Block 2 Flashcards
(294 cards)
1
Q
AE of SNRIs?
A
SSRI AE
+
Noradrenergic AE such as dry mouth, tachycardia, constipation. Venlafaxine worsens HTN and arrhythmias
2
Q
How does estrogen affect bone mass?
A
Stimulates osteoblast activity Decrease number of osteoclasts Prevents Ca2+ resorption from cortical bone
3
Q
Estrogen prevents the pituitary from producing _____
A
LH + FSH (ovulation won’t occur)
4
Q
Monitoring serum testosterone + IM testosterone undecanodate?
A
Right before 4th dose
5
Q
What are the therapeutic uses of androgens?
A
- Androgen replacement therapy 2. Breast cancer 3. Endometriosis 4. Female hypopituitarism 5. Anabolic therapy 6. Anemia
6
Q
Androgen AE?
A
- Inhibit gonodotropin release - suppress testicular function, decrease testicular size, testosterone release and lower sperm count 2. Acne 3. CV issues 4. Neuropsychiatric effects
7
Q
What are some indications for increased % of gestational diabetes?
A
- Macrosomia (>8 lbs)
- Neonatal hypoglycemia
8
Q
What is the treatment algorithm for heavy menstrual bleeding?
A
First find out if contraception is desired If no, give them NSAIDs If not effective consider TXA or progesterone If neither work, consider hormonal contraceptives, levonorgestrel-releasing system, or surgery If they wanted contraception, consider levonorgestrel-releasing system If not effective, consider oral contraceptives If that doesnt work, surgery
9
Q
To be considered prediabetic, what results do you need?
A
2 out of 3 positive results (HgbA1c, Fasting, or OGTT)
10
Q
Basic breakdown of uterine cycle
A
Menses ► Proliferative ► Secretory
11
Q
What are some pearls of norethindrone and norethindone acetate?
A
Raises HDL and lowers LDL
12
Q
What are the functions of amylin?
A
- Secreted w/ insulin
- Suppresses postprandial glucagon secretion
- Reduce food intake + maintain body wt
- slows gastric emptying + increases satiety
13
Q
Norethindrone or Norethindrone acetate are considered to be ____ gen
A
1st
14
Q
Type 1 vs 2 diabetes
Which one progressively loses beta cell function?
A
Type 2
15
Q
If you miss the last week of active pills on combined oral contraceptives, what should you do?
A
Omit the hormone-free stuff and finish the active drug tablets Use backup for 7 days. Counsel on emergency contraception
16
Q
Type 1 vs 2 diabetes
Which one has an increased % of micro and macrovascular disease?
A
Type 2
17
Q
What are the therapeutic uses of progestins?
A
- Hormone replacement 2. Contraceptive (planned or emergency) 3. Tx endometriosis and menstrual disorders
18
Q
What is the pathophysiology behind menopause?
A
- Estradiol goes down
- FSH + LH goes up
- Loss of ovarian follicular activity, so corpus luteum has to handle it all
19
Q
What are some pearls of drospirenone?
A
Fewer androgenic ADRs Higher risk of blood clots Hyperkalemia Approved for premenstrual dysphoric disorder
20
Q
When is a pregnancy test supposed to be used by?
A
Measured 1 wk after missed period
Measures hCG hormone
21
Q
What are some non-pharmacologic options for amenorrhea?
A
Too much exercise? Decrease it Calcium and Vit. D if hypoestrogenic
22
Q
20mcg of EE is found in Yaz or Gianvi, what progestin is found?
A
Drospirenone
23
Q
AE of progestin excess?
A
- Noncyclic weight gain* 2. Headache between pill pack* 3. Fatigue *Cyclic weight gain in estrogen *Headache during active pill in estrogen
24
Q
Monitoring of Alprostadil?
A
- First dose should be given under supervision 2. Take on an empty bladder 3. Max of 2 doses/day
25
What are the high risk categories to be prescribed oral contraceptives?
1. \<42 days postpartum + VTE risk factors 2. Breastfeeding ≤ 30days postpartum 3. Moderate risk for VTE 4. On ritanavir, rifampin, rifabutin, or anticonvulsants 5. Multiple CV risk factors
26
How long do you leave Nuvaring for?
Leave in place for 3 wks, then remove for 1 wk
27
What are some cautions with Bazedoxifene?
Exposure to obesity (BMI \>27) may have increassed risk of endometrial hyperplasia
28
Type 1 vs 2 diabetes
Which one has increased % of hyperosmolar hyperglycemia syndrome?
Type 2
29
What are the therapeutic uses of Ospemifene?
\*Agonist in vaginal epithelium and endometrium \*Antagonist in breast \*Treats dyspareunia (painful sex)
30
To treat amenorrhea, what is the whole algorithm?
1st = check to see if they are pregnant. If not, find underlying cause If anorexia or excessive exercise, consider psychotherapy. If that doesnt work consider estrogen If hyperprolactinemia, consider bromocriptine or cabergoline If unknown, use progestin to induce bleeding followed by estrogen/progestin therapy
31
Granulosa cells found in the ovary produce what?
Feed into progestins Converts to Inhibin, which negatively impacts the hypothalamus only Estrogens, which either go to target tissue or travels to CNS for behavioral effects
32
Contraindications of Alprostadil?
1. Pregnant partner 2. Sickle cell disease 3. Anticoagulants (warfarin, rivaroxaban, etc)
33
Gestational diabetes is diagnosed when?
2nd or 3rd trimester of pregnancy
34
Monitoring serum testosterone + buccal system?
Before dose
35
Beta cells found in the pancreas produce...
Both insulin and amylin
36
Which AE of contraceptives should you d/c immediately?
