womens health Flashcards
1
Q
What are the consequences of menstrual cycle disorders?
A
Negative impact on QOL, reproductive health, long term detrimental health effects (increased risk of osteoporosis with amenorrhea, risk of diabetes with PCOS)
2
Q
what are the Menstrual Cycle Disorders?
A
- Amenorrhea
- menorrhagia
- dysmenorrhea
- premenstrual syndrome
- polycystic ovary syndrome
3
Q
what is Amenorrhea?
A
No menstrual bleeding in a 90 day period
4
Q
what are the types of amernorrhea?
A
- Types
- Primary/ functional
- Absence of menses by age 15 in females who never menstruated
- Rare
- Secondary
- Absence of menses for 3 cycles in a previously menstruating female
- Rare, but more common than primary
- More frequent in <25 yo with history of menstrual irregularities, competitive athletics or massive weight loss
- Primary/ functional
5
Q
what is the etiology of amenorrhea?
A
- Anatomical causes: Pregnancy, uterine structural abnormalities
- Endocrine disturbances leading to chronic anovulation (egg does not release or ovulate)
- Ovarian insufficiency/ failure
6
Q
what is the treatment for amenorrhea?
A
- Identify underlying cause
- Non-pharmacological: Gain weight/ reduction of exercise intensity/ Stress management
- Pharmacological: Combined oral contraceptive (COC), Estrogen, Progestin, Copper IUD
7
Q
what is Menorrhagia?
A
- Heavy menstrual bleeding
- Menstrual blood loss >80ml per cycle OR Bleeding >7d per cycle
8
Q
what is the pathophysiology of Menorrhagia?
A
Uterine-related factors
- Fibroids (benign tumors growing in or on uterine wall)
- Adenomyosis (endometrial tissue grows into muscular wall of uterus)
- Endometrial polyps
- Gynecologic cancers
- Alterations in hypothalamic-pituitary-ovarian (HPO) axis
Coagulopathy factors
- Cirrhosis
- von Williebrand disease (deficiency of pro-von Willebrand factor)
- Idiopathic thrombocytopenic purpura (abnormal decrease in platelets)
9
Q
how to treat Menorrhagia?
A
- Contraception: COC/ Progestin IUD/ Progestin only oral contraceptive/ Progestin injection
- Non-contraceptive: NSAIDs during menses/ Tranexamic acid (clots blood) during menses/ Cyclic progesterone
- Endometrial ablation: Destroy endometrial lining of uterus
- Hysterectomy: Remove entire uterus
10
Q
what is Dysmenorrhea?
A
- Crampy pelvic pain with or just before menses
- Primary and secondary
11
Q
how does Dysmenorrhea happen?
A
- For primary: Release of prostaglandins and leukotrienes —> Vasoconstriction —> Cramps
- For secondary: Endometriosis (tissue similar to lining of uterus (endometrium) grows outside uterus)
12
Q
how to treat Dysmenorrhea?
A
- Nonpharacological: Topical heat therapy, exercise, acupuncture, low-fat veg diet
- Pharmacological:
- First line: NSAIDS
- Second line: COC
- Third line: Progestin injections/ IUD (BUT can cause render amenorrhea 😖)
13
Q
what is Premenstrual syndrome (PMS)?
A
- Cyclic pattern of symptoms occurring 5 days before menses that resolve at onset of menses
- Does not impair daily activities
14
Q
what are the symptoms for Premenstrual syndrome (PMS)?
A
- Somatic (physical): Bloating, headache, weight gain, fatigue, dizziness/ nausea, appetite changes
- Affective (mood): Anxiety/ depression, angry outburst, social withdrawal, forgetfulness, tearful, restlessness
- Severe: Premenstrual dysophoric disorder (PMDD) —> Psychiatric condition
15
Q
how to treat Premenstrual syndrome (PMS)?
A
- Selective serotonin reuptake inhibitors
- COC more for physical, not so much for mood symptoms
16
Q
what is Polycystic ovary syndrome (PCOS)?
