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Pharmacology > Chapter 20: Women's health > Flashcards

Chapter 20: Women's health Flashcards

1
Q

drug metabolism in women

A

women have more CYP450, 3A4 substrates

better able to metabolize drugs affected by the P450 system

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2
Q

drug absorptionin women

A

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

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3
Q

drug distribution in women

A

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

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4
Q

drug excretion in women

A

differs due to weight differences

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5
Q

drug pharmacodynamics in women

A

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

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6
Q

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

A

anemia

thyroid disorder

depression or other mood disorders

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7
Q

therapeutic issues in womens health

A

menopause

hormone replacement therapy

osteoporosis

oral contraceptives

menstruation disorders

endometriosis

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8
Q

treatment options for PMS and PMDD

A

medication

exercise

dietary changes

supplements

counseling and mind-body approaches

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9
Q

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

A

alprazolam (anxiety)

danazol (moderate endometriosis)

ibuprofen

SSRIs (very effective for behavioral & physical symptoms)

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10
Q

herbals that can be used in treatment of PMS or PMDD

A

evening primrose

chaste tree berry

page 382

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11
Q

supplements used in treatment of PMS and PMDD

A

calcium, magnesium, B6

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12
Q

medical management of dysfunctional uterine bleeding

A

first correct volume status, then stabilize bleeding

goal is to prevent endometrial hyperplasia and cancer

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13
Q

menorrhagia

A

prolonged or excessive bleeding that occurs at regular intervals

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14
Q

metrorrhagia

A

bleeding at irregular intervals between periods

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15
Q

menometrorrhagia

A

bleeding at irregular intervals with heavy or prolonged flow

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16
Q

polymenorrhea

A

bleeding occuring at regular intervals of less than 21 days

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17
Q

oligomenorrhea

A

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

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18
Q

amenorrhea

A

Primary - no menarch by age 16

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

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19
Q

DUB treatment varies depending on

A

severity and type of bleeding

fertility status

contraception needs

patient preference

side effects

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20
Q

pharmaceutical management of severe uterine bleeding

A

IV conjugate equine estrogen therapy

combination oral contraceptives

oral progestins

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21
Q

combination oral contraception therapy dosage

A

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

then once daily x 3 weeks

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22
Q

average time to stop bleeding with combination oral contraceptive therapy

A

3 days

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23
Q

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

A

norethindrone 5-15mg daily

medroxyprogesterone acetate up to 80mg daily

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24
Q

side effects of high estrogen doses

A

nausea

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

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25
Q

common side effects of progestins

A

headaches and breast tenderness

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26
Q

drugs that CAUSE abnormal uterine bleeding

A

anticoagulants

antidepressants (usually tricyclics)

antipsychotics

oral contraceptives

oral corticosteroids

phenytoin

tamoxifen

tranquilizers

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27
Q

herbals that can CAUSR abnormal uterine bleeding

A

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

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

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28
Q

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

A

menstrual blood loss

increased iron requirements in pregnancy

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29
Q

treatment option for menorrhagia (heavy bleeding)

A

Mirena IUD

estrogen-containing contraceptives (pill, patch, ring)

progestins

NSAIDs

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30
Q

treatment of anovulatory bleeding in women younger than 35

A

combination oral contraceptive therapy

cyclic progestin therapy

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31
Q

when should polycystic ovary disease be suspected

A

when there at least 2 of the 3:

oligomenorrhea and/or anovulation

clinical and/or biochemical signs of hyperandrogenism

evidence of polycystic ovaries

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32
Q

anovulatory bleeding in women OLDER than 35

A

assessment of endometrium because of cancer risk

treatment with COC, IUD, or cyclic progestins

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33
Q

peripheral smear in iron deficiency anemia will show

A

hypochromic, microcytic red blood cells

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34
Q

lab results with iron deficiency anemia

A

low serum ferritin and iron

increased total iron binding capacity

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35
Q

treatment of iron deficiency anemia

A

first increase intake in diet

second oral supplementation (325mg TID)