ACHES Abdominal pain Chest pain Headache Eye problems Severe leg pain
37
What are some absolute contrainidcations for hormonal therapy?
* Undiagnosed genital bleed
* Breast cancer
* Estrogen / Progesterone dependent neoplasia
* VTE
* Heart issues
* Liver issues
38
Type 1 vs 2 diabetes
Which one has a % of diabetic ketoacidosis?
Type 1
39
If patient is on anticonvulsants and oral contraceptives, what could they do?
Besides d/c, you can switch to another form of contraception Depot medroxyprogesterone or IUDs
40
Where is the primary location for insulin resistance?
Skeletal muscle
41
What creams can decrease latex strength of condoms?
Cleocin, Premarin, and Monistat
42
What are the intra-vaginal estrogen formulations?
Mix of creams, ring, and tablet
_Cream_
* Premarin - conjugated estrogen
* Estrace - 17 ß-estradiol
_Ring_
* Estring - 17 ß-estradiol
_Vaginal tablet_
* Vagifem - Estradiol hemihydrate
43
Abrupt decline in ______ induces menstruation
Progestins
44
What class increase thick cervical mucus secretion?
Progestins
45
What is the first line Tx for erectile dysfunction?
PDE inhibitors
46
MOA of Alprostadil?
Stimulates adenylyl cyclase, which increases cAMP production, which decreases Ca 2+, causing arterial blood vessel relaxation
47
Type use of oral contraceptives are \_\_\_% effective
92
48
ACHES side effects refer to what kind of contraceptives?
Oral
49
What are some advantages of Annovera over Nuvaring?
1. no refrigeration 2. used for 13 cycles 3. Cannot be removed for more than 2 hrs during 21 day cycle
50
How does Goserelin work?
Analog of GnRH - injection Initially increases serum lvls of LH and FSH which will lead to suppression of those sex hormones Tx endometriosis AE = hot flash, sexual dysfunction, diarrhea
51
What is a normal testosterone level?
300 to 1,100
52
Type 1 vs 2 diabetes
Which one is associated w/ weight loss?
Type 1
53
Pearls of Amethyst?
28 days w/o placebos - all active pills
54
What are some pearls of desogestrel?
Slight increase % of thrombosis Fewer androgenic ADRs
55
What is the characteristic of ovary (follicles) during the control of the menstrual cycle?
Develops female sex characteristics Thickens endometrium for pregnancy Antagonizes PTH Increase blood clotting
56
AE of testosterone?
1. Gynecomastia (mostly in obese or pt w/ liver cirrhosis) 2. Hepatotoxicity (oral) 3. Polycythemia (stop ins and replace w/ transdermal)
57
20mcg of EE is found in "drug" 24 or 1/20, what progestin is found?
Norethindrone acetate
58
What happens if you displace the Nuvaring?
\<3hrs = no backup, rinse and re-insert ≥3hrs? = insert new ring and use backup for 7 days During 3rd week? = skip hormone free and insert new ring
59
Estradiol vs Progestin only pills Which must be taken continuously (no placebo tablets are found)?
Progestin
60
What are some counseling points with Andoderm?
1. Rotate application site q7days 2. Avoid swimming/showering/washing for 3 hrs after patch application
61
What is the Tx algorithm for HRT on someone who has NOT tried 3 months of lifestyle modifications + has moderate to severe hot flashes and/or night sweats?
* First find out if they have any genitourinary symptoms
* If **no**, avoid hormone therapy
* If **yes**, find out if they have breast/endometrial cancer or any other hormonal-sensitive cancer
* Yes = Vaginal lubricant/moisturizer
* No = Vaginal lubricant/mositurizer +/- low dose vaginal estrogen or ospemifene
62
What self-monitoring tool detects baseline chloride ion levels peaks?
OV-Watch Fertility Predictor
63
If you miss one tablet of progestin-only pill, what should you do?
If it is more than 3 hrs late, backup should be used for 48hrs
64
Type 1 vs 2 diabetes
Which one has relative insulin deficiency?
Type 2
65
Type 1 vs 2 diabetes
Which one has Autoimmune beta cell destruction?
Type 1
66
AE of Alprostadil?
Penile pain + urethral burning
67
Which self-monitoring tool identifies up to 6 fertile days for women?
Clearblue Ferility Monitor
68
20mcg Drospirenone, what's the brand?
Yaz or Gianvi
69
What are the progestogen only Rx for HRT?
* 1st Gen
* Norethindrone, norgestrel (2nd as well)
* 2nd Gen
* Levonorgestrel, MPA
* 4th Gen
* Drospirenone
* Micronized progesterone
Provera - MPA
Aygestin - Norethindrone
Prometrium - Micronized progesterone
70
When is it recommended and not recommended to screen for T1DM?
* Appropriate = research trials, first-degree family members with T1DM
* Not recommended = asymptomatic general population
71
What AE do hormonal contraceptives cause?
Breast tenderness, fluid retention, spotting
72
How would you assess ASCVD risk since menopause onset?
* \> 10 yrs ► AVOID HORMONAL THERAPY
* \< 10 yrs ► calculate risk
* \<5% = gucci
* 5 - 10% = consider transdermal
* \>10% = AVOID HORMONAL THERAPY
73
What is the characteristic of ovary (corpus luteum) during the control of the menstrual cycle?
Prepares endometrium for pregnancy Inhibits contraction of uterus Inhibits development of new follicles
74
Androgens (promotes/inhibits) FSH and LH release
inhibit + develop male sex organs and increase bone/muscle growth
75
Testing for prediabetes and/or T2DM should be considered in children (aged 10+ or after puberty) when...