A
- Ovaries produce an abnormal amount of androgens
- Small cysts (fluid-filled sacs) form in ovaries
17
Q
what is the clinical presentation of Polycystic ovary syndrome (PCOS)?
A
- Menstrual irregularities
- Androgen excess
- Acne/ Hirustism/ Obesity
- Metabolic disorders/ Insulin resistance —> DM, CVS disease
18
Q
how to treat Polycystic ovary syndrome (PCOS)?
A
- COC (can consider anti-androgenic progestin if acne/ hirsutism)
- Metformin
19
Q
What is menopause?
A
Permanent cessation of menses following the loss of ovarian follicular activity
20
Q
how does menopause happen?
A
- Natural
- Induced: Removal of both ovaries or iatrogenic (illness due to treatment) ablation of ovarian function: Chemotherapy, pelvic radiation
21
Q
whats the Clinical presentation for menopause?
A
note: DUE TO DECREASED ESTROGEN LEVELS
- **Vasomotor symptoms: Several times a day due to thermoregulatory dysfunction which is triggered by a decreased estrogen, starting in the hypothalamus
- Intense feeling of heat on face
- Rapid or irregular heart rate
- Flushing
- Perspiration, Cold sweats
- Sleep disturbances
- Feeling of anxiety
- Genitourinary syndrome
- Changes to labia, clitoris, vestibule, vagina, urethra, bladder due to decreased estrogen
- Genital dryness
- Burning/ irritation/ pain
- Sexual symptoms of lubrication difficulty
- Impaired sexual function/ libido/ painful intercourse
- Urinary urgency
- Dysuria (painful urination)
- Recurrent UTI
- Psychological/ Cognitive
- Likely multi-factorial (stress/ hormonal fluctuations)
- Depression/ anxiety
- Poor concentration/ memory
- Mood swings
- Bone fragility
- Decreased estrogen —> More bone loss
- Increased risk of osteoporosis and fractures
- Increased joint pain
22
Q
whats the Non-pharmacology for menopause?
A
- For mild vasomotor symptoms
- Layered clothing that can be removed or added as necessary to adapt to temp fluctuations
- Lower room temp
- Less spicy food/ caffeine/ hot drinks
- More exercise
- Dietary supplements (but conflicting results)
- Isoflavones (phytoestrogen): Soybean, Leumes (lentils, chick pea)
- Black cohost (herb): Serotonergic (serotonin) activity at hypothalamus
- For mild vulvovaginal symptoms
- Nonhormonal vaginal lubricants/ moisturizers
23
Q
whats the pharma for menopause?
A
- Menopausal hormone therapy
- antidepressants
- gabapentin
- tibolone
24
Q
what is Menopausal hormone therapy for in menopause?
A
Reserved for moderate/ severe symptoms or insuff response to nonpharma
- Dont use this solely for
- Treatment of low libido
- CVD prevention
- Depression/ anxiety/ cognitive/ memory issues
- Itchy skin/ hair loss
- Treatment of osteoporosis
25
is Menopausal hormone therapy the gold standard for menopause?
yes!!! GOLD
26
how does Menopausal hormone therapy work for menopause?
Increases Estrogen
27
what are the types of Menopausal hormone therapy for menopause?
1. Estrogen only (unopposed estrogen)
2. Estrogen + Progestin
- Progestin addition
- If have intact uterus: To protect endometrium from overgrowth and **reduce risk of endometrial cancer**
- May improve vasomotor symptoms (VMS)
- Dydrogesterone, norethisterone, medroxyprogesterone, micronized progesterone, norgestrel, levonorgestrel, gestodene, desogestrel, norgestimate
28
what are the sub types of Estrogen + Progestin under Menopausal hormone therapy for menopause?