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36
Q

considerations with iron supplementation

A

take between meals to enhance absorption

antacids can impair absorption

side effects include constipation, nausea

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37
Q

dosage of oral contraceptive agent should be individualized how

A

lowest estrogen dose tolerable by patient

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38
Q

tailoring oral contraceptive progesterone

A

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

less androgenic ones are norgestimate and desogestrel

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39
Q

monophasic oral contaceptives

A

allow for continous dosing for 3 months

periods only 4x per year

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40
Q

multiphasic oral contraceptives

A

monthly cycles

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41
Q

combined oral contraceptives

A

have estrogen and progesterone agents

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42
Q

pros and cons of progesterone only therapy

A

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

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43
Q

who should NOT be prescribed oral contraceptives

A

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

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44
Q

combination oral contraceptives mechanism of action

A

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

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45
Q

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

A

ethinyl estradiol

mestranol

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46
Q

most potent progestins approved for use in the US

A

levo-norgesterol

norethindrone

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47
Q

what is in “the pill”

A

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

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48
Q

other conditions treated by hormones

A

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

49
Q

pharmacokinetics of combination oral contraceptives

A
  • 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
Q

adverse drug reactions of COCs

A
  • CV: hypercoagulability, DVT, PE, CVA risk
  • GI: liver abnormalities, cholelithiasis
  • OTHER: may stimulate estrogen sensitive cancer cells
51
Q

which medications decrease the efficacy of oral contraceptives

A

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

52
Q

which drug increases OCP hormone levels

A

protease inhibitors

53
Q

what medications are increased BY oral contraceptives

A

benzodiazepines

corticosteroids

54
Q

alternate forms of birth control

A

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
Q

contraindications for oral contraceptives

A

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
Q

contraceptive patches should not be worn where?

A

over breast or broken skin

57
Q

mechanism of action for injectable contraception

A

IM formula provides protection for 3 months by thickening cervical mucosa

58
Q

disadvantages of “the shot”

A

pain at injection site, weight gain, irregular menses

59
Q

pharmacokinetics of depo shot

A
  • slow absorption over 12-14 weeks
  • widely distributed, ipophilic, crosses blood-brain barrier
  • hepatic metabolism via CYP450 system
  • half-life: 50 days
60
Q

adverse reactions of depo shot

A

​

  • 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
Q

containdications for the depo shot

A

not for IV use

pregnancy

any vaginal or urinary issue

62
Q

subdermal implants for contraception

A

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

lasts up to 3 years

63
Q

side effects of subdermal implants

A

irregular bleeding, weight gain, acne

64
Q

intravaginal rings

A

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
Q

diaphragms and cervical caps

A

uses latex as internal barrier to sperm passage

failure rate approx 11%

66
Q

spermicides

A

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

67
Q

condoms

A

failure rate approx 10-20%

68
Q

sponge

A

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

69
Q

emergency contraception

A

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
Q

“plan B” emergency contraceptive

A

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
Q

emergency contraception if a woman is already pregnant

A

will not cause an abortion

72
Q

drugs used to treat osteoporosis and osteopenia

A

cacium

vitamin D

biphosphonates

zoledronic acid

selective estrogen modulators (SERMs)

calcitonin

recombinant parathyroid hormone

73
Q

follow-up for treatment of osteoporosis or osteopenia

A

no clearly defined protocol

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

74
Q

medication goals for treatment of osteoporosis or osteopenia

A

achieve optimal peak bone mass

minimize further bone loss

decrease falls and fractures

75
Q

non-pharmacologic treatment for osteoporosis

A

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

76
Q

medical conditions associated with higher risk of osteoporosis

A

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
Q

what is calcium required for

A

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

78
Q

what is vitamin D needed for

A

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

79
Q

ergocalciferol and cholecalciferol

A

ergocalciferol is vitamin D2 from plants

cholecalciferol is vitamin D3 from sunlight

80
Q

FDA recommended daily calcium need

A

1000mg/day for males 51-70

1200mg/day for females 51-70

females under 70 have an upper limit of 2500

81
Q

IOM recommended daily vitamin D need

A

600IU/day for females

800IU/day for males

82
Q

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

A

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

83
Q

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

A

calcitrol (Rocaltrol)

paricaltrol (Zemplar)

doxercalciferol (Hectoral)