* BMI ≥85th percentile (overweight) or ≥95th percentile (obese)
* 2+ additional risk factors (1+ in adults only)
76
Why is there a sudden increase of LH on day 14?
Estrogen is produced by dominant follicle, also causes FSH to go down slightly
77
Contraindications and Flibanserin?
1. Alcohol 2. Using CYP3A4 inhibitors \*Start Flibanserin 2 wks after CYP3A4 inhibitor \*\*Start CYP3A4 inhibitor 2 days after last dose of Flibanserin 3. Hepatic impairment D/C after 8 wks of no improvement
78
What are the 1st Gen select progestin oral contraceptives?
Norethindrone and norethindone acetate Norgestrel (also considered Gen 2)
79
What is primary amenorrhea?
Absence of menses by 15 yrs old with otherwise normal secondary sexual development
80
Day 0 of menstrual cycle, which one has a higher level FSH or LH?
FSH
81
How is Clomiphene dosed?
1. 50mg daily x5days, if no ovulation, continue
2. 100mg daily x5days, if no ovulation , repeat
3. 100mg daily x5days, continue for 6 cycles
4. Consider alternative Tx
82
What are the therapeutic uses of estrogens?
1. Hormone replacement (hot flash, vaginal dryness, urogenital atrophy, or osteoporosis) 2. Contraceptive (by suppressing LH surge and prevent ovulation
83
How does vomiting/diarrhea affect oral contraceptives?
V/D \<48hrs = no redoes V/D \>48hrs = use back for 7 days after V/D subsides V/D is on the last week = skip placebos and begin new pack + use backup for 7 days
84
Which ADR of contraceptives have a higher % of thrombotic risk?
Transdermal (has higher estrogen exposure)
85
What is HgbA1c? When does it lose accuracy?
Marker for glycemia over 3 months
Loses accuracy in anemia, pregnancy, or hemodialysis
86
How does estrogen affect lipids?
Increase HDL Decrease LDL Decrease cholesterol Increase TG
87
What is the function of the uterus, fimbriae and ovary?
Uterus - where eggs implant and develop during pregnancy Fimbriae - tissue that swells during ovulation to facilitate egg release into Fallopian tube Ovary - egg producing organ
88
What are the clinical uses of Clomiphene? Place in therapy?
1. Induce ovulation
2. Secondary hypogonadism
Useful for PCOS/Anovulation + test for ovarian reserve
89
When is fasting + random blood glucose testing preferred?
To those w/ increased RBC turnover
EX: sickle cell, second + third trimester pregnancy, hemodialysis, blood loss, erythropoietin therapy
90
20mcg Levonorgestrel, what's the brand?
Lutera or Aviane
91
AE of Gabapentin?
1. Somnolence
2. Dizziness
92
What are the general non-hormonal Rx for HRT?
1. Vaginal lubricants/moisturizers
2. SSRIs + SNRIs
3. Gabapentin, Pregabalin, clonidine
93
What are the functions of incretin?
* Includes GLP-1 + Gastric inhibitory polypeptide (GIP)
* Only GLP-1 inhibits glucagon secretion
* Stimulates postprandial insulin secretion
* Released in response to oral glucose
* Degraded by DPP-4
94
What hormones do the anterior pituitary stimulate for the menstrual cycle?
Estrogen - to stimulate growth of immature ovarian follicles in ovary Progesterone - trigger ovulation + development of corpus luteum
95
What are some counseling points with Androgel?
1. Apply in the morning 2. Site of application should not be washed for 4 to 6 hours to prevent reduced absorption or transfer of drug
96
AE of Pregabalin?
1. Sedation
2. Dependence
3. Dizziness
4. Headache
97
What happens if you forget to use the Nuvaring?
As long as the total time is ≤4 wks, you Gucci, no backup needed
98
Type 1 vs 2 diabetes
Which one contains absolute insulin deficiency?
Type 1
99
FSH from the anterior pituitary promotes the production of what in the ovary?
Only Granulosa cells
100
MOA of aromatase inhibitors?
Inhibits conversion of androgens to estrogens
101
What are the therapeutic uses of Raloxifene? AE?
Agonist in bone cells Treat/prevent osteoporosis Antagonist in breast and uterus Reduction in risk of invasive breast cancer AE = hot flash
102
What are the common symptoms of diabetes?
1. Polyuria
2. Polydipsia
3. Polyphagia
103
What are some issues surrounding progestin only contraceptives?
1. Taken continuously w/o placebo 2. Taken at the same time every day (3hr delay = backup method x48 hrs) 3. May not block ovulation
104
AE of estrogen?
1. Carcinogenicity (endometrium and breast) 2. CV disease
105
What is the incretin effect?
* Greater insuilin effect due to oral glucose intake vs IV intake
106
AE of Clonidine?
1. Dizziness
2. Drowsiness
3. Hypotension
4. Dry Mouth
107
Testing for prediabetes and/or T2DM in asymptomatic ppl should be considered of any age who...
* BMI ≥25 or ≥23 in Asian Americans
* 1+ additional risk factor for diabetes (2+ in children)
108
Pathophysiology behind Polycystic ovarian syndrome (PCOS) includes what?
* Increase androgen ► increase testosterone
* Increase insulin due to resistance (glucose up as well which results in wt gain
109
Rifampin and oral contraceptives have an interaction, how long should you use the backup for after d/c?
7-28 days
110
Progesterone vs Estrogen Which one thickens the cervical mucus which hinders sperm travel?
Progesterone
111
What are the main categories that cause infertility for women?