- Continuous-combined
- Estrogen and progestin daily
- No withdrawal bleeding although chance of breakthrough bleeding initially
- After several months: Possible amenorrhea
- Continuous-cyclic
- Progestin added on either 1st or 15th of month, for 10-15 days
- Withdrawal bleeding when progestin stopped
- Regulate menses, which allows for predictable bleeding
29
how does menopausal hormone therapy compare with coc in terms of Physiologic goal?
mht: Replace/ supplement endogenous estrogen to alleviate symptoms and risks of lower estrogen production
coc: Suppress hypothalamus-pituitary-ovarian axis to avoid ovulation
30
how does menopausal hormone therapy compare with coc in terms of Amount of ethinyl-estradiol equivalents?
mht: 10-15mcg
coc: 20-50mcg
31
how does menopausal hormone therapy compare with coc in terms of Common formulations of estrogen used?
mht:
- 17 beta estradiol
- Conjugated equine estrogens (CEE)
coc:
- Ethinylestradiol
- Estradiol
32
why are systemic oral tablets for menopausal hormone therapy good and yet bad?
good: Cheaper
BAD:
- Higher dose required —> Higher risk of side effects
- Potential for missed dose —> Irregular bleeding
33
why are Systemic Topicals (Patches, Gels) for menopausal hormone therapy good and yet bad?
good:
- Lower systemic dose than oral
- Convi
- Continuous estrogen release
BAD:
- Expensive
- Skin irritation (rotating sites helps)
- Gel has more variability in absorption
34
why are Local vaginal (Pessary, Creams) for menopausal hormone therapy good and yet bad?
good:
- Lowest estrogen dose —> No need concomitant progestin
- Continuous estrogen release
BAD:
- Inconvi/ uncomfortable
- Vaginal discharge
- Only for localised urogenital atrophy
35
what are the risks associated with mht?
- Breast cancer
- Endometrial cancer
- Venous thromboembolism
36
how to monitor if use mht?
- 2-3 months of use before improvement with symptoms
- Continue MHT if there is a need
- Upon initiation
- Annual mammography
- Endometrial surveillance
- Unopposed estrogen: Vaginal bleeding
- Continuous-cyclic: Bleeding occurs when progestin is still on
- Continuous-combined: Prolonged bleeding, heavier than normal, frequent, persists after >10 months of usage
- Upon discontinuation
- 50% chance of symptoms returning
37
what are the diff types of antidepressants one can use for menopause?
- Serotonin and norepinephrine reuptake inhibitors
- Venlafaxine
- Selective serotonin reuptake inhibitors
- Paroxetine
38
how can Gabapentin help with menopause?
Helps with night sweating and sleep disturbances
39
what is tibolone?
Synthetic steroid with estrogenic, progestogenic, androgenic effects
costly
40
how can tibolone help with menopause?
- Improves mood, libido, menopause symptoms, vaginal atrophy (less than estrogen)
- Protects against bone loss
41
who is tibolone for?
Only for postmenopausal women more or equal to 12 months since last natural period
42
what risks is tibolone associated with?
Risk of stroke, breast CA recurrence, endometrial cancer
43
best treatment for severe vasomotor symptoms of menopause
MHT
44
what is Hypertension in Pregnancy?
One of the most common causes of mortality in pregnancy
- Based upon >1 measurement min 4h apart
- **SBP >140mmHg or DBP >90mmHg**
- Severe Hypertension, based upon 2 measurements
- **SBP >160mmHg and/or DBP >110mmHg**
45
what are the Categories for htn in preggos?
- Chronic Hypertension
- Before 20 weeks gestation: Pre-existing or new onset hypertension
- No proteinuria (albuminuria: elevated levels of proteins)
- Gestational Hypertension
- After 20 weeks of gestation: New onset hypertension
- No proteinuria
- Pre-eclampsia
- After 20 weeks of gestation: New onset hypertension AND new onset of (either one?????)
- Proteinuria
- **24h urinary protein (UTP) >300mg**
- normal is <150mg/day
- **Dipstick protein >2**
- **Urine protein: Creatinine ratio (uPCR) >0.3mg/dL**
- Signs of end-organ dysfunction
- **Platelet count <100 —> Clotting factors so bleeding complications**
- **Liver Function Tests >2x ULN**
- **Doubling of SCr in absence of other renal disease**
- **Pulmonary edema (accumulation of fluids in lungs) —> SOB**
- **Neurological complications**
- Utero**placental** dysfunction
- Chronic Hypertension with superimposed pre-eclampsia
- Superimposed: Secondary infection that occurs during an existing infection, or immediately following a previous infection.
