Womens Health Flashcards
1
Q
Which contraceptive tier is more effective?
A
Tier 1
2
Q
Tier 1 contraceptive methods
A
Implant
Vasectomy
Tubal occlusion
IUD
After procedure require little or nothing to do or remember
3
Q
Tier 2 contraceptive method
A
Injectable: Get repeat injections on time
Pill: take pill each day
Patch: keep in place or change on time
Ring: keep in place or change on time
4
Q
Tier 3: least effective
A
Use correctly everytime you have sex: Male or female condom Diaphragm Sponge With-drawl Spermicides
Abstain or use condom on fertile days:
Fertility awareness based methods
5
Q
What are key points to consider when selecting contraceptives
A
Evaluate for contradictions
Present all medically appropriate contraceptive options: discuss pros and cons
Recommend most effective method that acceptable to the patient: do they want period or not and route of administration
6
Q
What is the primary contraceptive agent?
A
Progestin
7
Q
Mechanism of action for progestin based contraceptive is dependent on what factor?
A
Dose
8
Q
Low dose progestin mechanism of action
A
Thickens cervical mucus, preventing sperm penetration
9
Q
Moderate dose progestin mechanism of action
A
Often blocks LH surge = often suppresses ovulation
10
Q
High dose progestin mechanism of action
A
Block LH surge = suppresses ovulation
11
Q
What other reproductive system effect can progestin based contraceptive have?
A
Endometrial atrophy
12
Q
What are the cons of progestin non-contraceptive effects?
A
Irregular bleeding or amenorrhea
Acne, hirsutism ( at high dose)
13
Q
What are the pros of progestin non-contraceptive effects?
A
Amenorrhea
Reduction in:
Menustral bleeding
Cramping
Endometrial cancer
14
Q
How is Estrogen used in contraception?
A
Adjunctive to progestin contraceptive
15
Q
What is the mechanism of action for estrogen based contraception?
A
Suppress FSH
Contribute to blocking LH surge
16
Q
What other reproductive system effect does estrogen have?
A
Menustral cycle control
17
Q
Withdrawl of estrogen could lead to what effect?
A
Menustral bleeding
18
Q
What are the cons of estrogen based contraception?
A
Increased risk of: Thrombosis MI Hypertension Hepatic neoplasms Breast cancer
19
Q
What are the pros of estrogen based contraception?
A
Reduces: Dysmenorrhea or blood loss PMS or PMDD Endometriosis Acne Hirsutism Ovarian cyst and cancer Endometrial and colon cancer Benign breast condition
20
Q
Incapacitate sperm
A
Copper IUD
21
Q
Prevent ovulation
A
Hormonal contraceptives combined:
COCs
Emergency contraceptive pills ( plan B)
Combined hormonal vaginal ring
22
Q
Prevent ovulation
A
Hormonal contraceptives (progestin only) Implants Injectable POPs Progestin only vaginal ring
23
Q
Prevent ovulation
A
Lactation amenorrhea method (LAM)
24
Q
Thickens cervical mucus
A
Hormonal contraceptive (progestin only) Hormonal IUDs Implants Injectable POPs Progestin only vaginal ring
25
Blocks sperm
Male and Female condom
26
First generation progestin agents
Norethindrone
| Norethindrone acetate
27
Second generation progestin only
Levonorgestrel
| Norgestrel
28
3rd generation progestin
Norgestimate
| Desogestrel
29
Fourth generation progestin
Drospirnone
30
Estrogen agents
Mestranol
50mcg
Metabolized EE
31
Estrogen agents
Ethinyl estradiol ( most oral contraceptives)
Low dose: 10,20,25,30,35 mcg
50 mcg rarely used
32
Estrogen agent
Estradiol valerate
Contained in quadriphasic product
33
Estrogen agent
Esterol
34
How's the USMEC organized?
Contraceptive method
Patient characteristics
Preexisting condition
35
Intrauterine contraception and can be inserted anytime during the menustral cycle except when pregnant
LARC
36
LARC
Copper-T IUD
LNG IUD
Arm implant
37
Patient wants regular menses and not want to use hormones
Copper-T IUD.