1. Hypothalamic-pituitary failurek
2. HPO axis (85%)
3. Ovarian failure
Primary cause - ovulatory DYSFUNCTION
112
Whats the definition of dysmenorrhea?
Pelvic pain prior to or concurrent with menses
113
Which select progestins are the most to least androgenic?
Most = Levonorgestrel 2nd most = Norgestrel Middle = Norethindrone w or w/o acetate, norgestimate, and desogestrel Least = Drospirenone and segesterone acetate
114
115
What are the AE associated with androgenic progestins?
1. Acne/oily skin 2. Noncyclic Wt gain 3. Hirsutism 4. Fatigue 5. Depression
116
Besides using aromatase inhibitors or clomiphene, what alternatives are there to help with ovulation?
Metformin + Pioglitazone (thiazolidinediones)
117
Planned contraceptives contain (estrogen/progestin)
Progestins w/ or w/o estrogen
118
If you miss one tablet or are late on combined oral contraceptives, what should you do? Two tablets missed/late?
One tablet = take one as soon as you remember. Take rest of the pack as prescribed. Typically no backup needed Two tablets = take one as soon as you remember. Throw away remaining missed tablets. Take rest of pack as prescribed (Two may need to be taken at the same day, one for missed dose and another for scheduled dose). Use back up for 7 days. Counsel on emergency contraception
119
50mcg Norethindrone, what's the brand?
Necon 1/50
120
What are the general Rx (hormonal) Tx for menopause?
1. Estrogen
2. Estrogen w/ Progesterone
121
What are the second and third line Tx for erectile dysfunction?
Intracavernosal and intraurethral alprostadil
122
Basic breakdown of ovarian cycle
Follicular ► Lutueal
123
What are the select estrogen based contraceptives?
Ethinyl estradiol + mestranol
124
With the hypothalamus-pituitary-ovarin axis, how is amenorrhea started?
Stress causes hypothalamus to not secrete GnRH Dopaminergic Rx or thyroid disease cause altered secretion of LH and FSH Ovarian failure or Uterus obstruction
125
Norgestrel is considered to be ____ gen
1st or 2nd
126
What are the oral **estrogens** for HRT?
* Premarin - dosed daily
* Menest - dosed daily for 3 wks, then 1 wk off
127
Which oral contraceptive has 10mcg of EE content?
Lo Loestrin Fe - Norethindrone acetate
128
What is fasting?
No caloric intake for at least 8 hrs
129
What are the transdermal estrogen formulations?
* Alora, Climara, Estraderm, Minivelle/Vivelle - 17 ß estradiol
* Most twice weekly
130
Women should get a lower dose of oral contraceptives if...
1. Underweight 2. \>35 yrs old 3. Perimenopausal
131
What should you do if you missed a patch exchange?
Delayed by \<48 hrs w/ old patch still on? = no backup and apply new patch ASAP Delayed ≥48hrs? = new patch ASAP and backup for 7 days On third week? = omit hormone-free week and apply new patch ASAP
132
What are some pearls of segesterone acetate?
Approved in one-year ring product
133
AE of Leuprolide?
Vaginal dryness, hot flash, bone density loss
134
Pros and Cons of topical estrogen?
Pros
* Limited systemic absorption and AE
Cons
* Variability in Rx absorption
135
What are some pearls of diaphragms?
88% effective \*Reusable \*\*Requires sizing and RX \*\*\*Can insert ≤6hrs prior to intercourse and must leave in for 6-24hrs after (48hrs for cervical caps) \*\*\*\*Does NOT protect against STIs
136
What are the contraindications to SSRI/SNRIs?
1. Neuroleptic Malignant Syndrome
2. Serotonin Syndrome
3. Concurrent MAOI use
4. Hypersensitivity
137
For non-pharmacologic Tx of menopause, how long of a period should you see if symptoms improve?
For any severity, trialed for 3 months
138
What is the continuous (non-cyclic) estrogen-progestogen for HRT?
* Both estrogen + progestogen are administered for 28 days
* Leads to endometrial atrophy and NO vaginal bleed
139
What are the therapeutic uses of Clomiphene? AE?
Primarily antagonist in pituitary and hypothalamus Binds to estrogen receptor Increases release of gonadotropins (FSH + LH) to induce ovulation - induces ovulation AE = Ovarian enlargement + hot flash
140
AE of progestin deficiency?
1. Weight loss 2. Heavy menstrual bleed 3. Late cycle breakthrough bleed\* \*Early/mid = estrogen deficiency
141
Which Rx can cause infertility?
* NSAIDs
* Spironolactone
* Thyroid Rx
* Narcotics
* Sulfasalazine
* Chemos
* Antipsychotics + Antiepileptics
* Steroids
* Recreational stuff
142
What are the selective estrogen receptor modulators (SERM) drugs?
Ends w/ "fene" or "phene" Raloxifene Bazedoxifene Ospemifene Clomiphene
143
What are the macrovascular complications associated w/ diabetes?
1. Coronary heart disease
2. Stroke
3. Peripheral arterial disease (feet)
144
AE of estrogen deficiency?
1. Early - mid breakthrough bleed\* 2. Decreased libido 3. Vasomotor symptoms 4. Dry vaginal mucosa 5. Headaches \*Late cycle = progestin deficiency
145
What are the non pharmacological options for premenstrual dysphoric disorder (PMDD)?
Attempt lifestyle intervention for 2 months while keeping a symptom journal Decrease sodium, caffeine, and sugar\* Increase exercise\* \*insufficient evidence
146
What is the Black Box Warning on Ospemifene (Osphena)?
Increased risk for endometrial hyperplasia + endometrial cancer, stroke, and VTE
147
Day 14 of menstrual cycle, which one has a higher level? FSH or LH?
