Chapter 20: Women's health Flashcards Preview

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Flashcards in Chapter 20: Women's health Deck (119):
1

 

 

drug metabolism in women

 

 

 

women have more CYP450, 3A4 substrates

better able to metabolize drugs affected by the P450 system

2

 

 

drug absorptionin women

 

 

longer gastric emptying times which affect bioavailability and absorption

affeted by estrogen levels

less alcohole dehydrogenase than men

lipophilic drugs are more readily distributed in women

3

 

 

drug distribution in women

 

 

women tend to have lower body weights and BMI but a higher proportion of body fat

 

4

 

 

drug excretion in women

 

 

differs due to weight differences

5

 

 

drug pharmacodynamics in women

 

 

differences with cardiovascular drugs and opiate analgesics

longer QT interval makes more susceptible to arrhythmias

greater analgesic effect in women, also more likely to cause n/v

6

 

 

what is important to rule out first when consiering a diagnosis of PMS or PMDD

 

 

 

anemia

thyroid disorder

depression or other mood disorders

7

 

 

therapeutic issues in womens health

 

menopause

hormone replacement therapy

osteoporosis

oral contraceptives

menstruation disorders

endometriosis

8

 

 

treatment options for PMS and PMDD

 

medication

exercise

dietary changes

supplements

counseling and mind-body approaches

9

 

 

medications that can be used in the treatment of PMS and PMDD

 

alprazolam (anxiety)

danazol (moderate endometriosis)

ibuprofen

SSRIs (very effective for behavioral & physical symptoms)

 

 

10

 

 

herbals that can be used in treatment of PMS or PMDD

 

evening primrose

chaste tree berry 

page 382

11

 

 

supplements used in treatment of PMS and PMDD

 

 

calcium, magnesium, B6

12

 

 

medical management of dysfunctional uterine bleeding

 

 

first correct volume status, then stabilize bleeding

goal is to prevent endometrial hyperplasia and cancer 

13

 

 

menorrhagia

 

 

prolonged or excessive bleeding that occurs at regular intervals

14

 

 

metrorrhagia

 

 

bleeding at irregular intervals between periods

15

 

 

menometrorrhagia

 

 

bleeding at irregular intervals with heavy or prolonged flow

16

 

 

polymenorrhea

 

 

bleeding occuring at regular intervals of less than 21 days

17

 

 

oligomenorrhea

 

 

infrequent, scanty bleeding occuring at intervals of greater than 35 days

18

 

 

amenorrhea

 

Primary - no menarch by age 16

secondary - absence of bleeding for more than 6 months in nonmenopausal women

19

 

 

DUB treatment varies depending on

 

severity and type of bleeding

fertility status

contraception needs

patient preference

side effects

20

 

 

pharmaceutical management of severe uterine bleeding

 

 

IV conjugate equine estrogen therapy

combination oral contraceptives

oral progestins

21

 

 

combination oral contraception therapy dosage

 

 

35mcg ethinyl estradiol/1mg norethindrone TID x 7 days

then once daily x 3 weeks

22

 

 

average time to stop bleeding with combination oral contraceptive therapy

 

 

3 days

23

 

 

progestins used for abnormal uterine bleeding in women who are contraindicated to estrogen therapy

 

norethindrone 5-15mg daily

medroxyprogesterone acetate up to 80mg daily

24

 

 

side effects of high estrogen doses

 

 

nausea

caution with hx of liver disease, over 35, or smoke

25

 

 

common side effects of progestins

 

 

headaches and breast tenderness

26

 

 

drugs that CAUSE abnormal uterine bleeding

anticoagulants

antidepressants (usually tricyclics)

antipsychotics

oral contraceptives

oral corticosteroids

phenytoin

tamoxifen

tranquilizers

27

 

 

herbals that can CAUSR abnormal uterine bleeding

 

 

garlic, ginko biloba, ginseng, soy, st. john's wort, arnica

aspen, bladderwrach, capsicum, dong quai, omega-3 fatty acids, parsley

28

 

 

what are the most common causes of iron defiency anemia in the developed world

 

