would high dose estrogen be favoured in COC?
1) Obese patient or weight > 70.5kg
2) Problem with adherence
3) Early to mid cycle breakthrough bleeding
Which Progestins have less Androgenic side effects and can be solely used for contraception?
Drospirenone (4th gen)
What are the potential side effects of using Drospirenone? (4 total)
Hyperkalemia, bone loss, thromboembolism, increased frequency of urination (mild diuretic)
When will higher progestin activity be required?
1) Mid to late cycle breakthrough bleeding
2) Painful menstrual cramps
What are the side effects that early generation Progestins have that 4th gens have less of?
Oily skin, Hirsutism, Acne
What are the common side effects of using COC? (7 total)
1) Breakthrough bleeding
2) Bloating
3) Acne (for early gen progestin users)
4) Menstrual cramps
5) Breast tenderness/weight gain
6) Headache/dizziness
7) Nausea/vomiting
What are the rare side effects of using COC? (4 total)
1) Breast cancer
2) Venous Thromboembolism (estrogen and 4th gen progestin)
3) MI/Stroke (more due to estrogen)
4) Liver damage (estrogen SE, pharmaco lecture)
What are the risk factors for VTE development?
1) > 35 y.o
2) obese
3) immobile
4) smoking
5) cancer
6) family history
What are the absolute contraindications to use of COC? (total 12)
1) Current / recent history of breast cancer (within 5 years)
2) History of DVT/PE, acute DVT/PE or currently with DVT/PE and on anticogulant tx
3) Major surgery with prolonged immobilisation
4) Thrombogenic mutations
5) < 21 days postpartum
6) Migrane with aura
7) SBP> 160mmHg or DBP > 100mmHg
8) HTN with vascular disease
9) Current/history of ischemic heart disease
10) Cardiomyopathy
11) Smoking ≥ 15 sticks/day AND age ≥ 35yo
12) History of cerebrovascular disease
What are the DDIs for COC?
1) Rifampin
2) Anticonvulsants
3) HIV antiretrovirals
State how you would counsel a patient who is on COC and missed one dose.
Take the missed dose immediately and continue the rest as usual. This may mean taking 2 pills on the same day. No additional contraception methods required.
State how you would counsel a patient who is on COC and missed 2 or more consecutive doses.
Take the missed dose immediately and discard the rest of the missed doses. Continue the rest as usual. This may mean taking 2 pills on the same day. Backup contraception methods required for 1 week.
State how you would counsel a patient who is on COC and missed 2 or more doses during the last week of hormonal tablets (day 15-21).
Finish the remaining active pills in the current pack and start a new pack the next day. Skip the hormone-free interval. Backup contraceptive required for at least 1 week
What is/are the contraindication(s) of the Progesterone only pill?
Current/ recent history of breast cancer (within last 5 years)
List the various methods of COC initiation and state whether backup contraceptive is required and duration of backup required.
1) First Day method
- no backup required
2) Sunday start method
- start on first sunday after menstruation
- backup of at least 7 days required
3) Quick start method
- backup of at least 7 days required and potentially until next menstrual cycle begins (unless it is the first day)
When would backup contraception be required if the woman is using Progesterone only pill? State the duration of backup required
1) If started on any other day (not within 5 days of menstruation/bleeding)
2) If subsequent dose is administered late by > 3 hours
Backup for 2 days
What is the main disadvantage of using transdermal patches/ vagina rings?
Increased risk of VTE
What are considered Long acting reversible contraception (LARC)?
Intrauterine Devices (IUD), subdermal progestin implants
Who should not use Progestin injections due to side effect of bone loss?
1) older women
2) osteoporosis risk factor (e.g long term steroid),
3) those who desire long term use (> 2 years)
What are the main disadvantages of progestin injections?
1) Need regular doctor visit
2) Return to fertility might be delayed (since dk when depot will run out)
3) Weight gain (more than other types of contraception)
4) Short term decrease in bone mineral density (bone loss)
5) Variable breakthrough bleeding esp in first 9 months
What are the contraindications for the use of IUDs? (total 5)
1) Current pregnancy
2) Current STI
3) Undiagnosed vaginal bleeding
4) Malignancy of genital tract
5) Uterine anomalies or uterine fibroids
Compare and contrast the 2 IUDs
Levonorgestrel IUD:
- Decreases menstrual flow (typically cause spotting or amenorrhea)
- Good if Pt has concomitant heavy bleeding
- Each IUD can use up to 5 years
Copper IUD:
- Induce heavier bleeding compared to Levonorgestrel IUD
- Ideal if concomitant amenorrhea
- Each IUD can use up to 10 years
- Can be used as emergency contraception
What are general risks of using an IUD?