LH
148
When initiating oral contraceptives, when should the start date be?
1. First day of bleeding 2. First Sunday after menstrual cycle begins 3. 5th day after menstrual cycle begins
149
Plasma glucose is maintained at what level?
70 to 100mg/dL
150
What are some pearls of spermicide?
85% effective \*apply 10 min before intercourse \*\*effective for 1hr \*\*\*Does NOT protect against STIs
151
Drospirenone is considered to be ____ gen
4th
152
General oral contraceptive AE?
1. No protection from STIs 2. Small increase in BP 3. Thromboembolism\* \*Estrogen increase factor VII and X, and fibrinogen 4. Breakthrough bleeding 5. Weight gain
153
Progesterone prevents the pituitary from producing \_\_\_\_
LH (ovulation won't occur)
154
How does Clomiphene work on females and males?
* Females = follicular growth + rupture
* Males = increase testosterone and sperm count
155
Theca cells found in the ovary produce what?
Androgens which feed into granulose cells Progestins which loops back to the hypothalamus and anterior pituitary as well as goes to target tissue
156
What are the 2nd Gen select progestin oral contraceptives?
Norgestrel (also considered Gen 1) Levonorgestrel
157
What is the intermittent estrogen-progestogen for HRT?
* 3 days of estrogen ► 3 days of progesogen ► repeat
* Lower risk of bleed
158
What is secondary amenorrhea?
Absence of menses for 3 cycles in previously menstruating women
159
What are the concerns with using oral contraceptives and being postpartum?
1. Those women are hyper coagulable 2. OC may interfere w/ lactation 3. Avoid estrogen for 21 days after birth 4. Consider only progestin only OC
160
Monitoring serum testosterone + IM testosterone cypionate or enathate?
Midpoint of dosing interval
161
What are the SERM Rx for HRT?
1. Duavee - Conjugated estrogen + Bazedoxifene
2. Osphena - Ospemifene
162
What are the unacceptable risk categories to be prescribed oral contraceptives?
1. \<21 days postpartum 2. Breast cancer (current) 3. Decompensated cirrhosis 4. High risk for VTE 5. Heart issues 6. Migraines w/ aura
163
What should you do if detachment occurs with transdermal contraceptives?
\<24hrs? = no backup, new patch ASAP or reapply old patch \>24hrs? = new patch ASAP + backup for 7 days If on 3rd week? = omit hormone-free week and apply new patch ASAP
164
What are the doses of ethinyl estradiol?
10 to 50mcg ≤20 = ultra low ≤35 = low ≥50 = high
165
What are some pearls of norgestimate?
Slight increase % of thrombosis Fewer androgenic ADRs Approved for acne
166
What abortifacients are used to induce abortion?
First, Mifepristone (blocks progesterone) - effective for 10wks after first day of last period Second, Misoprostol (induce uterine contraction) - expect cramps and heavy period Premedicate with ibuprofen 30min prior to misoprostol Use anti-nausea and/or heating pads NO ASPIRIN!
167
What are the hormonal Tx options for someone w/ an intact uterus?
* Estrogen
* Estrogen w/ Progesterone
168
Segesterone acetate is considered to be ____ gen
4th
169
Which oral contraceptive has 50mcg of EE content?
Necon 1/50 (Norethindrone)
170
10mcg of EE is found in Lo Loestrin FE, what progestin is found?
Norethindrone acetate
171
What are the vaginal estrogen formulations?
* Femring
* changed every 3 months
* **delivers estrogen systemically**
172
What class does Danazol (Danocrine) belong to?
Weak androgen agonist
173
What is the 1st line pharmacologic therapy for premenstrual dysphoric disorder (PMDD)?
SSRSs; will see effect within 2 cycles Concern w/ paroxetine due to congenital effects ADRs = sedation, sexual dysfunction
174
What are the diabetic HbA1c, fasting plasma glucose, and oral glucose tolerance test values?
* HBA1c = ≥6.5
* Fasting = ≥126
* OGTT = ≥200
175
Conception is most effective from what days?
Days 12-14
176
What does the dominant follicle eventually become? What is its function?
Corpus luteum Produces progesterone (to prepare endometrium for pregnancy, thicken cervical mucus and elevate body temp) Produces Estrogen
177
When is the oral glucose tolerance test preferred?
* Gestational diabetics
* Post transplantation
* Cycstic fibrosis-related diabetes
178
20mcg Norethindrone acetate, what's the brand?
Look for 24 or 1/20
179
What is the continuous long-cycle estrogen-progestogen for HRT?
* Estrogen is admin daily
* Progestogen is co-admin 12-14 days of the 28 day cycle every other month
* Results in 6 periods / year
* Decreases incidence of withdrawal, but there may be heavier bleeds
180
What is the definition of heavy menstrual bleeding?
Blood loss \>80mls/cycle Bleeding \>7days/cycle
181
What are the main categories that cause infertility for men?
1. Hypogonadism
2. Erectile and ejaculatory dysfunction
3. Anatomical abnormalities
182
Which selection progestins have the most estrogenic property?
Norethindrone w or w/o acetate
183
What are some pearls of norgestrel?
Androgeneic ADRs are common
184
10mcg Norethindrone acetate, what's the brand?
Lo Loestrin Fe
185
What are the SSRIs and SNRIs used for HRT?
SSRIs
* Brisdelle or Paxil (Paroxetine)
* Fluoxetine
SNRIs
* Effexor (Venlafaxine)
* Pristiq (Desvenlafaxine)
186
How would you administer Flibanserin?
