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thera 2 > Gynecology > Flashcards

Gynecology Flashcards

1
Q

Contraindications of IUDs

A

Large intracavitary pathology, breast CA, recurrent/recent PID
Caution with patients who are severely immunocompromised

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2
Q

What are some potential harming effects of estrogen therapy?

A

Increased risk of endometrial and breast carcinoma, MI, stroke and venous thromboembolism (VTE).

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3
Q

When should treatment of vasomotor symptoms associated with menopause be considered?

A

Patient experiencing mod-severe symptoms, significant impact on QOL

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4
Q

What are some non-pharm interventions for VMS?

A
  • Cooling techniques (e.g., dressing in layers, using fans, lowering the ambient temperature)
  • Trigger avoidance (e.g., spicy foods, hot drinks, caffeine, alcohol).
  • Weight loss
  • Smoking cessation
  • CBT - doesn’t help VMS but assists with coping
  • Clinical hypnosis
  • Exercise, yoga and paced respiration. Exercise to improve mood, reduce cardiovascular risk and improve bone health
  • Self help groups
  • Mindfulness based stress reduction
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5
Q

What are some contraindications to estrogen therapy?

A
  • undiagnosed vaginal bleeding
  • pregnancy
  • Active liver disease, cancer (breast or estrogen sensitive tumor), thromboembolic disease
  • Age >60
  • > 10 years since menopause onset (inc CV harm)
  • high CV risk
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6
Q

Which hormone therapy is required for those with an intact uterus? Why?

A

Estrogen - Progestogen Therapy
- Estrogen controls VMS symptoms
- Progesterone is needed to prevent endometrial hyperplasia

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7
Q

What is the difference between continuous and cyclic administration of Estrogen-Progestogen therapy?

A

Estrogen always taken continuously
Progesterone can be taken 1 of 2 ways:
Continuous: taken every day of month
Cyclic: taken on days 1-12/14 of each month
*continuous associated with better protection against endometrial hyperplasia

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8
Q

What signs of bleeding are expected with cyclic vs continuous Progestogen therapy

A

Continuous - unexpected spotting, or vaginal bleeding may occur
Cyclic - expect a withdrawal bleed when the progestogen is stopped at the end of the cycle.

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9
Q

How soon would you expect to see results of estrogen therapy on VMS?

A

Dose-related but typically within 4 weeks of standard doses

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10
Q

When would transdermal estrogen be preferred?

A
  • high VTE risk
  • women with hypertriglyceridemia (transdermal eliminates the first-pass effect through the liver = less of an increase of triglyceride levels)
  • obese women with metabolic syndrome
  • ↑CVD risk/smoking/HTN/DM/gallstones/obesity.
  • shift workers
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11
Q

Would transdermal or oral estrogen be best for a smoker?

A

Transdermal

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12
Q

A patient started on estrogen therapy and is concerned as she is experiencing breast tenderness, bloating, and spotting? What can we do for her?

A

If she has just started on therapy - Explain that these are expected side effects within the first year of initiation and typically temporary

If she has been on a stable dose for awhile - consider decreasing dosing?

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13
Q

What are some contraindications to progestogen therapy?

A
  • Undiagnosed vaginal bleeding
  • Known or suspected carcinoma of the breast
  • Pregnancy
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14
Q

What progestogen routine would be preferred if the LMP was <1yr ago?

A

If last menstrual cycle was < 1yr ago, use 10-14
days progestogen/month; otherwise continuous HT to avoid monthly withdrawal bleed.

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15
Q

How is transdermal estrogen administered?

A

Patch - alternate sites (abdo, thigh, buttocks)
Gel - same site (arm, abdomen, thigh)

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16
Q

Which therapy would be preferred for VMS treatment in the women with an intact uterus, is 52yrs and had the LMP 8 years ago?

A

Hormone Therapy = Combo estrogen + prestogen

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17
Q

T/F: Women on estrogen & progestogen were at an increased risk of breast ca after 5 or more years.

A

As per The Women’s Health Initiative (WHI) - True

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18
Q

Contraindications to hormone therapy

A

ABCD

Acute liver disease
Bleeding undiagnosed
Cancer (breast/uterine) /Cardiovascular disease
DVT (thromboembolic disease)

+ pregnancy

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19
Q

Post hormone therapy initiation when should discontinuation be reviewed?