84
Q

symptoms of acute hypercalcemia

A

headache, nausea, dizziness, vomiting, and anorexia

85
Q

coadministration of vitamin D, calcium, and HCTZ

A

renal secretion of calciumis inhibited leading to hypercalcemia

86
Q

vitamin D interferes with the absorption of which other 3 medications

A

steroids, dilantin, and phenobarbital

87
Q

contraindications for calcium and vitamin D

A

vitamin D: parathyroidism

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

use caution in paitent taking digoxin

88
Q

first line treatment for post-menopausal women with osteoporosis

A

bisphosphonates

reduces fractures by 40-70%

89
Q

examples of bisphosphonates

A

alendronate (Fosamax)

ibandronate (Boniva)

risedronate (Actonel)

raloxifene (Evista)

etidronate (Aredia

zoledronic acid (Zometa)

90
Q

challenges with bisphosphonates

A

correct adminstration

avoiding serious GI upset

poor bioavailability

91
Q

bisphosphonate mechanism of action

A

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

92
Q

bisphosphonate pharmacokinetics

A

oral forms are poorly absorbed

adhere transiently to bone

no metabolism

excreted in urine

half life about 10 years

93
Q

clinical uses of bisphosphonates

A

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
Q

adverse reactions of bisphosphonates

A
  • 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
Q

contraindications for bisphosphonates

A

decreased creatinine clearance

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

96
Q

bisphosphonate patient education

A

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
Q

conscientious considerations for bisphosphonates

A

caution in patients with renal impairment

watch for jaw bone necrosis

watch for abnormal diagnostic imaging

monitor serum calcium and phosphorus

98
Q

bisphosphonate interactions

A

antacids effect absorption

NSAIDs increases GI side effects

caffeine, mineral water, and orange juice decrease absorption

99
Q

SERM activity

A

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

100
Q

SERM pharmacokinetics

A

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

101
Q

examples of SERMs

A

tamoxifen (Nolvadex) - treats breast cancer

toremifene (Fareston) - treats breast cancer and osteoporosis

raloxifene (Evista) - treats osteoporosis

102
Q

adverse reactions of SERMs

A
  • CV: increased vasomotor symptoms, thromboembolism
  • MS: leg cramps
  • MISC: hot flashes
  • NEURO: dizziness
103
Q

SERM interaction

A

warfarin and other highly protein bound drugs

104
Q

contraindications for SERMs

A

history of thromboembolic events

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

105
Q

SERM patient education

A

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
Q

calcitonin-salmon

A

synthetic form of calcitonin found in salmon

promotes new bone formation by unknown method

not considered first line therapy

administered as nasal spray

107
Q

parathyroid hormone therapy

(Teriparatide) Forteo

A

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

manufactured by recombinant DNA using e.coli

108
Q

adverse reactions of forteo

A

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

109
Q

contraindications for forteo

A

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

110
Q

conscientious considerations for hormone replacement therapy

A

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
Q

conjugated estrogen (Premarin)

mechanism of action

A

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
Q

Premarin pharmacokinetics

A

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

113
Q

estrogen adverse reactions

A
  • 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
Q

premarin interactions

A

grapefruit juice will increase estrogen levels

will alter requirements for warfarin, oral hypoglycemics, and insulin

smoking will increase risk of cardiovascular events

115
Q

conscientious considerations for estrogen replacement therapy (Premarin)

A

caution in smokers with high triglycerides

evaluate any unusual bleeding

lowest dose for shortest period of time

116
Q

patient education for estrogen replacement therapy

A

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
Q

clinical use of progestins

A

decrease endometrial hyperplasia

treatment of secondary amenorrhea and abnormal bleeding caused by homronal imbalance

emergency contraceptive

118
Q

adverse reactions of progestins

A
  • 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
Q
A

Pharmacology (28 decks)

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