Bedtime for reduce hypotension and CNS depression
187
If one PDE-5 inhibitor does not work, what do you do?
You can try using another PDE-5 inhibitor rather than moving to a second-line agent
188
What are some pearls of levonorgestrel?
Most widely prescribed Negative impact on lipids Used for emergency contraception
189
What are some non-pharmacologic options for dysmenorrhea?
1. Heat 2. Exercise 3. Low fat vegetarian diet 4. Powdered ginger (reduce pain) 1-3 decrease intensity
190
What are some pearls of sponges?
91% effective to those that never gave birth 80% effective to those who did \*contains 1g of nonoxynol-9 \*\*Moisten w/ water, insert ≤6hrs prior to intercourse, and must leave in 6-24hrs after (48hrs for diaphragms) \*\*\*effective for multiple acts of intercourse within 24hrs \*\*\*\*Does NOT protect against STIs
191
Monitoring serum testosterone + Transdermal gel?
Anytime after first 1-2 wks of continuous use
192
PDE-5 inhibitors + Vardenafil, what happens?
QT interval prolongation; monitor therapy
193
What are the benefits and risks of long-term hormonal replacement therapy?
_Benefits_
* Alleviates symptoms
* Decreased fractures
* Decreased colorectal cancers
_Risks_
* Heart issues
* Breast cancer
194
Texas requires parental consent for prescription contraception unless...
1. Married 2. 16/17 yrs old, lives apart from parents, AND manages own finance 3. Emancipated from parental guardian 4. On medicaid
195
When should you consider changing contraceptives if you have breakthrough bleeding?
Btw, it is expected If it lasts longer than 6 months
196
What Rx are the GnRH agonists/antagonists?
1. Leuprolide 2. Elagolix 3. Goserelin
197
What is the most potent estrogen type?
Estradiol
198
What is the ovarian cycle?
Follicular phase: Follicular growth period in ovary (10days to 3wks) Ovulation: 1+ ripened follicle is released by ovary Luteal phase: Ruptured follicle -\>Corpus luteum secretes hormones to prepare for pregnancy \*\*if no pregnancy occurs, corpus luteum stops working after 2 wks
199
Estrogen and Progesterone are dominant in which phase of the ovarian cycle?
Estrogen for follicular Progesterone for luteal, estrogen is present however
200
Norgestimate is considered to be ____ gen
3rd
201
AHA recommendations of PDE-5 inhibitors and peeps w/ CVD?
Useful only to those with STABLE CVD
202
What are the subcategories that result from HPO axis failure that results in infertility?
1. Polycystic ovarian syndrome (PCOS)
2. Hyperprolactenemia
203
Pros and Cons of transdermal estrogen?
Pros
* Less risk of breast tenderness, heart issues compared to PO
Cons
* Compliance + skin irritation
204
What are the normal HbA1c, fasting plasma glucose, and oral glucose tolerance test values?
* HBA1c = about 5.7
* Fasting = ≤99
* OGTT = ≤139
205
When would you use non-hormonal therapy for HRT?
* Mild symptoms
* Contraindications from moderate-severe
* Patient preference
206
What are aromatase inhibitors used for? AE?
1. Tx breast cancer in menopausal women 2. Treat endometriosis 3. Treat gynecomastia in men AE = hot flash, joint pain, bone fracture, wt gain, headache
207
Levonorgestrel is considered to be ____ gen
2nd
208
What physical factor can contribute to a higher % of pregnancies even with oral contraceptives? Mechanism?
Obesity Mechanism: Increase basal metabolic rate, increases liver enzymes, lowers serum concentration of contraceptives Issue with low dose oral contraceptives
209
AE of injectable progestins?
1. Short term bone loss 2. Return of fertility may be delayed 3. Can receive immediately postpartum if not breastfeeding
210
What is the concern with using vaginal lubricants and moisturizers for HRT?
Oil-based stuff may weaken latex condoms
211
What is the continuous cyclic estrogen-progestogen for HRT?
* Estrogen is admin. daily continously
* Progesogen is co-admin for 12-14 days of the 28 day cycle
* Scheduled withdrawal bleed in most women 1-2 days after progestogen stops
212
What are the general lab values for secondary hypogonadism in men?
* Low T
* Low or normal LH + FSH
213
Alpha cells found in the pancreas produce....
Glucagon
214
What are the intracellular receptors for estrogen?
ERalpha ERbeta Both are not always expressed in same tissue ERalpha is predominant for growth regulation
215
What are the microvascular complications associated with diabetes?
1. Retinopathy
2. Neuropathy
3. Nephropathy
216
What is the oral glucose tolerance test?
Having no food/drink for 8 to 12 hrs, then having exogenous glucose intake, and then plasma blood glucose levels are checked
217
When does your basal body temperature begin to drop during the menstrual cycle? Increase?
Day 14 - lowest After Day 14 it goes up much higher
218
What Rx is indicated for hypoactive sexual desire disorde in premenopausal women? MOA?
Flibanserin 5HT1A and 2A antagonist
219
When managing with ADR of oral contraceptives, how long should you wait before changing?
≥3months
220
What antagonizes the parathyroid hormone in the control of menstrual cycle?
Ovary (follicle)
221
What are the prediabetic HbA1c, fasting plasma glucose, and oral glucose tolerance test values?
* HbA1c = 5.7 to 6.4
* Fasting = 100 to 125
* OGTT = 140 to 199
222
What are the therapeutic uses of Bazedoxifene?
Antagonist in uterus
If added w/ conjugated estrogens (Duavee), reduces risk of endometrial hyperplasia
223
What are the oral estrogen formulations?