Uterine perforation, expulsion, pelvic infection
What is the MOA of IUD?
Inhibition of sperm migration, damage ovum, damage/disrupt transport of fertilized ovum.
* If with progestin additional effects of endometrial suppression and thicken mucus
What is the most common side effect of Subdermal progestin implants?
Irregular bleeding pattern
Define Primary Amenorrhea
Absence of menses by age 15 in females who never menstruated
Define secondary amenorrhea
No menstrual bleeding in a 90 day period (3 cycles) in a woman who was previously menstruating
What can be used to treat amenorrhea? (Both pharma and non-pharm management)
Pharm:
- COC
- Estrogen only
- Progestin only
- Copper IUD
Non-Pharm (dependent on underlying cause):
- Weight gain
- Reduce exercise intensity
- Stress management
State possible pharm treatments of Menorrhagia if contraception is not desired
1) NSAIDs
2) Tranexamic acid during menses (slows breakdown of clots)
3) Cyclic progesterone (used only ~1wk/cycle so no contraceptive protection)
State possible pharm treatments of Menorrhagia if contraception is desired
1) Levonogestrel IUD
2) COC
3) Progestin only oral contraceptive
4) Progestin injection
State possible non-pharm treatments of Menorrhagia
Endometrial ablation to hysterectomy
Define dysmenorrhea
crampy pelvic pain with or just before menses
How can dysmenorrhea be managed? (both pharmaco and non-pharmaco)
Non-pharmacological:
- heat therapy
- exercise
- acupuncture
- Low-fat vegetarian diet
Pharmacological:
- NSAIDs
- COC (2nd line)
- Progestin injection/ IUD (3rd line)
Describe clinical presentation of polycystic ovary syndrome
1) Menstrual irregularities (amenorrhea or heavy bleeding or bleeding in the middle of the cycle etc)
2) Androgen excess (excess male hormones)
* Acne/ Hirsutism/ Obesity
* Prone to metabolic disorders/insulin resistance -> increased risk for DM, CVS disease
What can be used to manage PCOS?
1) COC (consider anti-androgenic progestin if acne/hirsutism)
2) Metformin (more used when person dev metabolic disorders)
What is the definition of menopause?
Permanent cessation of menses (no menses for > 12 months) following the loss of ovarian follicular activity
What are the common symptoms of Menopause?
1) Vasomotor symptoms aka hot flushes and night sweats
2) Genitourinary syndrome of menopause (GSM)
3) Psychological/ cognitive (Anxiety, depression, mood swings, poor concentration/memory)
4) Bone fragility (increased risk of osteoporosis and fractures, joint pain)
State what symptoms a woman with VMS might experience
- Intense feeling of heat on face
- Rapid/ irregular heart rate
- Flushing/ reddened face
- Perspiration
- Cold sweats
- Sleep disturbances
- Feeling of anxiety
State what symptoms a woman with Genitourinary Syndrome of Menopause might experience
- Genital dryness
- Burning/ irritation/ pain
- Sexual symptoms of lubrication difficulty
- Impaired sexual function/ libido/ painful intercourse
- Urinary urgency
- Dysuria
- Recurrent UTI
What are some non-pharmacological measures for mild vasomotor symptoms?
- Layered clothing that can be removed or added as necessary
- Lower room temp
- Less spicy food/ caffeine/ hot drinks
- More exercise
- Dietary supplements conflicting evidence: Isoflavones & Black Cohosh (these 2 have better evidence)
What are some non-pharmacological measures for mild vulvovaginal symptoms?
Non-hormonal vaginal lubricants/ moisturisers
What should Hormone Replacement Therapy (HRT) not be used solely for?
- Treatment of low libido
- CVD prevention
- Depression, anxiety, cognitive, memory issues
- Itchy skin, hair loss
- Treatment of osteoporosis (can be used however for prevention)
What are the indications for HRT?
HRT is used for vasomotor and genitourinary symptoms of menopause.
Reserved for patients who have moderate to severe symptoms, or those with insufficient response to non-pharmacological strategies.
What are the indications for estrogen-only (unopposed estrogen) therapy for patients with menopause?
- No uterus (hysterectomy)
- Topical (vaginal) formulations
What are the pros and cons of systemic (oral) estrogen-only tablets?