A

Annually review, no good evidence to say when to DC, should be based on the individual patient and ongoing symptom relief

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20
Q

T/F: hormones should be weaned

A

False: Not necessarily, no evidence indicating difference between abruptly stopping and slowly tapering when it comes to return of menopause symptoms

General recommendation: Avoid abrupt discontinuation of therapy by gradually reducing the dose and frequency. If the patient becomes symptomatic with lower doses when tapering, continue that dose until the VMS abate

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21
Q

What can be used for vaginal atrophy?

A

local estrogen: cream (Premarin), vaginal suppository (VagiFem), ring (Estring).
Lubricants (Replens)
Vaginal moisturizers improve vaginal dryness & dyspareunia when used at least twice a week.

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22
Q

How to prevent osteoporosis while on hormone therapy?

A

The primary prevention of osteoporosis should be achieved through diet, exercise, and calcium and vitamin D
Rx Ca 600 mg BID, Vit D 800-2000 iu
Non-pharm: Regular exercise (especially impact type), Reduce risk of falling

For menopausal women requiring treatment of osteoporosis in combination with treatment for vasomotor symptoms, hormone therapy can be used as first-line therapy for prevention of hip, nonvertebral and vertebral fractures

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23
Q

Which hormone therapy treatment can be used for osteoporosis prevention and treatment?

A

The estrogen-bazedoxifene combination
*must have a uterus?

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24
Q

What is one of the main determining factors when deciding on treatment options for AUB?

A

Desire for fertility
Medical treatment should be first line, approx 50% will go on to have surgical intervention

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25
Q

What are the treatments for active bleeding? (During menses)

A

In clinic: high dose OCs/progestins, NSAIDs
If symptomatic of severe blood loss: ↓BP↑HR: send to ED for IV TXA, IV estrogen,

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26
Q

When are oral combined contraceptives contraindicated?

A

Avoid in patients with history of stroke or VTE, uncontrolled HTN, migraine with neurologic symptoms, breast cancer, or active liver disease, smoker >35yrs & >15 cigarettes/day

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27
Q

What hormones are in the Mirena and Kyleena?

A

Progestin only

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28
Q

How often is Depo-Provera administer?

A

q3months IM

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29
Q

Which OCs are best for acne control?

A

TRI-CYCLEN, ALESSE, YASMIN, YAZ, YAZ-PLUS

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30
Q

T/F Progestin IUDs can increase acne

A

True

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31
Q

How often is the Evra patch changed?

A

weekly

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32
Q

Which birth control method has the lowest failure rate at 0.02%?

A

Nexplanon Implant

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33
Q

Which IUD brings heavier periods? What can be given to help?

A

Copper IUDs: FLEXI-T LIBERTE MONA LISA
NSAIDs

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34
Q

How long does the Nexplanon last?

A

Up to 5 years

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35
Q

what is the most effective method of treatment for AUB?

A

LNG-IUS (IUD)
Evidence suggests LNG-IUS superior to non-surgical treatment methods and ↓ blood loss compared to progestins
Menstrual blood loss: ↓ by 86% - 3mos & 97% - 12 mos, 20-80% at 1yr - ammenorrhic;

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36
Q

what is the preferred method of treatment for adolescents with AUB?

A

All options equal, patient preference toward OCs and NSAIDs

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37
Q

Adverse effects of IUDs?

A

Minimal amount absorbed systemically - ↓ hormonal AE Most common31: irregular bleeding/spotting (esp.in first 3-6months), cramping, risk of expulsion & hormonal (breast tenderness, mood changes, acne)
Rare: perforation, PID (low risk; more likely within ~20 days after insertion); consider screen for STI risk via hx & physical exam before insertion

38
Q

T/F IUDs are most reliable in obese & overweight women

A

True

39
Q

How are OCs dosed for AUB?

A

must be monophasic
1 tab BID-TID until bleeding ceases (usually <7 days), then taper to once daily taken continuously x 3 mos OR Daily pill for 21d each month OR
[Alternatively, NUVARING or EVRA patch, cyclic or continuous, are options]

40
Q

Side effects of OCs?

A

AE: breast tenderness, mood change, fluid retention, breakthrough bleeding, nausea, headache (Rare: VTE, stroke, MI)

41
Q

How do NSAIDS help AUB?

A

NSAIDs can increase bleeding in general; however, they cause a paradoxical reaction when treating AUB
↓ total prostaglandin production to
promote uterine vasoconstriction & dec bleeding in AUB

No substantial differences in the effectiveness of different NSAIDS

All of the hormonal options can be combined with NSAIDs to optimally manage AUB

42
Q

List the hormonal options for treatment of AUB?

