Chapter 7: Gentio-urinary system Flashcards
1
Q
What are the two hormones in combined hormonal contraceptives? What three forms can they come in, can you think of the brand name of any of these?
A
Oestrogen and Progestogen COC pill
e.g. Microgynon (Ethinylestradiol + Levonorgestrel) Cilest (Ethinylestradiol + Norgestimate)
Combined transdermal patch (Evra)
Combined vaginal ring (NuvaRing)
2
Q
What guidelines should be followed when providing contraception to under 16’s?
A
Fraser Guidelines
3
Q
IUD’s are less appropriate for women with increased risk of _____?
A
- Pelvic Inflammatory Disease (infection of upper part of female reproductive system- uterus, fallopian tubes, and ovaries, and inside of pelvis)
- Not for <25yrs
4
Q
COC’s reduce the risk of what conditions?
A
PID
Ovarian + endometrial cancers ( progestogen reduces endometrial)
benign breast disease
5
Q
What is the difference between monophasic and phasic COC’s?
A
Monophasic contain same amount of oestrogen + progestogen in each tablet. Most commonly used.
Phasic contain different amounts in each tablet- i.e. some tablets in strip may contain 30 mcg of ethinylestradiol & some may 40 mcg
~usually used for those that do not have withdrawal bleed or breakthrough bleeds on monophasic.
6
Q
What oestrogen do the majority of COC’s contain?
A
Ethinylestradiol
7
Q
COC’s and surgery?
A
- Discontinue 4 weeks before major surgery/ leg surgery/ immobilisation
- Re-start at next period at least 2 weeks after re-mobilised
POP’s aren’t issue- can keep these going through surgery as no risk of clots with oestrogen-free
8
Q
Above what BP should the COC be avoided in ?
A
Over 160/ 95 mmHg
9
Q
What is the mechanism of action of COC’s?
A
Stop follicles (containing egg) developing in ovary + prevent ovulation (release of egg from follicle to travel down fallopian tube to uterus) through suppression of LH + FSH.
10
Q
What is the mechanism of action of POP’s?
A
Alter cervical mucus to prevent sperm penetration (creates a hostile environment)
Some (desogestrel) inhibit ovulation- this has become a much more common MofA rather than just altering mucus
11
Q
What kind of contraceptive is the contraceptive Injection? What do women need to be warned of with these?
A
Long- acting Progestogen only
Last around 3 months (12 weeks) at a time
Menstrual disturbance- troublesome bleeding reported
12
Q
How long does the subdermal implant provide contraceptive cover for?
A
up to 3 years Implant should be removed within 3 years of insertion
13
Q
Two types of Intrauterine devices?
A
Copper- toxic to sperm Progestogen only (levonorgestrel releasing- called Intrauterine system)
14
Q
In terms of cancers, which may the COC protect against, and which may it increase the risk of?
A
Protect against: Ovary and endometrial cancer
Progestogen reduces risk of endometrial
Small increased risk of: Breast and cervical cancer; risk diminishes after 10 years of stopping.
15
Q
What are some of the side effects of the COC?
A
Abdominal cramps Leg cramps Nausea breastchanges depression hypertension Headaches irregular bleeding (NB: does not appear to cause weight gain!)
16
Q
Other than contraceptive purposes, what can COC’s/ POP’s be used for?
A
Reducing menstrual pain and bleeding- medical terms?ACNE
17
Q
If a woman has one of the risk factors for VTE/ CV disease (over 35, obese, FH, migraine with aura, heavy smoker) caution is advised. IF a COC is going to be used, what strength?What about if they had 2 or more risk factors?
A
One risk factor- exercise caution, go for lower strength Oestrogen (ethinylestradiol 20 mcg. Usual strength= 30- 35 mcg)2 or more: avoid use of a COC
18
Q
What is the criteria used to assess whether a woman with pre-existing medical conditions would be suitable for a COC?
A
UKMEC scoring(Medical Eligibility criteria for contraceptive use) Risk benefit analysis for prescribing guidance
19
Q
What assessments are needed prior to starting a COC/ POP?
A
Relevant History
BP
BMI
For COC’s- reassess BP after 3 months, then yearly after that
20
Q
What are the instructions for initiating the COC?