- Before 20 weeks gestation: New onset proteinuria
- No proteinuria previously
46
what is Eclampsia?
MEDICAL EMERGENCY: Risk for both maternal and fetal
- Sudden onset of seizures, which can be tonic-clonic (involve whole body), focal (affect specific part) or multifocal superimposed on pre-eclampsia
- Pre-eclampsia can progress rapidly to eclampsia
47
what are the symptoms of eclampsia?
- N/v
- Palpitation
- Flushing
- Headache
- Tremor
48
how to prevent pre-eclampsia?
- Low dose 100mg or more aspirin
- Start after 12 weeks, ideally before 16 weeks, continue till delivery
- Reco for high risk patients: Hypertension on prev preggo, multifetal gestation, autoimmune disease, DM, CKD
49
what is the Pharmacology for hypertension in preggos?
1. Methyldopa
2. Labetalol
3. Calcium channel blocker: Nifedipine ER
4. Hydrochlorothiazide
5. Hydralazine
50
why does methyldopa suck in treating htn in preggos?
- Low potency
- Increase ADR (sedation, dizziness)
51
which are the most commonly used drugs for htn in preggos?
1. Labetalol
- Preferred over other beta blockers because less ADR on uteroplacental blood flow and fetal growth
- Bronchoconstrictive effects, bradycardia
2. Calcium channel blocker: Nifedipine ER
- Monitor for pedal edema (fluid gathers in feet), flushing, headaches
52
whats the 2nd or 3rd line drug for htn in preggos?
Hydrochlorothiazide
but note Potential interference with normal blood volume expansion during preggo
53
what to watch out for when taking hydralazine for htn in pregos?
ADR mimics symptoms assoc with severe preeclampsia and imminent eclampsia
54
When to initiate treatmen for htn in pregs?
- 140/90mmHg
- Used to be >160/110mmHg (severe chronic hypertension)
55
what are the Non-hormonal contraceptives: Barrier techniques?
1. Male condoms (external)
2. Female condoms (internal)
3. Diaphragm with spermicide
4. Cervical cap
56
what are the contraindicates for the following?
1. Male condoms (external)
- Latex or rubber allergy
2. Female condoms (internal)
- Polyurethane allergy
- History of toxic shock syndrome (TSS)
3. Diaphragm with spermicide
4. Cervical cap
- Latex or rubber or spermicide allergy
- Recurrent UTIs
- History of TSS
- Abnormal gynaecological anatomy
57
what are the adv for the following Non-hormonal contraceptives: Barrier techniques?
1. Male condoms (external)
- STI protection
2. Female condoms (internal)
- Can be inserted ahead of time
- STI protection
3. Diaphragm with spermicide
4. Cervical cap
- Low cost
- Reusable
58
what are the disadv for the following Non-hormonal contraceptives: Barrier techniques?
1. Male condoms (external)
- High user failure rate
- Poor acceptance
- Possibility of breakage
2. Female condoms (internal)
- Very High user failure rate
- Dislike ring hanging outside vagina
3. Diaphragm with spermicide
4. Cervical cap
- High user failure rate
- Low protection against STIs
- Increased risk of UTI
- Cervical irritation
59
what are the Hormonal contraceptives avail?
1. Oral contraceptives
2. Transdermal contraceptives
3. Long acting injections: Progestin injections
4. Long acting reversible contraception
60
what is hormonal contraceptives?
Combination of progestin and/or estrogen
61
what are the hormonal Oral contraceptives avail?
1. Combined Oral Contraceptives (COC)
2. Progesterone Only Pill (POP)
62
how does progestin work ?
Block LH surge —> Prevents ovulation
63
whats the goals of the usage of progestin?