 

menstrual blood loss

increased iron requirements in pregnancy

29

 

 

treatment option for menorrhagia (heavy bleeding)

 

Mirena IUD

estrogen-containing contraceptives (pill, patch, ring)

progestins 

NSAIDs

30

 

 

treatment of anovulatory bleeding in women younger than 35

 

 

combination oral contraceptive therapy

cyclic progestin therapy

31

 

 

when should polycystic ovary disease be suspected

 

 

when there at least 2 of the 3:

oligomenorrhea and/or anovulation

clinical and/or biochemical signs of hyperandrogenism

evidence of polycystic ovaries

32

 

 

anovulatory bleeding in women OLDER than 35

 

 

assessment of endometrium because of cancer risk

treatment with COC, IUD, or cyclic progestins

33

 

 

peripheral smear in iron deficiency anemia will show

 

 

hypochromic, microcytic red blood cells

34

 

 

lab results with iron deficiency anemia

 

 

low serum ferritin and iron

increased total iron binding capacity

35

 

 

treatment of iron deficiency anemia

 

 

 

first increase intake in diet

second oral supplementation (325mg TID)

36

 

 

considerations with iron supplementation

 

 

take between meals to enhance absorption

antacids can impair absorption

side effects include constipation, nausea

37

 

 

dosage of  oral contraceptive agent should be individualized how

 

 

lowest estrogen dose tolerable by patient

38

 

 

tailoring oral contraceptive progesterone

 

older ones (norethindrone and levonorgestrel) are cheaper but more androgenic so they worsen acne and lipid profiles

less androgenic ones are norgestimate and desogestrel

39

 

 

monophasic oral contaceptives

 

 

allow for continous dosing for 3 months

periods only 4x per year

40

 

 

multiphasic oral contraceptives

 

 

monthly cycles

41

 

 

combined oral contraceptives

 

 

have estrogen and progesterone agents

42

 

 

pros and cons of progesterone only therapy

 

 

continuous use with no withdrawal periods

strict schedue adherance needed (at 24 hour intervals)

allow breast feeding without inhibiting milk production

reduced risk of ovarian cancer

43

 

 

who should NOT be prescribed oral contraceptives

 

hx of CVA, complicated migranes, heart/liver disease, clotting disorders, estrogen-sensitive cancers, undiagnosed vaginal bleeding, possible pregnancy

44

 

 

combination oral contraceptives mechanism of action

 

 

inhibits ovulation by suppressing mid-cycle surge of FSH and LH

estrogen inhibits FSH release

progesterone inhibits LH and withdrawl bleeding

cervical mucosa is changes making it inhospitable to sperm

45

 

 

what are the only 2 estrogen ingredients approved for use in the US

 

 

ethinyl estradiol

mestranol

46

 

 

most potent progestins approved for use in the US

 

 

levo-norgesterol

norethindrone

47

 

 

what is in "the pill"

 

different amounts of synthetic estrogen and progestins, chemical analogues of the natural hormones estradiol and progesterone

48

 

 

other conditions treated by hormones

 

 

polycystic ovary syndrome, endometriosis, anemia r/t menstruation, painful menstruation, mild-mod acne, dysfunctional uterine bleeding

49

 

 

pharmacokinetics of combination oral contraceptives

 

  • rapidly absorbed in intestine
  • readily diffuses across lipid bilayers and blood-brain barrier
  • metabolized extensively by first pass metabolism (then in liver via CYP450
  • excreted enterically
  • half-life: 12-30 hours

50

 

 

adverse drug reactions of COCs

 

  • CV: hypercoagulability, DVT, PE, CVA risk
  • GI: liver abnormalities, cholelithiasis
  • OTHER: may stimulate estrogen sensitive cancer cells

51

 

 

which medications decrease the efficacy of oral contraceptives

 

ABTs, mineral oil, chloramphenicol, barbituates, chronic alcohol abuse, steroids, primidone, phenytoin, caffeine, theophylline, carbamazepine, bromocriptine, st. john's wort

52

 

 

which drug increases OCP hormone levels

 

 

protease inhibitors

53

 