A
  • IUD - Mirena or kyleena
  • OCPs - monophasic
  • Depo-Prova
  • Progestin only pills
43
Q

When should progestin only pills be avoided?

A

patients with breast cancer or liver disease

44
Q

What options are available to treat AUB if not interested in contraception?

A

Non hormonal : NSAIDs
Progestin only pills

45
Q

A woman with an intact uterus experiencing VMT symptoms is prescribed estrogen and progestogen therapy. What is the purpose of the progestogen?
A. To protect the cervical lining
B. Reduce the risk of endometrial hyperplasia
C. To prevent uterine bleeding

A

B

46
Q

Which medication is a first-line option and should be considered for the prevention and treatment of osteoporosis in women who do not have vasomotor symptoms?

A

Bisphosphonates are a first-line option. Oral bisphosphonates, IV Zoledronic acid and denosumab are first line options for the treatment of osteoporosis and prevention of osteoporotic fractures in patients who do not have VMS

47
Q
  1. The most effective treatment for moderate-severe hot flashes?
    A. Antidepressants
    B. Hormonal Therapy
    C. Gabapentin
A

B

48
Q

A 40 year old woman with hysterectomy d/t fibroids what would you prescribe for VM symptoms?
A. Antidepressants
B. Estrogen & progestogen
C. Estrogen alone

A

C.

49
Q

Adverse effects with Depo-Provera?

A

Headache 17%,
↓libido 6%.
Highwest weight gain
** ↓ bone mineral density (reversible upon cessation)

50
Q

What is menopause defined as?

A

No period for >1yr in women >40yrs. Avg age 52

51
Q

What is perimenopause?

A

Perimenopause: Period of hormonal/menstrual variation preceding menopause up
to 1st year after last menses. Avg. duration 4-8 years. Do not d/c contraception

52
Q

What are the vasomotor symptoms women experience with menopause?

A

Hot flashes, sweating, palpitations, night sweats, insomnia

53
Q

T/F Methotrexate can inhibit folate?

A

True

54
Q

What would we advise the women with no known risk factors in regards to folic acid supplementation?

A

Daily multivitamin containing 0.4mg/day of folic acid 3m prior to conception and continuing into pregnancy

55
Q

What would we advise the women with personal hx of neural tube defects or previous pregnancy with neural tube defects in regards to folic acid supplementation?

A

Daily multivitamin + total intake of 4mg/day folic acid supplementation 3m preconception and during the 1st trimester then daily multivitamin containing 0.4mg/day of folic acid

56
Q

What would we advise the women with medium risk factors, 1st/2nd degree relative with pregnancy with neural tube defects, personal previous pregnancy born with folate sensitive conditions in regards to folic acid supplementation?

A

Daily multivitamin with 1mg/day folic acid supplementation 3m preconception and during the 1st trimester then daily multivitamin containing 0.4mg/day of folic acid

57
Q

What are the non-pharm recommended treatments for N/V in pregnancy?

A
  • small, frequent meals
  • bland diet
  • avoid spicy, fatty foods
  • frequent naps, rest
  • shorten work day if possible
  • Acupressure
  • ginger tablets 250mg POq6h
58
Q

What are the pharmacological recommended treatments for N/V in pregnancy?

A

Start with Pyrixidine 10mg QID OR Doxylamine-Pyridoxine (Diclectin) (controversial evidence in regards to Diclectin)

Continue with chosen agent and add on Benadryl, Gravol, Promethazine or Metoclopramide

Next step Ondansetron

If dehydration signs/persistent hyperemesis send to ED/OB for IV steroids, fluids

59
Q

Treatments for constipation in pregnancy

A

1st line – increase fluid intake 2-3L/day, high fibre foods - 28g/day (oatmeal, lentils, fruits and vegetables), activity, avoid prolonged sitting, exercise

Bulk laxative: ie psyllium regular use with slow taper up dose to reduce flatulence, bloating, GI upset

2nd line pharm: lactulose

*avoid mineral and castor oil as can stimulate uterine contractions

60
Q

Contraindications for all medical abortion regimens

A
  • confirmed/suspected ectopic pregnancy
  • IUD in place (risk for ectopic, US must be done and IUD must be removed prior)
  • bleeding risk ie hemorrhagic disorders or on anticoagulants
  • anemia (hub<95 - exercise caution)
  • known allergy
  • ambivalence - abortion irreversible
61
Q

When in the pregnancy can a medical abortion be considered?