Thickens cervical mucus to prevent sperm penetration, slows down tubal motility (delay sperm transport), induce endometrial atrophy
Provide most of contraceptive effect
64
what kind of activity does progestin have? and what are the side effects if any?
- Has progestational activity and inherent androgenic effects
- 😖 Androgenic ADR: Acne, oil skin, hirsutism (excess hair on certain parts)
65
what is a type of progestin?
- Drospirenone (4th gen)
- Analogue of spironolactone
- Goals: Anti-mineralcorticoid, some anti-androgenic action
- Less water retention, less acne
- 😖 ADR: Hyperkalemia, thromboembolism, bone loss
note: Cyproterone no longer used for birth control
66
whats the goals of using estrogen ?
Stabilise endometrial lining and provide cycle control
67
how does estrogen work?
Suppress FSH release —> Prevents ovulation
68
what are the types of estrogen?
- Ethinyl estradiol*
- Estradiol valerate
- Esterol
- Mestranol
69
whats the dosing for estrogen?
- Low dose: 15-25mcg
- For adolescence, <50kg, >35yo, peri-menopausal, fewer side effects
- Mod dose: 30-35mcg
- For >70.5kg, early to mid cycle breakthrough bleeding/ spotting or non-adherence
- High dose: >50 mcg
70
whats the types of COC based on content?
- Monophasic COC: **Same** amounts of estrogen and progestin in every pill
- Less confusing, less complicated missed dose
- Multiphase COC: **Variable** amounts of estrogen and progestin
- Lower progestin overall —> Lesser side effects
71
whats the Types of COC based on duration of treatment?
note: Placebo: Pill-free or placebo to allow for withdrawal bleed before starting a new pack if it’s a cycle
- Conventional-cycle COC
- 21d active pill+ 7d placebo = 28d
- Newer formulations: 24d active pill + 4d placebo = 28d
- Shorter pill-free interval to reduce hormone fluctuations between cycles —> Less SE
- Extended-cycle COC
- 84d + 7d placebo = 91d
- Convi, lesser periods
- Continuous COC
- Just keep taking, no placebo
- Convi, lesser periods
72
How to initiate a COC?
- First day method
- Start on first day of menstrual cycle
- No backup contraceptive required if on first day cos you stop the process before it starts
- Immediate protection against pregnancy
- Sunday start
- Start on first sunday after menstrual cycle begins
- Require backup contraceptive (eg. male condoms) for at least 7d
- May provide weekends free of menstrual periods
- Quick start
- Start now
- Require backup contraceptive for at least 7d and potentially till next menstrual cycle begins
73
what are the Factors to consider when selecting COC?
- Hormonal content required
- Convenience
- Adherence level
- Tendency for oily skin, acne, hirsutism —> COC has side health benefits
- Medical conditions (eg. premenstrual syndrome, dysmenorrhea)
74
what are the Bonus of other health benefits when using coc?
- Menstrual benefits
- Improve menstrual cycle regularity
- Relief from menstrual related problems
- Management
- Peri-menopause, Polycystic ovary syndrome (PCOS), Iron-deficient anemia due to reduction of bleeding, Premenstrual dysphoric (dissatisfied) disorder by regulating hormones, Acne
- Reduction of risk
- Ovarian and endometrial cancers, ovarian cysts, ectopic preggo, pelvic inflam diseases, endometriosis, uterine fibroids, benign breast disease
75
whats the adrs for coc?