 

what medications are increased BY oral contraceptives

 

 

benzodiazepines

corticosteroids

54

 

 

alternate forms of birth control

 

OrthoEvra: patch on for 3 weeks, off for a week

NuvaRing: monthly self-inserted vaginal ring

mirena: IUD good for 5 years

seasonale: extended cycle so only 4 periods a year

55

 

 

contraindications for oral contraceptives

 

 

HTN, smoker over 35, liver disease, heart disease, thromboembolic disease, breast cancer, undiagnosed vaginal bleeding, pregnancy, major surgery with prolonged immobilization, complicated migraine, diabetic neuropathy, breastfeeding

56

 

 

contraceptive patches should not be worn where?

 

 

over breast or broken skin

57

 

 

mechanism of action for injectable contraception

 

 

IM formula provides protection for 3 months by thickening cervical mucosa

58

 

 

disadvantages of "the shot"

 

 

pain at injection site, weight gain, irregular menses

59

 

 

pharmacokinetics of depo shot

 

  • slow absorption over 12-14 weeks
  • widely distributed, ipophilic, crosses blood-brain barrier
  • hepatic metabolism via CYP450 system
  • half-life: 50 days

60

 

 

adverse reactions of depo shot

 

  • CV: little to no risk with progestin-only injectables
  • DERM: acne
  • GI: liver toxicity and abnormal liver profile
  • META: decreased libido, osteoporosis, glucocorticoid activity

61

 

 

containdications for the depo shot

 

 

not for IV use

pregnancy

any vaginal or urinary issue

62

 

 

subdermal implants for contraception

 

 

progesterone implant under the skin that is a reliable alternative for women who cannot take estrogen

lasts up to 3 years

63

 

 

side effects of subdermal implants

 

 

irregular bleeding, weight gain, acne

64

 

 

intravaginal rings

 

combined hormone therapy with low systemic dose so there are few side effects and interactions

lasts up to 35 days

compliance rate is high if left in place

65

 

 

diaphragms and cervical caps

 

 

uses latex as internal barrier to sperm passage

failure rate approx 11%

66

 

 

spermicides

 

 

gels, foams, creams, and coatings on condoms using nonoxynyl-9 as active ingredient which can irritate  and may increase HIV transmission

67

 

 

condoms

 

 

failure rate approx 10-20%

 

68

 

 

sponge

 

 

must remain in place for 6hrs after intercourse or failure rate is 9-16%

69

 

 

emergency contraception

 

high dose estrogen to halt mobility in fallopian tube and thicken cervical mucosa

in two divided dosesgiven 12 hours apart (each 100mcg)

first dose within 72 hours of intercourse

 

70

 

 

"plan B" emergency contraceptive

 

high progesterone administration of 1.5 mg levonorgestrel in a single dose within 72 hours of intercourse (1

can take as one or divided dose)

OTC

71

 

 

emergency contraception if a woman is already pregnant

 

 

will not cause an abortion

72

 

 

drugs used to treat osteoporosis and osteopenia

 

cacium

vitamin D

biphosphonates

zoledronic acid

selective estrogen modulators (SERMs)

calcitonin

recombinant parathyroid hormone

73

 

 

follow-up for treatment of osteoporosis or osteopenia

 

 

 

 

no clearly defined protocol

evaulate therapy based on absence of fractures or increased bone density scores

74

 

 

medication goals for treatment of osteoporosis or osteopenia

 

 

achieve optimal peak bone mass

minimize further bone loss

decrease falls and fractures

75

 

 

non-pharmacologic treatment for osteoporosis

 

 

diet with adequate calcium and vitamin D, exercise, smoking cessation

76

 

 

medical conditions associated with higher risk of osteoporosis

 

 

alcoholism, chronic renal disease, cushing's syndrome, cyctic fibrosis, glucocorticoids, DM, eating disorders, GI disorders, hematological disorders, hyperthyroidism, hyperparathyroidism, hypergonadism, hyperprolactinism, drug induced, neuropathies

77

 

 

what is calcium required for

 

 

vascular contraction and dilation, nerve transmission, intracellular signaling, hormonal secretion