Advantages
- Inexpensive
Disadvantages
- Highest dose required - higher risk of side effects
- Potential for missed doses - irregular bleeding
What are the pros and cons of systemic topicals (patches and gels) for estrogen-only products?
Advantages
- Lower systemic dose than oral
- Convenient
- Continuous release of estrogen
Disadvantages
- Expensive
- Skin irritation (rotating sites helps)
- Gel has more variability in absorption
What are the pros and cons of local estrogen-only pessaries and vaginal creams?
Advantages
- Lowest estrogen dose - no need concomitant progestin
- Continuous estrogen release
Disadvantages
- Inconvenient/ Uncomfortable
- Vaginal discharge
- Only works for genital atrophy (NOT for VMS)
What are the indications for estrogen and progestin combined therapy?
- For patients with intact uterus (protect endometrium from overgrowth and risk of cancer)
Describe the continuous-cyclic regimen for estrogen + progestin therapy for menopause.
- Estrogen is given continuously
- Progestin is even in cyclical fashion, either on the 1st or 15th of the month, for 10-14 days
- Withdrawal bleeding (menses) occurs when progestin is stopped
Describe the continuous-combined regimen for estrogen + progestin therapy for menopause.
- Both estrogen and progestin given continuously (daily)
- No withdrawal bleeding, but chance of breakthrough bleeding initially
- Amenorrhea likely to occur after several months (endometrium becomes too thin)
Describe the follow-up actions that should be taken upon initiation of HRT.
1) Annual mammography (screen for breast cancer)
2) Endometrial surveillance:
- (Unopposed estrogen) any vaginal bleeding (should not have)
- (continuous-cyclic) if bleeding occurs when progestin is still on (signs of malignancy)
- (continuous-combined) if bleeding prolonged, heavier than normal, frequent, persists >10mths after initiation
State the non-hormonal therapy available and state what they are mainly used for.
Used for VMS symptoms.
1) Anti-depressants
SNRI: Venlafaxine
SSRI: Paroxetine
2) Gabapentin (side effect is drowsiness -> makes pt sleep so won’t be bothered by VMS)
How is ethinyl estradiol metabolised?
By liver via phase 1 hydroxylation and phase 2 glucuronidation and sulfation
The half life of Ethinyl estradiol is given as 13-27h. Suggest why the half life is so variable.
Due to the formation of EE sulfate, enterohepatic recirculation* is involved in the pharmacokinetics of EE -> EE sulfate get reuptake into body (and can get reconverted back to active EE), leading to increased half-life and EE effect in body
How is norethindrone metabolised?
Metabolized in liver by reduction (phase 1) followed by glucuronidation and sulfation (phase 2)
Describe the 4 types of COC available.
1) Monophasic:
- same amount of E and P in each pill. Less confusing, less complicated missed dose instruction
2) Multiphasic:
- higher amt of E at start of cycle, higher amt of P at end of cycle. -
- Overall, less total P than E.
- Less side effects but more expensive compared to monophasic
3) Conventional cycle:
- older formulation has 21 day active pill, 7 day placebo pill, menses occur 1-2 days after last active pill is taken
- newer formulations have 24 active pills, 4 day placebo, shorter pill free interval, less SE from hormonal fluctuation
4) Extended/continuous cycle:
- Extended: 84 days active pill then 7 day placebo (even lesser period)
- Continuous: No placebo
State how you would manage the following common side effects of COC:
a) Breakthrough bleeding
b) Acne
c) Bloating
d) Nausea/vomiting
e) Headache
f) Menstrual cramps
g) Breast tenderness/ weight gain
a) - If early/mid cycle increase estrogen
- If late cycle increase progestin
b) - Change to less androgenic progestin
- Can consider increase estrogen. If on progesterone only pills (POP), change to COC
c) - Reduce estrogen
- Change to progestin with mild diuretic effect (Drospirenone)
d) - Reduce estrogen
- Take pills at night / change to POP
e) - Exclude migraine with aura first!
- Usually occurs in pill free week switch to extended cycle/continuous/shorter pill free interval
f) - Increase progestin / switch to extended cycle or continuous
g) - Keep both estrogen/progestin as low as possible
What are the risk factors for secondary amenorrhea?
1) < 25 y.o with history of menstrual irregularities
2) Competitive athelete (low body fat)
3) Massive weight loss
• Causes GnRH secretion to drop rapidly leading to ↓ FSH and LH secretion leading to no estrogen secretion -> whole menstrual cycle stops working. (Applicable to low body fat also)