* Premarin - Conjugated **estrogen**
* Dosed daily
* Femtrace - **Estradiol** acetate
* Dosed daily
* Estrace - Micronized **estradiol**
* Dosed daily, but 3 wks on and 1 wk off
* Menest - esterified **estrogens**
* Dosed daily, but 3 wks on and 1 wk off
224
Pros and Cons of vaginal estrogen formulations?
Pros
* Less systemic exposure, so less AE
* Decrease vaginal pH ► less risk of UTI
Cons
* Treats urogenital atrophy only
* AE = VVC, vaginal bleed, breast pain, nausea
225
What are some pearls of female condoms?
79% effective Patient complains of noise
226
Monitoring serum testosterone + Transdermal patch?
3-12 hrs after patch application
227
What is the effective % of the withdrawal method?
70%
228
What are the instructions of use for transdermal contraceptives?
1. Apply to abdomen, butt, upper torso, or upper arm 2. Apply at beginning of menstrual cycle 3. Replace weekly and be patch-free on week 4
229
50mcg of mestranol is found in Necon 1/50, what progestin is found?
Norethindrone
230
Which contraceptive uses mestranol instead of EE?
Necon 1/50 (Norethindrone progestin)
231
What are some Rx associated w/ hyperglycemia?
1. Glucocorticoids
2. Nicotinic acid or Niacin
3. Thyroid rx
4. Beta adrenergic agoinsts
5. Thiazide diuretics
6. Phenytoin
7. Protease inhibitors
8. Atypical antipsychotics
232
What is the treatment algorithm for dysmenorrhea?
First try non-pharmacological stuff like heat pad If not effective, try monthly NSAIDs If not effective, try hormonal contraceptives for 2-3 cycles If not effective, try depo shot or levonorgestrel-releasing system
233
Monitoring serum testosterone + testosterone SubQ implant?
1-4 months after implantation
234
What are some lifestyle modifications for Tx of menopause?
* Lowering room temp.
* Decrease spicy foods, caffeine, hot items, alcohol
* Smoking cessation
* "Paced" respiration
235
What is the effective % of condoms?
82% due to spillage or perforation Use water-soluble lubricants only
236
What class of drugs can cause or exacerbate erectile dysfunction?
Antihypertensives + Antidepressants
237
What does insulin maintain in adipose tissue?
Insulin stimulates uptake and storage of FA (inhibits lipase)
238
Alcohol + PDE-5 inhibitors, which ones are affected?
Only avanafil (3) and tadalafil (5)
239
What are the combination estrogen + progestogen Rx for HCT?
Oral
* Prempro - Conjugated estrogen + MPA
Transdermal
* CombiPatch - Estradiol + Norethindrone
240
Which oral contraceptive has 20mcg of EE content?
Brand names? Look for 24 Fe or 1/20 - Norethindrone acetate
Yaz + Gianvi - Drospirenone
Lutera + Aviane - Levonorgestrel
241
What is infertility?
- Failure to conceive after 12 months of regular, unprotected sexual intercourse (\<35 yrs old)
- 6 months for ≥35yr olds
242
What happens around day 26 of the menstrual cycle in regards to the corpus luteum?
Apoptosis, egg passes through Fallopian tube and decreases estrogen and progesterone Removes negative feedback on hypothalamus and with the decrease of progesterone, menstruation occurs
243
What are the subcategories that result from hypothalamic-pituitary failure that results in infertility?
1. Amenorrhea
2. Low gonodatropin levels
244
How many doses of PDE-5 inhibitors should you take before you declare it as a non-viable option?
At least 5 to 8
245
How many doses of PDE-inhibitors can you have in one day?
Just one
246
During the menstrual cycle, when does progesterone increase?
A little after day 14
247
How does Leuprolide work?
Analog of GnRH - injection Initially increases serum lvls of LH and FSH which will lead to suppression of those sex hormones Tx endometriosis AE = hot flash only
248
Backup method for oral contraceptives must be used for ___ days
≥7 days
249
What is the pathophysiology behind dysmenorrhea?
Primary - prostaglandins and leukotrienes are released into menstrual fluid which cause inflammation and vasoconstriction
250
What are some special characteristics of mestranol?
Must be activated by liver
251
Desogestrel is considered to be ____ gen
3rd
252
If a patient has met the criteria for T1DM, what needs to be done next?
1. C-peptide or insulin level needs to be drawn
2. If insulin deficient, ß-cell auto AB will be tested for BG rather than HgbA1c
253
What kind of condom is NOT impermeable to viruses?
Lamb intestine
254
When d/c oral contraceptions to return to fertility, how long is ovulation delayed?
Typically 1-2 wks If it continues for \>6 months, see physician
255
Pearls of Yaz, Gianvi, Loestrin 24, Beyaz?
Only has 24 tablets, causes lighter, shorter menses
256
When should injectable progestins be administered?
Within 5 days of bleeding every 3 months \*\*97% effective
257
What are the (minor) risk factor categories to be prescribed oral contraceptives?
1. Age ≥40 yrs old 2. Sickle cell 3. Untreated cervical cancer 4. DM 5. Major surgery 6. Migraines
258
20mcg of EE is found in Lutera or Avaiane, what progestin is found?
Levonorgestrel
259
What is included in the male fertility assessment?
* Abstinence from ejaculation (48-72 hours)
* Minimum of 2 samples (wait 3 months before 2nd sample)
260
What are the 4th Gen select progestin oral contraceptives?
Drospirenone Segesterone acetate
261
What are the hormonal Tx options for someone w/ a hysterectomy?
Only estrogen
**NO PROGESTERONE**
262
PDE-5 inhibitors + alpha 1 antagonists, what happens?