A
Can start it on any day of cycle
Day 1 = 1st day of period
If starting on day 6 or later = contraceptive precautions needed for 7 days
=> Same applies if switching from POP to COC = use contraceptive precautions for 7 days
21
Q
Name some Progestogens? Which can be used as Long acting progestogens?
A
Ulipristal
Levonorgestrel
Desogestrel
Norethisterone
LARC’s: Norethisterone
Levonorgestrel Medroxyprogesterone
Etonogestrel
22
Q
In terms of cancer risk, what can progestogen only contraceptives do?
A
Small increased risk of breast cancers as with COC’s, diminished after 10 years of use.
Breast cancer = contra-indication
Small increased risk of cervical cancer with Injectable progestogen use.
Progestogen protects against endometrial cancer
23
Q
Side effects of POPs?
A
Oral use:
Nausea
Depression
Headaches
Breast discomfort
Appetite disturbance
Menstrual irregularities
24
Q
What are the instructions for initiating the POP?
A
Start on day 1 of cycle (1st day of period), no extra protection needed, as cannot start on any day of cycle like COC’s.
~ Take continuously- no pill-free interval with POP’s!
~ new blister started directly day after previous one.
~ Should get no withdrawal bleeds- however women who experience some irregular bleeding should possibly switch to different method (bleeding irregularity reported in up to 50% of women using Cerazette)
~ After couple of months of TX, bleedings tend to become less frequent.
25
After how many years should copper IUD's usually be replaced?
5 years
26
What are the different types of Long acting reversible contraception?
~ Intrauterine contraceptive device (IUCD- copper releasing, non-hormonal)
~ Intrauterine system (IUS Mirena- Levornogestrol releasing)
~ Injectable Progestogen- oily based, released slowly over 12 weeks (IM injection) or 13 weeks (SC injection)
~ Sub-dermal progestogenic implant
27
Which progestogen injection has been associated with a reduction in bone mineral density and therefore increased osteoporosis risk?
Medroxyprogesterone
28
What is the only implant licensed in the UK?
Etonogestrel (nexplanon)
29
What is the main undesirable SE associated with Progestogen only contraceptive use (both POP's and long acting)?
Undesirable/ irregular vaginal bleeding patterns
30
How is erectile dysfunction treated?
With drugs improving flow of blood to penis
~ Phosphodiesterase type- 5 inhibitors usually used (sildenafil, avanafil, tadalafil)
31
What drug, used for erectile dysfunction, may result in priapism (prolonged painful erection?)
Alprostadil
32
If men are to get certain erectile dysfunction meds such as sildenafil and tadalafil, on an NHS prescription, because they meet certain criteria, what must be endorsed?
SLS
33
Which erectile dysfunction drugs can also be prescribed for pulmonary arterial hypertension?
Tadalafil
Sildenafil
~ These relax muscles in blood vessel walls in lungs, dilating them & reducing BP
~ used under specialist supervision
34
What are the common side effects of the Phosphodiesterase type- 5 inhibitors (sildenadil, tadalafil, avanafil) used in erectile dysfunction??
Flushing
Back pain
Dyspepsia (heart burn)
migraine
Blocked nose
VISUAL disturbance
35
What are the risk factors for erectile dysfunction?
Similar to those for CV disease:
Obesity
Sedentary lifestyle (blood isn't flowing much)
Smoking
High cholesterol
36
What is the new drug used for premature ejaculation?
Dapoxetine
37
What drug can be used to induce labour?
Oxytocin
38
What are Gemeprost, misoprostol and mifepristone used for?
**Induction of ABORTION**
Mifepristone can be used to facilitate process: sensitises uterus to administration of abortion drugs Gemeprost & Misoprostol.
39
What is the treatment for bacterial vaginosis?
Metronidazole gel
Clindamycin cream
40
We know that clotrimazole cream can be used for fungal vaginal infection (thrush). What is the strength of each formulation used?
**Internal** vaginal cream:
Clotrimazole 10% - insert 1 applicatorful into vagina at night- can repeat dose once if needed.
**External** cream, to be applied to ano-genital area 2-3 times a day:
Clotrimazole 1% cream
Canesten 2% thrush cream
41
What are the instructions for use of clotrimazole vaginal pessaries for thrush?
200mg pessary insert at night for 3 nights (use at night as minimal movement)
Recurrent thrush:500mg pessary weekly for 6 months after using clotrimazole cream for 10-14 days
42
Bar clotrimazole (Canesten), what other topical Imidazole cream can be used for thrush?