1. breast cancer
2. venous thromboembolism
- Estrogens: Increase hepatic production of factor VII, X and fibrinogen of coagulation cascade
- New gen progestins (drosperinone, cyproterone, desogestrel)
3. Ischemic stroke/ Myocardial infarction
76
when to avoid using coc?
if have risk factors for the following:
1. Breast cancer
- Avoid if FH or risk factors of breast cancer, >40 years old, current history/ recent (within 5y)
- Risk increases with duration and age >40
- Risk removed upon discontinuation
2. Venous thromboembolism
- risk factors: >35yo, obesity, smoker, immobilization, cancer, hereditary thrombophilia
3. Ischemic stroke/ Myocardial infarction
- risk factors: Age, hypertension, obesity, dyslipidemia, smoking, prothrombotic mutations —> Consider low dose estrogen/ progestin-only/ barrier instead
- contraindications: Migraine with aura (recurring headache that strikes with sensory disturbances called aura)
77
what to consider instead of coc if have risk factors for the following:
1. risk factors for Venous thromboembolism
- Consider
- Low dose estrogen with older progestins
- Progestin-only contraceptive
- Barrier methods
2. risk factors for ischemic stroke/ mi
- Consider low dose estrogen/ progestin-only/ barrier instead
3. risk factors of ischemic stroke/ mi and migraine with aura
- Consider progestin-only/ barrier instead
78
what are the contraindications for coc?
- Current/ recent history (within 5y) breast CA
- History of venous thromboembolism or pulmonary embolism and/or on anticoagulent therapy
- Major surgery with prolonged imobilization
- <21d postpartum with other risk factor
- <6weeks postpartum if breastfeeding
- Thrombogenic mutations
- Systemic Lupus Erythematosus and/or Antiphospholipid Syndrome
- Migraine with aura
- SBP > 160mmHg / DBP > 100mmHg
- Hypertension with vascular disease
- Current/ history of ischemia heart disease
- Cardiomyopathy
- Smoking >15 sticks/d AND age >35yo
- History of cerebrovascular disease
- Diabetes >20y or with complications
79
when do adr for coc occur?
Normally occurs during early COC use, may improve by 3rd-4th cycle after adjusting to hormone levels
Counsel to ensure continued adherence on COC for 2-3 months before changing products UNLESS vv serious ADR like VTE/ stroke/ migraine with aura/ MI
80
how to manage adr (Breakthrough bleeding) for coc?
- If early/ mid cycle: Increase estrogen
- If late cycle: Increase progestin
81
how to manage adr (menstrual cramps) for coc?
- Increase progestin/ switch to extended cycle or continuous
82
how to manage adr (acne) for coc?
- Change to less androgenic progestin
- Consider increasing estrogen: If on POP, change to COC
83
how to manage adr (bloating) for coc?
- Reduce estrogen
- Change to progestin with mild diuretic effect: Drospirenone
84
how to manage adr (n/v) for coc?
- Reduce estrogen
- Take pills at night/ change to POP
85
how to manage adr (Headache) for coc?
- Exclude migraine with aura first
- Usually occurs in pill-free week —> Switch to extended cycle/ continuous/ shorter pill-free interval
86
how to manage adr (Breast tenderness/ weight gain) for coc?
- Keep both estrogen/ progestin as low as possible
87
whats the ddi to take note of for coc?
note: Lower the dose of hormone in COC, greater risk of DDI —> Lesser efficacy
1. Rifampin (antibiotic)
2. anticonvulsants
3. hiv antiretrovirals
88
how does rifampin affect coc? (ddi)
- Alters gut flora —> Alter metabolism —> Less active drug
- Use additional contraception till rifampin discontinued for at least 7 days
89
how does Anticonvulsants affect coc? (ddi)
- Reduces free serum conc of both estrogens and progestin
- Phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine, lamotrigine
90
how does HIV antiretrovirals affect coc? (ddi)
- Reduces both effectiveness of COC and antiretrovirals
- Protease inhibitors: Ritonavir, darunavir
91
what happens if miss dose of coc?
1. Miss one dose (within 48h)
- Take missed dose immediately and continue the rest as usual —> So take the next pill as if never miss the prev one
- No need additional contraceptive
2. Miss two or more consec doses (>48h)
- Take missed dose immediately and discard rest of missed dose
- Continue rest as usual as if never miss prev dose
- Backup contraceptive required for at least 1 week
3. Miss dose during last week of cycle
- Finish remaining active pills in current pack
- SKIP hormone-free interval and start new pack the next day
- Backup contraceptive for at least 7d
92
what is pop for?