Consider therapy modification; hypotensive episode
263
Progesterone vs Estrogen Which one supports uterine lining to prevent breakthrough bleeding?
Estrogen
264
What is the uterine cycle?
Menses: Corresponds to beginning of follicular phase \*\*Menstrual bleeding from uterus Proliferative phase: Corresponds w/ later part of follicular phase \*\*Endometrium adds a new layer of cells in anticipation for pregnancy Secretory phase: Corresponds w/ luteal phase \*\*Corpus luteum converts endometrium into secretory structure \*\*Layers are lost during menstruation if pregnancy doesn't occur
265
What are some pearls of cervical caps?
86% effective to those that never gave birth 71% effective to those who did \*Requires sizing and RX \*\*Fill with spermicide prior to insertion \*\*\*Can insert ≤6 hrs prior to intercourse and must leave in 6-48hrs afters (24hrs for diaphargms and sponges) \*\*\*\*Does NOT protect against STIs
266
How does Elagolix work?
GnRH receptor antagonist Tx pain associated w/ endometriosis AE =hot flash, bone loss, menstrual pattern change
267
What is the policy on ADA screening for gestational DM?
* Test at first prenatal visit in those w/ risk factors
* Test at wks 24-28 of gestation in pregnant women not previously known to have diabetes
* Test women w/ gestational DM for prediabetes/diabetes at wks 4-12 postpartum using 75g oral glucose tolerance test
* Women w/ history of gestational DM should have lifelong screening at least every 3 yrs
268
What is Ovarian Hyper-stimulation Syndrome?
Caused by excess response to FSH or Clomiphene which produce large amounts of estrogen and progesterone
269
What is the Tx algorithm for HRT on someone who has tried 3 months of lifestyle modifications + has moderate to severe hot flashes and/or night sweats?
* First find if they have any contraindications for hormonal therapy
* If **no**, do they have a prior hysterectomy?
* Yes = estrogen
* No = estrogen + progesterone or estrogen + bazedoxifene
* If **yes**, do they have any contraindications to SSRI/SNRIs?
* Yes = consider gabapentin, pregabalin, clonidine
* No = SSRI/SNRI
270
Estradiol vs Progestin only pills Which is more effective
Estradiol
271
What are some counseling points on placebo pills in contraceptives?
Encourage pt to take them to enhance adherence
272
MOA of PDE-5 inhibitors?
Inhibits PDE-5, therefore blocks breakdown of cGMP and resulting in vasodilation
273
Which select progestins have the most to least progestational properties?
Highest = Levonorgestrel, Desogestrel 2nd highest = Norgestrel 3rd highest = Northindrone w or w/o acetate Lowest = Drospirenone and segesterone acetate
274
Pros and Cons of oral estrogen
PRO
* Patient acceptance
CON
* Nausea, headache, breast tenderness, bleed
* Serious AE = increased risk of heart issues, breast cancer, gallbladder disease
275
LH from the anterior pituitary promotes the production of what in the ovary?
Theca cells and Granulosa cells
276
Progestins (promotes/inhibits) FSH and LH release
inhibits
277
What are the pharmacologic options for premenstrual dysphoric disorder (PMDD)?
Vitamins/Minerals (Vit. B6 + calcium carbonate) SSRIs SNRIs Hormonal contraceptives Leuprolide
278
What is the pathophysiology behind premenstrual dysphoric disorder (PMDD)?
Differs from major depressive disorder MIGHT be due to low levels of progesterone metabolite allopregnanolone in luteal phase and/or cortical gamma-aminobutyric acid levels MIGHT be due to low serotonin levels
279
Where is SGLT-2 found in the body? Purpose?
Proximal tubules
Reabsorbs 90% of urinary glucose
280
How long is Nuvaring good for outside the fridge?
4 months
281
What are the 3rd Gen select progestin oral contraceptives?
Norgestimate Desogestrel
282
AE of estrogen excess?
1. Cyclic weight gain\* 2. Uterine cramps 3. Headache during active pill\* 4. Bloating 5. Edema 6. Nausea \*Noncyclic wt gain in progestin and androgen excess \*Headache between pill pack in progestin
283
What are the oral estradiols for HRT?
* Femtrace
* Estrace
284
Pearls of Beyaz?
Similar to Yaz/Gianvi, but has levomfolate (active form of folate)
285
What is the alternative to the 1st line pharmacologic therapy for premenstrual dysphoric disorder (PMDD)?
SNRIs Venlafaxine ADRs = Increased BP, insomnia, diaphoresis (sweat), xerostomia (dry mouth)
286
What are the signs/symptoms of menopause?
1. Hot flashes/night sweats
2. Genitourinary symptoms
3. Impaired bone metabolism
4. Psychological symptoms
287
What Rx is a weak androgen agonist?
Danazol (Danocrine)
288
What Rx are the aromatase inhibitors?
Anastrozole Letrozole
289
Testing for prediabetes and/or T2DM should begin at what age?
45 yrs old
290
What are the general lab values for primary hypogonadism in men?
* Low T
* High LH + FSH
291
Monitoring serum testosterone + Oral?
2-3 hrs after dose
292
What are the topical estrogen formulations?
* Estrasorb - 17 ß estradiol
* 2 pouches once daily (legs)
* Elestrin - 17 ß estradiol
* 1-2 does once daily (upper arm)
293
AE of SSRIs?
1. Insomnia
2. Sexual AE
3. Serotonin syndrome
4. Risk of upper GI bleed
5. Low sodium
294
What are some Rx for hypoactive sexual desire disorder in women?
1. Sildenafil 2. Bupropion 3. Hormonal Therapy 4. Ospemifene