Ketoconazole cream (Nizoral)
Also used for dandruff/ seborrhoiec dermatitis/ Fungal skin condition called pityriasis versicolor as Nizoral shampoo
43
What class of medications is usually used for treating Urinary frequency/ Urinary Urgency?
Antimuscarinics (Anti-cholinergic's): 1 of their side effects = urinary retention!
i.e:
**Fesoterodine
OXYBUTININ
Darifenacin
SOLIFENACIN
Tolterodine
Trospium**
44
What is Beningn prostate Hyperplasia?
Enlarged prostate gland
~ prostate gland surrounds urethra, tube that carries urine from bladder out of body
~ As prostate gets bigger, it may squeeze or partly block urethra = problems with urinating- trouble to start weeing trouble to stop weeing (dribbling)
Weak stream
Often feeling you need a wee- gets you up at night
45
What are the alpha blockers used in BPH, and what do they do?
Relax smooth muscle = increase urine flow
Examples:
Doxazosin
Alfuzosin
Indoramin
Tamsulosin (can get OTC- Flomax)
Prazosin
46
What are Finasteride and Dutasteride used for? What are the associated warnings?
Also used for BPH
~ WOMEN of child bearing age NOT handle crushed or broken tablets.
~ excreted in semen so use of condom recommended
~ Cases of Male Breast Cancer reported: males to report any changes in breast tissue: lumps, pain, nipple discharge
47
What is the extra precaution needed before inserting an intra-uterine device into some women?
Risk of infection due to pre-existing STI's:for women under 25 years, over 25 years with a new partner- perform an STI check before fitting the device Risk of infection occurs in first 20 days after insertion- if woman has sustained pain attend emergency department ASAP as this could indicate Pelvic inflammatory disease
48
What is the first dose effect associated with the alpha blockers used for BPH?
Patients should be advised that their first dose may cause hypotension therefore there is risk of falling. They should take their first dose in bed- lie down if symptoms of sweating and dizziness develop and stay lying down.
49
What conditions and cancers does HRT increase the risk of?
Clots- VTE (DVT and PE)
Stroke
Breast cancer- risk disappears within 5 years of stopping
Ovarian cancer
Endometrial cancer
Same as COC's as oestrogen that causes these.
HRT containing progestogen (for women with uterus) provide some protection against endometrial cancer [but still increased risk of breast cancer].
50
What is the menopause?
Where a womans periods cease as her oestrogen levels decline.
~ Results in hot flushes, night sweats, low mood (caused by vasomotor instability).
~ Usually happens 44-55 years of age.
~ Treatment of symptoms usually involves HRT- small doses of oestrogen to soften blow of oestrogen decline. Also given progestogens if still has uterus.
~ Tibolone: drug with oestrogenic, progestogenic and weak adrenergic activity used in HRT.
51
What condition can HRT be used to prevent?
OSTEOPOROSIS
52
How many days are the progestogen tablets used in HRT taken for each cycle? What about the oestrogen tablets? What is the prescription charge for the HRT packs containing oestrogen and progestogen tablets?
Progestogen tablets: for 12- 14 days of each cycle for women with UTERUS
Oestrogen tablets: taken continuously
Usually separate prescription charge for each of tablets in pack: e.g. Prempak- C renders 2 prescription charges.
53
Does HRT provide contraceptive cover, considering it comprises oestrogens and progestogens?
NO
~ woman still considered fertile for 2 years after her last menstrual period (if under 50- for 1 year if over 50 years). If any potentially fertile women on HRT, non-hormonal contraceptive measures advised such as Condoms.
54
What are the side effects of the alpha blockers used in BPH?
Dizziness (Most common) Postural HypotensionBack painBlurred visionDry mouth
55
How many weeks can Tamsulosin OTC be given for treatment of BPH before clinical assessment by a doctor?
Max 6 weeks treatment OTC
56
What is the treatment for Chlamydia, OTC?
Azithromycin1g STAT (2 x 500mg tablets)Need to have tested positive for chlamydiaPartner does not need to be tested to receive dose
57
What should patients report with treatment with Tamoxifen, a hormone used in treating Breast cancer?
* Risk of VTE- report to hospital if there is any redness, swelling or pain in the leg.