Good for breast feeding, intolerant to estrogen (eg. n/v), conditions that preclude (rule out) estrogen
93
what is the failure rate for pop?
Typical use failure rate 7% (same as COC)
94
when to NOT use pop?
AVOID if breast cancer
95
what are the diff types of pop?
- Norethindrone or Levonorgestrel
- 28 active pills (continuous)
- Drospirenone
- 24 active pills, 4 inactive
96
when to start treatment for pop?
- Within 5d of menstrual cycle —> No need backup
- Any other day —> Backup contraceptive for 2d (7d for drospirenone)
97
what happen if miss dose for pop?
- N/L: If miss by >3h, take extra and continue + backup for 2d
- Drospirenone: If <24h, take extra and continue. If >2 active pills missed, backup needed for 7d
98
what kind of transdermal contraceptives are there?
1. patches
2. vaginal rings
note: Continuous, higher exposure to estrogen —> Increased risk of VTE
99
what is the failure rate for use of patches and vaginal rings as contraceptives?
Typical use failure rate 7% (same as COC)
100
what does patches and vaginal rings as contraceptives contain?
Contains estrogen and progestin
101
who is patches as contraceptives reco to?
Reco for those <90kg
102
how to apply patches as contraceptives?
Apply once weekly x3weeks, then 1 patch-free week
103
when to discard vaginal rings?
Use for 3 weeks then discard
104
how to put on vaginal rings?
Precise placement not an issue as hormones are absorbed (unlike diaphragms/ cervical caps)
105
whats the failure rate for long acting progestin injections?
Typical use failure rate 4%
106
what is a type of long acting progestin injections?
- Depo-Provera
- IM injection Q12h
107
whats the thing about long acting progestin injections?
- Good for adherence, but need visit doc regularly
- Might delay return to fertility
108
whats the adr for long acting progestin injections?
- 😖 ADR
- Variable breakthrough bleeding esp first 9 months
- Amenorrheic: 50% after 12m, 70% after 2y
- Weight gain (more than other types!!)
- BLACK BOX WARNING: Short term bone loss —> Bone mineral density decrease
- Avoid in older women, osteoporosis risk factors (eg. long term steroids), >2y
109
what is Long acting reversible contraception? and what are the two types?
Hormonal and non-hormonal contraceptives
- Effects quickly reversible upon removal
- Not commonly used due to invasiveness
1. subdermal implants: progestin implants
2. intrauterine devices (iud)
110
whats the failure rate for Long acting reversible contraception?
Highly effective: Typical use rates, perfect-use rates <1%
111
what is Subdermal implants: Progestin implants?
- Single 4cm long implant
- Contains 68mg of etonogestrel
- Last 3 years
- Irregular bleeding pattern with continued use: Amenorrhea*, prolonged bleeding, spotting**, frequent bleeding
112
how does iud work?
- MOA: Inhibit sperm migration, damage ovum, damage/disrupt transport of fertilized ovum
- If have hormones like progestin: Endometrial suppression, thicken mucus
113
when to avoid using iud?
AVOID inserting if preggo, current STI, undiagnosed vaginal bleeding, malignancy of genital tract, uterine anomalies, uterine fibroids
114
whats the adr for iud?
😖 ADR: Uterine perforation, expulsion, pelvic infection
115
what are the two types of iud?
1. levonorgestrel iud
2. copper iud
116
whats the diff between the two types of iud?
1. levonorgestrel iud
- leads to a Menstrual flow decreased
- associated with Typical spotting, amenorrhea
- 5 years
2. copper iud
- leads to Heavy menses
- Ideal if concomitant amenorrhoea
- 10y
- can use as emergency contraception
117
how to get access to emergency contraception?
Requires prescription
118
what are the types of emergency contraception?