78

 

 

what is vitamin D needed for

 

 

required for uptake of calcium and phosphorus for gut and absorption into bone

79

 

 

ergocalciferol and cholecalciferol

 

 

ergocalciferol is vitamin D2 from plants

cholecalciferol is vitamin D3 from sunlight

80

 

 

FDA recommended daily calcium need

 

 

 

1000mg/day for males 51-70

1200mg/day for females 51-70

females under 70 have an upper limit of 2500

81

 

 

IOM recommended daily vitamin D need

 

 

600IU/day for females

800IU/day for males

82

 

 

which medications should be given either several hours befor or after calcium due to its binding potential

 

 

 

 

 

levothyroxine, fluoroquinolones, tetracyclines, phenytoin, ACE inhibitors, iron, biphosphonates

 

 

83

 

 

which three drugs induce symptoms of acute hypercalcemia when given with vitamin D

 

 

calcitrol (Rocaltrol)

paricaltrol (Zemplar)

doxercalciferol (Hectoral)

84

 

 

symptoms of acute hypercalcemia

 

 

headache, nausea, dizziness, vomiting, and anorexia

85

 

 

coadministration of vitamin D, calcium, and HCTZ

 

 

renal secretion of calciumis inhibited leading to hypercalcemia

86

 

 

vitamin D interferes with the absorption of which other 3 medications

 

 

steroids, dilantin, and phenobarbital

87

 

 

contraindications for calcium and vitamin D

 

 

vitamin D: parathyroidism

calcium: hx of V. fib, hypercalciuria, hyperphosphatemia, and renal stones

use caution in paitent taking digoxin

88

 

 

first line treatment for post-menopausal women with osteoporosis

 

 

bisphosphonates

reduces fractures by 40-70%

89

 

 

examples of bisphosphonates

 

alendronate (Fosamax)

ibandronate (Boniva)

risedronate (Actonel)

raloxifene (Evista)

etidronate (Aredia

zoledronic acid (Zometa)

90

 

 

challenges with bisphosphonates

 

correct adminstration

avoiding serious GI upset

poor bioavailability

91

 

 

bisphosphonate mechanism of action

 

 

inhibits both normal and abnormal bone reabsorption and slows down bone remodeling in postmenopausal women

92

 

 

bisphosphonate pharmacokinetics

 

 

oral forms are poorly absorbed

adhere transiently to bone

no metabolism

excreted in urine

half life about 10 years

93

 

 

clinical uses of bisphosphonates

 

treatment/prevention of osteoporosis is post menopausal women

treatment of osteoporosis in men

symptomatic Paget's disease

glucocorticoid-induced osteoporosis in men and women

94

 

 

adverse reactions of bisphosphonates

 

  • CV: A-fib
  • DERM: erythema, photosensitivity, rash
  • GI: abdominal distention, cramps, pain, constipation, reflux, dyspepsia, gas, ulcer, change in taste
  • MS: osteonecrosis of the jaw
  • NEURO: headache

95

 

 

contraindications for bisphosphonates

 

 

decreased creatinine clearance

hypocalcemia or any history of GI disease and patients with invasive dental work (risk of osteonecrosis)

96

 

 

bisphosphonate patient education

 

warn patient of joint, muscle, bone jaw pain

advise to take with full glass of water

food to minimize GI upset

there are IV forms for 3 months or yearly administration

97

 

 

conscientious considerations for bisphosphonates

 

caution in patients with renal impairment

watch for jaw bone necrosis

watch for abnormal diagnostic imaging

monitor serum calcium and phosphorus

98

 

 

bisphosphonate interactions

 

 

antacids effect absorption

NSAIDs increases GI side effects

caffeine, mineral water, and orange juice decrease absorption

99

 

 

SERM activity

 

 

mimics estrogen antagonists and provide astrogen resorption effects without need for estrogen

100

 

 

SERM pharmacokinetics

 

 

60% absorbed fro GI, 95% bound to plasma protein, hepatically metabolized, excreted in feces, half-life 27-32 hours

101

 