A

approved for use within first trimester <63days of gestation

62
Q

What is the first line preferred regimen for medical abortion? And how to take

A

Mifepristone/Misoprostol (Mifegymiso)
Day 1 - take 200mg tab PO
Day 2/3 - take 2 tabs buccally (each side of mouth) leave for 30mins and swallow remainder after 30mins

63
Q

Does surgical or medical abortion create more bleeding?

A

Medical

64
Q

Which medication instills heavy bleeding with Mifegymiso?

A

Misoprostol within 3hrs symptoms start and can expect bleeding 2wks post

65
Q

When should a pt seek urgent care regarding medical abortion treatment?

A
  • soaking 2 maxi pads/hr for more than 2 hours
  • clots larger than a lemon for >2hrs
  • pain not improved with meds
  • fever, nausea, diarrhea or weakness occurring within 24hrs of taking miso
66
Q

When should follow up take place for a MA patient

A

7-14days post to confirm abortion through US or serum beta-hcg - should see 80% decline from baseline

67
Q

Absolute contraindications for contraception

A
  • current or past hx of VTE or PE
  • Uncontrolled HTN (sbp >160, dbp > 90)
  • Heart disease – complex valvular or ischemic
  • Undiagnosed vaginal bleeding
  • Liver disease (cirrhosis, hepatitis, tumour)
  • Breast/Ovarian Cancers
  • Pregnancy, Postpartum < 6 wks
  • Smoker > 35 yrs or >15 cigarettes/day
  • Migraine with Aura; > 35 yrs
  • Diabetes with end organ damage, microvascular complications
68
Q

What pre investigations are required prior to contraception initiation?

A
  • Medical hx: including chronic medical conditions and current medications
  • Pregnancy test
  • Weight
  • Blood pressure for patients considering combined hormonal contraceptives (CHCs)
  • Bimanual examination and cervical inspection for patients considering intrauterine devices (IUDs), cervical cap or diaphragm
  • Sexually transmitted infection (STI) screening for patients considering intrauterine devices
69
Q

When would you recommend extended or continuous use contraceptives?

A

If the patient is experiencing unpleasant side effects.
The extended or continuous use can result in fewer bleeding days, and dec likelihood of pelvic pain, HA, bloating, swelling or tenderness, along with improved symptoms in endometriosis and PCOS

70
Q

Who would be a good candidate for Norethindrone (oral progestin)?

A

Norethindrone can be used in patients >35 years of age who smoke, cannot tolerate estrogen, have unwanted side effects with COCs, experience migraine headache with neurologic symptoms or are breastfeeding.

71
Q

Who would be a good candidate for Depot medroxyprogesterone acetate (DMPA)?
What are some important considerations with this med?

A

It may be a viable option for patients >35 years of age who smoke and for those who cannot
tolerate or have contraindications to estrogen.

Considerations: produces amenorrhea in the majority of patients, but some may experience irregular bleeding and side effects such as bloating, weight gain or loss, and mood swings.
Takes awhile to resume ovulation & regular mentraution post DC - therefore consider the pts preferences for childbearing
One study showed lower bone density in DMPA users when started <21 and long duration >15yrs *no strong evidence to support though

72
Q

How does the etonogestrel implant work?

A

The rod is inserted subdermally at the inner side of the
non-dominant upper arm. It is a progestin-only LARC - the implant works by continuously (over a period of 3 years) releasing a low-dose of progestin (etonogestrel), therefore inhibiting ovulation.
- return to fertility is expected within a couple of weeks of implant removal.
- suitable option in the management of dysmenorrhea, heavy menstrual bleeding and endometriosis associated pain.
- safe to be inserted immediately postpartum or
postabortion.
- Adverse effects include irregular bleeding and amenorrhea. Additionally, weight gain, acne, headache, breast tenderness and emotional lability have been reported.

73
Q

How does the levonorgestrel intrauterine system (LNG-IUS) work?

A

Upon insertion into the uterus, a low dose of of the levonorgestrel (progestin) is released continuously over a period of 5 years.
- Reduces menstrual blood loss, fibroid growth, dysmenorrhea and endometriosis pain. 20–30% of
patients will stop having periods. In fibroid-related menorrhagia, menstrual bleeding was reduced by 90% compared with a 13% reduction with COCs.
- Normal menstruation restarts within 1–3 months of IUS removal.
- The risk of expulsion higher in younger patients and early PP pts compared with older ones
- The most common adverse effect is occasional bleeding or spotting for the first 3 months after insertion. Treatment for spotting with NSAIDs or TXA (for the first 5–7 days of each 4‑week period)

74
Q

What are some risks associated with hormonal contraceptives?