38
No hx of menorrhagia or dysmenorhea
Copper-T IUD
39
Off label EC and last 10 years
Copper-T IUD
40
Acceptable amerrhea and tolerable irregular bleeding
LNG IUD
41
History of dysmenorrhea or menorrhagia
LNG IUD
42
3-5years
LNG IUD
43
Tolerable irregular bleeding and last 3 years
Arm implant
44
Not contraindicated for intrauterine contraception
```
Multiple partners
STD or PID history
Teens
Nulliparous women
Immediately post partum or post abortion
Ectopic pregnancy history
```
45
Actual contradiction for intrauterine contraception
Uterine fibrosis or uterus distortion
Active pelvic infection
Sepsis
Active pregnancy
46
What should a pharmacist do before prescribing: depo shot, pill, patch or ring
Review self-screening to evaluate contradictions
Screen for medication interaction
Rule out pregnancy
47
At what blood pressure should estrogen based depo shot, pill, patch or ring not prescribed
BP >140/90
48
DMPA
A dose progestin shot
49
DMPA dose
150 mg IM every 12 weeks
50
What is the benefit of DMPA
Last 3 months
Reduce risk of endometrial, Ovarian cancer or PID
Lacks estrogen
Decrease frequency of sickle cell or seizures
51
What are the adverse effect of DMPA?
Weight gain
Mood changes
Hair loss
Irregular bleeding
52
What are the disadvantages of using DMPA
Amenorrhea
Injection
Decrease HDL
Delayed return of fertility
Does not protect against STD
53
In patient with low HDL, which contraceptive is probably not appropriate
DMPA shots
54
In Patient who want to get pregnant immediately after the use of contraceptives, which contraception should not be recommended?
DMPA shots
55
According to WHO, which patient population does the benefit of DMPA outweigh its fracture risk
Adolescents and women >45 years old
56
True or false per WHO guideline: there is restriction on the use of DMPA in eligible women 18-45 years old
False
57
Combined contraceptive pills (COCs)
Multiphasic vs monophasic
Biphasic vs quadriphasic
21, 24, or 84 day active pills
Placebo vs active placebo
28 day or 84 day cycle
Iron supplementation
Folate supplementation
58
What is the 91-day extended cycle oral contraceptive( seasonale)
84 days of constant pill taking and 7 days of placebo
59
How is transdermal patch: Ortho Evra or Xulane once weekly used?
Apply once weekly for 3 weeks followed by one free week
60
How is transdermal patch: Ortho Evra or Xulane continuous use administered
Once weekly with no free days
61
What area of the body should transdermal patches be applied
Upper outer arm, upper torso, buttock or abdomen
62
How is vaginal ring (nuvaring) administered
Insert for 3 weeks, then removed for a week
Or
For continuous use change once every four weeks
63
What is Day 1 start of combined hormonal contraceptives
CHC use starts on first day of menses regardless what week day
64
What is quick start of combined hormonal contraceptives
Start using CHC on the day it was obtained
65
What is Sunday start of combined hormonal contraceptives
Start using on the Sunday after menses begins
66
which of the combined hormonal contraceptives do not require backup such as condom
Day I start
67
which of the combined hormonal contraceptives require backup such as condom for one week
Quick and Sunday start
68
What should a pt do if they miss a dose
Take ASAP
69
What should a pt do if they miss one pill
Take 2 pill the next day
70
What should a pt do if they miss 2 pills
Take 2 tabs per s day for 2 days and use backup for a week
71
How long does the ring have to be out to be considered a missed dose
> 3 hours
72
How long does the patch have to be out to be considered a missed dose
>24 hours
73
What is the appropriate way to managing a combination contraceptives with side effects such as: nausea and vomiting, weight gain, and headaches?
Reducing estrogen or progestin
74
What is the appropriate way to managing a combination contraceptives with side effects such as: mood changes
Reduce progestin
75
What is the appropriate way to managing a combination contraceptives with side effects such as: breast tenderness
Reduce estrogen
76
What is the appropriate way to managing a combination contraceptives with side effects such as: break through bleeding
Increase estrogen if in early cycle
Or
Increase progestin if late in cycle
77
What is the appropriate way to managing a combination contraceptives with side effects such as: acne
Reduce progestin
or
increase estrogen
78
What is the duration for starting IUD postpartum
Immediately postpartum or after 6 weeks
79
If the patient is not breast feeding postpartum what contraception methods should be recommended
Progestin only to be used anytime
Or
Combination methods at 3 weeks
80
What contraception method is recommended if the pt is breastfeeding postpartum
Progestin only method at anytime
Or
Combination when patient starts to wean
Or
Consider combo use as early as 4 weeks
81
Which progestin any pills have no placebo
28 days norethindrone
82
If norethindrone progestin only pill dose as missed what should pt do?