 

examples of SERMs

 

tamoxifen (Nolvadex) - treats breast cancer

toremifene (Fareston) - treats breast cancer and osteoporosis

raloxifene (Evista) - treats osteoporosis

102

 

 

adverse reactions of SERMs

 

 

 

 

  • CV: increased vasomotor symptoms, thromboembolism
  • MS: leg cramps
  • MISC: hot flashes
  • NEURO: dizziness

103

 

 

SERM interaction

 

 

warfarin and other highly protein bound drugs

104

 

 

contraindications for SERMs

 

 

history of thromboembolic events

women who are pregnant, breast feeding, or may become pregnant

105

 

 

SERM patient education

 

take full course of therapy

do not double dose if one is missed

drug will not reduce incidence of hot flashes

weight-bearing exercise is helpful

advise on adequate calcium/vitD intake

avoid prolonged sitting as leg cramps could be risk for clot

106

 

 

calcitonin-salmon

 

synthetic form of calcitonin found in salmon

promotes new bone formation by unknown method

not considered first line therapy

administered as nasal spray

107

 

 

parathyroid hormone therapy

(Teriparatide) Forteo

 

 

stimulates new growth of bone in postmenopausal women at high risk for fracture

manufactured by recombinant DNA using e.coli

108

 

 

adverse reactions of forteo

 

 

 

 

orthostatic hypotension, nausea, leg cramps, increase in serum calcium

109

 

 

contraindications for forteo

 

 

risk of osteosarcoma (Paget's disease, previous skeletal radiation, unexplained elevation of alkaline phosphatase level)

110

 

 

conscientious considerations for hormone replacement therapy

 

lowest effective dose to control symptoms for the shortest amount of time

consider use of natural products (Cohash) and non-pharmacologic therapy (exercise)

frequent follow-ups

use strogen only if they have NO uterus, otherwise estrogen-progestin

dont use if preventing CVD, osteoporosis, and demetia

111

 

 

conjugated estrogen (Premarin)

mechanism of action

 

helps modulate pituitary secretion of FSH, LH, and gonadotropins to reduce elevated levels in post-menopausal women,

thus maintaining female reproductive system and secondary sexual characteristics

112

 

 

Premarin pharmacokinetics

 

well absobed orally, circulates bound to protein, liver CYP450 converts to metabolite, excreted in urine, half-life 1-2 hours

113

 

 

estrogen adverse reactions

  • CV: thromboembolism, MI, retinal thrombosis, stroke, HTN
  • DERM: acne, oily skin, urticaria, increased pigment
  • ENDO: hyperglycemia
  • GI: nausea, weight gain, jaundice, vomiting
  • META: water retention, hypercalcemia
  • MS: leg cramps
  • NEURO: lethargy, depression, headache, dizziness
  • OB: ovarian, breast, cervical cancer; endometriosis, fibroids, amenorrhea, breast tenderness

114

 

 

premarin interactions

 

 

grapefruit juice will increase estrogen levels

will alter requirements for warfarin, oral hypoglycemics, and insulin

smoking will increase risk of cardiovascular events

115

 

 

conscientious considerations for estrogen replacement therapy (Premarin)

 

caution in smokers with high triglycerides

evaluate any unusual bleeding

lowest dose for shortest period of time

116

 

 

patient education for estrogen replacement therapy

 

do not double dose 

withdrawal bleeding will occur with missed week

may take with food for GI upset

instruct on water retention, pregnancy, sunscreens, PAP screen, and routine wellness checks

117

 

 

clinical use of progestins 

 

decrease endometrial hyperplasia

treatment of secondary amenorrhea and abnormal bleeding caused by homronal imbalance

emergency contraceptive

118

 

 

adverse reactions of progestins

  • CV: fluid retention, PULMONARY EMBOLISM
  • DERM: alopecia, acne, melasma, chloasma, rashes
  • EENT: retinal thrombosis
  • ENDO: amenorrhea, brekthrough bleeding, breast tenderness, changes in mestrual flow, spotting, hyperglycemia
  • GI: weight gain, nausea, GI-induced hepatitis, gingival bleeding
  • NEURO: depression

119