A
  • Breast Ca (conflicting evidence)
  • CV risk (stroke, MI, VTE)
  • Depression (conflicting evidence)
75
Q

What signs should you educate your patient to look for when taking contraceptives?

A

Abdo pain (gallbladder, pancreatitis, hepatic adenoma, thrombosis)
Chest pain, SOB (MI or PE)
Headache (stroke, HTN, migraine)
Eye concerns (stroke, HTN, vascular insufficiency)
Severe leg pain (DVT)

*severe symptoms of each

76
Q

Which emergency contraceptive method is considered to be the most efficacious?

A

Copper IUD
- best option for high BMI (>30)
- canoe inserted 5-7 days post unprotected sex
- only EC option to provide ongoing contraception

77
Q

What are the oral options for emergency contraception? and when can they be taken?

A

Most common OTC - Plan B (levonogestrel)
- single dose 1.5mg or 2dose
- take within 72hrs
- less effective for wts >75kg
- SE: N/V, fatigue, dizziness
- can restart contraception 24 hrs post taking

Ella (Ulipristal acetate) *prescription
- 30mg x 1 dose
- can be taken up to 5d post unprotected sex
- favourable for those requiring contraception 72-120hrs post unprotected sex or BMI >25
- SE: N/V, HA, dysmenorrhea, abdo pain, fatigue, dizziness
- delay restarting COC for 5 days

Yuzpe Method (with certain OCs ie Alesse)
- 1 dose=ethinyl estradiol 100mcg/levonorgestrel 0.5mg Admin: 1 dose stat (e.g. 1 dose = 5 ALESSE pills), repeat in 12hr.
- beneficial to use if unable to access other options

78
Q

Which route is more effective for uncomplicated vulvovaginal candidiasis: vaginal or oral?

A

Equally effective

79
Q

What prevention treatment can be used to prevent yeast infections while on antibiotics?

A

oral or vaginal probiotics

80
Q

Do sexual partners have to be treated post sex with female with yeast infection?

A

Generally, sexual partners are not treated for candidal infection; however, a minority of male sex partners may experience balanitis
Monitor for symptoms

81
Q

When should yeast infection symtoms start to resolve once therapy has been initiated?

A

Within 7 days, if not see HCP, may need to extend treatment course

82
Q

At what age can oral canister be given for yeast infection treatment. What population should it not be used in?

A

> 12, do not give if pregnant or BF use vaginal instead

83
Q

Can vaginal canister be given if someone is menstruating?

A

Yes

84
Q

How is Depot (DMPA) administered?

A

IM

85
Q

Which contraception is associated with the highest wt gain?

A

Depo

86
Q

When should EC be considered if missed contraction doses/patches/rings?

A

For all missed cases with unprotected sex, along with having back up contraception for 7 days

87
Q

What to do if dose missed of contraception in week 1

A

Take missed dose ASAP and continue as per usual

88
Q

What to do if dose missed of contraception in week 2/3?

A

Take missed dose ASAP and skip/discard placebo pills for that cycle

89
Q

What to do if more than 1 dose is missed of contraception?

A

Take todays pill and last forgotten pill (2 pills in that day)

90
Q

A woman who has used any form of oral emergency
contraception should be advised that if she does not
have a normal menstrual period within weeks,
a pregnancy test should be obtained.
A. 1 to 2
B. 2 to 3
C. 3 to 4
D. 4 to 5

A

C. 3 to 4

91
Q

Emergency Contraception Mechanism of Action

A

Emergency Contraception Mechanism of Action
With Levonorgestrel (Plan B®, Plan B One Step®,
Candidates for Emergency Contraception Next Choice®) or Ulipristal (ella®)
Depending on time taken during menstrual cycle
■ Inhibit or delay ovulation (most likely effect)
■ Inhibit tubal transport of egg or sperm
■ Interfere with fertilization

Possible effect on endometrium:
■ With levonorgestrel use as emergency contraception,
minimal to no alteration to endometrium;
therefore, unlikely to inhibit implantation of a
fertilized egg.
■ With ulipristal use as emergency contraception,
changes in the endometrium can potentially alter
likelihood of fertilized egg implantation.

92
Q

T/F Use of oral hormonal emergency contraception will interrupt an established pregnancy

A

False: Use of oral hormonal emergency contraception will not interrupt an established pregnancy or increase risk of early pregnancy loss. If pregnancy does occur, use of this therapeutic method does not appear to be teratogenic.

thera 2 (9 decks)

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