Use back up for 48 hours
83
What is the dose window for progestin only norethindrone
3 hours
84
What is the advantage of progestin only pills
No estrogen
Decrease risk of endometrial Cancer
Fertility return quickly after stopping
85
What is the disadvantage of progestin only pills
Must be taken at the same time everyday
Irregular bleeding or mood changes
Does not protect against STDs
86
By what mechanism does hormonal contraceptives interact with other drug
Some drugs can increase the hepatic metabolism of Estrogen or progestin via CYP enzymes
87
What drugs interacts with hormonal contraceptives lowering its efficacy
Anticonvulsants
Barbiturates
Protease inhibitor
Antibiotics
88
Which antibiotics are not listed as safe to use with hormonal contraceptives
Rifampicin or rifabutin
89
Which emergency contraception is prescription only
Ulipristal acetate (Ella)
90
What is the FDA approved timing for the use of UPA EC after sex
Take within 5 days
91
What is the FDA approved timing for LNG EC after sex
Take within 72 hours
92
When is hormonal contraception resumed after use of UPA EC
5 days after use
93
What is the mechanism of action for Emergency contraceptives
Release delay of eggs, preventing sperm from reaching the egg
94
LNG mechanism of action
Delays ovulation and egg release if LH surge has not started
It does not prevent implantation
95
UPA EC mechanism of action
Delays ovulation and egg release sometimes after LH surge
96
Which emergency contraceptive may less effective in obese patient or those weighing over 1651bs
LNG EC
97
What are side effects experienced from EC?
Headache ( equal in both)
Nausea ( UPA > LNG)
Dizziness ( equal in both)
Back pain ( UPA > LNG)
98
For which condition should contraception not be recommended?
Smoke ≥ 15 cigarettes/day
Multiple risk factors for arterial cardiovascular disease
Systolic ≥ 160 mmH or diastolic ≥ 100 mmHg
Vascular disease
At blood pressure systolic 140-159 or diastolic 90-99 ( risk > benefit)
DVT or PE
Active cancer
Prolonged immobilization
Current or history of Ischemic heart disease (stroke)
Migraine with aura
Do not continue in patient ≥ 35 years with migraine
Diabetes complications (neuropathy, retinopathy, nephropathy)
Acute viral hepatitis and severe cirrhosis
Complicated solid organ transplant
99
Which contraceptive can protect against STI
Male condom
100
What is the disadvantage of latex condom
Allergy
| Degrades with oil based lubricant
101
What is the advantage of latex based condom
Includes reservoir tip
102
What is the disadvantage of non-latex condoms
Breaks easily
| Costly
103
What is the advantage of non-latex condoms
Does not degrade with oil based lubricant
104
What is the disadvantage of natural membrane condom
Only for pregnancy protection
105
What is the advantage of natural membrane condom
Very strong
| Does not degrade with oil based lubricant
106
What is the patient education for use of male condom
```
Only use once
Use with expiration date
Keep with sealed package
Avoid oil base lubricant
Checks for holes and breaks
```
107
Male condom advantage
STD protection
Easily accessible and inexpensive
No system effect or rare ADR
Used when sexually active
Proof of protection
108
Disadvantages of male condom
Less effective than systemic
Dull sensation and reduced spontaneity
Must be prepared
109
How long can a female condom be inserted prior to sex
8 hours
110
What is the advantage of female condoms
STD protection
Female controlled
Insert 8 hours prior
Lower risk of breakage
111
What are the disadvantage of female condom
Less effective than systemic
Dulled sensation
Can be noisy and expensive
112
Surfactant that destroy sperm cell membrane are called?
Spermicides
113
True /False: spermicides should be used alone to increase efficacy
False
114
Which patient population should not use spermicides
HIV infected women or at risk of acquiring HIV
115
True/False: spermicides do not protect against STIs
True
116
Immediate action and can be combined with condom to provide additional lubrication
Gel
117
Immediate action and can adhere to vaginal wall and less lubricating than gel
Foam
118
Onset 15 mins and can present with gritty sensation
Suppository
119
Onset 15 mins and activated by vaginal secretion and most difficult to use
Film
120
immediate action and provide spermicide and absorb semen
Sponge
121
Inserted up to 24 hours before sex and leave in ≥ 6 hours after sex
Sponge
122
How does spermicides increases risk of STI
Destroy Vaginal flora
Increase vaginal irritation, ulcers or lesions
123
Effective one hour
Foam/Jelly/Gel
124
Wait 15 minutes after insertion and effective for one hour
Suppository
125
Wait 15 minutes after insertion and effective for three hours
Film
126
Physical barriers
Diaphragm, femcap, sponge
127
Must be fit/sized and prescription only
Diaphragm and femcap
128
Diaphragm and femcap proper case
Apply OTC spermicidal jelly
Reapply spermicide after 6 hours
Must leave in 6-24hs after sex
Wash with mild soap and water
Replace every year
129
Gives 24hs protection and must be removed within 24 hours
Sponge
130
Proper sponge use
Wet
Fold and insert
Can be use repeated with 24hrs
Effective upon insertion
131
Which Emergency contraceptive is anti-progestin
Ulipristal (Ella)
132
Which emergency contraceptive is progestin only and OTC
Levonorgestrel (plan B)
133
Can be used upto 120 hours after sex
Ulipristal (ELLA)
134
Most effective within 72 hours of sex but can last up to 120 hours
Levonorgestrel (plan B)
135
Most expensive Emergency contraceptive ( $ 750 + visit fee )
Copper IUD (paragard)
136
Less effective in BMI > 25 and ineffective in BMI >30.