- Copper IUD**
most effecitve
insert within 5d
inhibits sperm migration, damage ovum, disrupt transport of fertilised ovum
- Ella tablet
1 tablet asap within 5d
slows release of GnRH inhibiting ovulation
thins uterine lining
- Postinor 2 tablet (levonorgestrel 0.75mg)
2 tabs asap within 12h
slows release of GnRH inhibiting ovulation
thins uterine lining
119
what are the side effects of emergency contraception?
- Side effect: **Nausea** with oral option
- If vomits within 3h of taking tablet, redose!!!
120
whats the female pharmaco for oral contraceptives?
1. Ethinyl estradiol (synthetic estrogen)
2. Norethindrone (synthetic progestogen)
121
how does Ethinyl estradiol (synthetic estrogen) work?
- Estrogen receptor agonist: Binds to estrogen receptors
- Negatively regulates hypothalamic-pituitary-ovarian axis —> **Inhibits follicle-stimulating hormone released** from anterior pituitary —> Suppresses development of ovarian follicle —> Makes endometrium unsuitable for implantation of ovum
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what is Ethinyl estradiol (synthetic estrogen) for?
- Menopausal symptoms (mood swings, body changes)
- Gynecological disorders
- Certain hormone-sensitive cancers
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whats the pkpd for Ethinyl estradiol (synthetic estrogen)?
- A
- Well absorbed orally (but also can be admin parental, transdermal, topical)
- OD
- Fast Onset 30-69mins
- Good F = 0.45
- D
- Very highly plasma protein bound
- M
- Metabolised by liver
- Phase 1: Hydroxylation by CYP3A4
- Phase 2 (make more water soluble): Conjugation with glucuronide and sulfation —> **Ethinylestradiol glucuronides** and **Ethinylestradiol sulfate**
- Both inert, so no estrogenic effect
- t1/2 = 13-27h
- Inert compounds can undergo **enterohepatic recirculation** from liver to bile to small intestine to be reabsorbed back to liver —> Long half life
- E
- Metabolites excreted in faeces and urine
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whats the adr for Ethinyl estradiol (synthetic estrogen)?
- Breast tenderness
- Headache
- Fluid retention (bloating)
- Nausea
- Dizziness
- Weight gain
- Venous ThromboEmbolism (VTE) —> block blood vessel !!!
- MI/ stroke
- Liver damage
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who should not take Ethinyl estradiol (synthetic estrogen)?
- Known history or susceptibility to arterial or venous thrombosis (because potential severe side effect)
- Advanced diabetes with vascular disease
- Hypertension >160/100
- Avoid in breastfeeding <21d postpartum and breast cancer
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how does Norethindrone (synthetic progestogen) work?
- Progesterone receptor agonist: Binds to progesterone receptors
- Negatively regulates hypothalamic-pituitary-ovarian axis —> **Inhibits luteinizing hormone released** from anterior pituitary —> Prevents ovulation —> Makes endometrium unsuitable for implanation of ovum
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who is Norethindrone (synthetic progestogen) for?
- Endometriosis (Tissue similar to uterus lining grows outside of uterus)
- Abnormal periods or bleeding and to bring on a normal menstrual cycle
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whats the pkpd for Norethindrone (synthetic progestogen) ?
- A
- Well absorbed orally OD
- Quick onset
- Good bioavailability 64%
- D
- Highly plasma protein bound
- M
- Metabolised in liver by phase 1 reduction then phase 2 glucuronidation and sulfation
- t1/2 = 8h
- Some % of norethindrone can be metabolised in liver to EE
- E
- Metabolites excreted in urine and faeces
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whats the adr for Norethindrone (synthetic progestogen) ?
- Headache
- Dizziness
- Bloating
- Weight gain
- Episodies of unpredictable spotting and bleeding
- Amenorrhea (absence of periods)
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who is Norethindrone (synthetic progestogen) not desirable for?
Not desirable for women planning for pregnancy soon after cessation of therapy as ovulation suppression can persist for like 1.5y
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can Norethindrone (synthetic progestogen) convert to Estrogen? and if so what does this cause?
yes
Partial conversion of nonethindrone to EE may cause potential CVS complications of EE (eg. Venous thromboembolism)