Levonorgestrel (plan B)
137
May be less effective with BMI >35
Ulipristal (Ella)
138
Efficacy is not dependent on weight
Copper IUD
139
30 mg single dose
Ulipristal
140
1.5mg single dose
Levonorgestrel
141
Single device
Copper IUD
142
Must be inserted within 5 days
Copper IUD
143
Prevents pregnancy but Not STD if sex was unprotected
Emergency contraception
144
What is the timeframe for getting period after EC use?
Within 3 weeks
145
What emergency contraception requires prescription for all ages and can get through website
Ulipristal
146
Cottage cheese, no odor, erythema and itching
Vulvovaginal candidiasis
147
Yellow green frothy discharge, malodorous, erythema and valvular edema
Trichomonas vaginalis
148
Thin watery off white or discolored discharge
| Strong foul fishy odor (increases after intercourse)
Imbalance in normal flora
149
Referral
Imbalance in normal flora and trichomonas
150
Anti-fungal or referral
Vulvovaginal candidiasis
151
Yeast infection or vaginal thrush
Vulvovaginal Candidiasis
152
Oral: metronidazole _ 500 mg x7 days
Bacterial vaginosis
153
Topical: metronidazole 0.75% gel _ 1 applicator every night x 5 days
Clindamycin 2% cream _ 1 applicator vaginally at night x 7 day
Bacterial vaginosis
154
No partner management
Bacterial vaginosis and vulvovaginal candidiasis
155
Oral: metronidazole _ 2 grams once or 500 mg twice daily x7 days
Or
Tinidazole _ 2 grams once
Tichromonal vaginitis
156
Partner management: Exam for STI Mgmt
| Metronidazole 2g po x 1
Trichomonal vaginitis
157
Oral: fluconazole _ 150 mg once
Vulvovaginal candidiasis
158
Topical TX: Clotrimazole* Miconazole *Tioconazole*Butoconazole*Terconazole
- 1, 3, or 7 day internal
cream or suppository
- External cream for
itching
Vulvovaginal candidiasis
159
Pregnancy
* Girls < 12 years
* Fever or pain in lower abdomen, back or shoulder
• Medications that predispose to VVC
– Steroid or antineoplastic agents
• Medical disorders that predispose to VVC
– DM, HIV infection
• Recurrent VVC
– > 3 infections/year or infection in last 2 months
Refer for treatment
160
Limit sucrose and carbohydrates consumption
– Increase consumption of yogurt containing live cultures
– Avoid tight-fitting, nonabsorbent
clothing or underwear
Non-pharmacologic therapy for VVC
161
Avoid intercourse after insertion
Vaginal treatment products
162
Irritation and burns
Vaginal treatment side effect
163
Probiotics
– Lactobacillus preparations – Yogurt with live cultures – Probiotic feminine supplements – RepHresh Pro-B
• Sodium bicarbonate sitz bath
– Relief of vulvar irritation
• Tea tree oil suppository 200mg
– Intravaginally daily x 6 days
• Gentian violet
– Soak tampon in dye and use daily or BID x5 days
• Boric Acid 600mg capsule
– Intravaginally daily or BID x 14 days
VVC complimentary therapies
164
In vaginal infections when does relief occur and
| When would symptoms be resolved
1-2days and one week
165
In vaginal infections, when should patient seek medical evaluation
When symptoms persist beyond 48hours
166
How is STI prevented
Condom
167
Inflammation of Vagina due to estrogen reduction
atrophic vaginitis
168
Menopause
• 10-40% of postmenopausal women have symptoms
– Breastfeeding
– Low estrogen oral contraceptives
– Decreased ovarian estrogen production related to
antiestrogenic drugs
• tamoxifen, clomiphene, raloxifene, danazol
Secondary causes atrophic vaginitis
169
Decrease in vaginal lubrication
– Hallmark of hormone insufficiency
• Genital symptoms
– Vaginal irritation, dryness, burning, itching, leukorrhea,
dyspareunia
• Presence of watery, thin malodorous vaginal discharge
or occasional “spotting”
• Symptoms are exacerbated by simultaneous infections
Presentation of Atrophic vaginitis
170
Short term improvement for atrophic vaginitis
Moisturizers or lubricants
171
Intravaginal cleansing with water or acetic acid solutions
Vaginal douching