* Endometrial changes- report any abnormal vaginal bleeding, vaginal discharge and pelvic pain due to risk of cancer/ polyps
58
Which oral contraceptives offer everyday dosing- i.e. you don't need to take a pill free break as there are 7 inactive pills in there so can help with compliance as people don't have to remember to start a new pack?
Zoely: Estradiol and Nomogestrol (oestrogen + progestogen)These are monophasic pills (i.e. the active pills contain the same amount of actives in each tablet)
59
Which oral contraceptive is a monophonic preparation i.e. each tablet contains a different amount of active so the patient has different levels of hormones throughout the month?
Qlaira (estradiol and dienogest)pack also contains 2 inactive pills
60
How do you manage acute urinary retention?
Catheterisation (alpha blocker such as tamsulosin, doxazosin should be given at least 2 days beforehand)
61
What is the pharmacological management of chronic urinary retention in men?
An alpha-adrenoceptor blocker (alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride or terazosin). Treatment should initially be reviewed after 4–6 weeks and then every 6–12 months.
62
What is the pharmacological treatment for benign prostate hyperplasia and raised PSA and high risk of progression eg elderly?
5a-reductase inhibitor - finasteride, dutasterideThis can be combined with an alpha blocker if symptoms remain an issue
63
What can be used for the pharmacological management of urinary incontinence?
Oxybutinin
Tolterodine
Fesoterodine
Solifenacin succinate
Mirabegron - only if antimuscarinics ineffective/not suitable
64
What is the suggested duration of treatment for an uncomplicated lower UTI in men and women?
7 days for men3 for women
65
What 3 antibiotics can be used for long term low dose lower UTI prophylaxis?
TrimethoprimNitrofurantoinCefalexin
66
What antibiotics should be used for management of upper UTIs (acute pyelonephritis)?How long should the treatment be?
IV Broad spectrum antibiotic e.g. cephalosporin, quinoloneOr IV gent if severely ill10-14 days
67
What would be the most appropriate antibiotic classes for a pregnant lady with a UTI?
Penicillins or cephalosporins
68
If non drug treatment is unsuccessful (e.g. using an alarm, fluid intake) in children who have nocturnal enuresis, what would be the pharmacological management?
Oral desmopressin if > 5 years
For children under 5 years, this should resolve spontaneously
69
When starting alpha blockers for urinary retention/benign prostate hyperplasia, when should the first dose be taken and why?
At bedtime ideally as can cause hypotension and possibly a collapse
70
What is the MHRA warning regarding the use of finasteride?
Rare reports of depression and suicidal thoughts
71
What is used for the alkalinisation of urine?
Potassium citrateSodium bicarbonate
72
If a patient requires major elective surgery and is on an oestrogen-containing contraceptive, how is this managed?
* Stopped 4 weeks before if it means surgery will result in prolonged immobilisation of lower limbs
* Restarted at 1st menses occurring at least 2 weeks after full mobilisation
* POP = alternative
73
Before surgery, if an oestrogen-containing contraceptive cannot be stopped beforehand, what is recommended?
Thromboprophylaxis
74
What would be the reasons to immediately stop combined hormonal contraceptives or HRT?
- Sudden severe chest pain (even if not radiating to left arm)
- Sudden breathlessness (or cough with blood-stained sputum)
- Unexplained swelling or severe pain in calf of one leg;severe stomach pain
- Serious neurological effects including unusual severe, prolonged headache
- Hepatitis, jaundice, liver enlargement
- BP >160 mmHg/95; (in adolescents stop if BP very high)
- Prolonged immobility after surgery or leg injury
75
What is an associated risk of the IUD in women under 25 years?
Increased risk of pelvic inflammatory diseaseCopper has higher risk over the progesterone only IUD
76
Other than patient choice, in what groups of patients would you consider the progesterone only pill over the combined hormonal contraceptive?
When oestrogens are contra-indicated
* history of VTE
* heavy smokers
* hypertension >160/95 mmHg
* valvular heart disease
* diabetes mellitus with complications
* Migraine with aura
77
Intravesical is administration into where?
Bladder
78
Combined oral contraceptives reduce the risk of what types of cancer?
Ovarian and endometrial cancer
79
It is recommended that combined oral contraceptives are not continued beyond what age?
50 years as there are more suitable alternatives
80
Low strength preparations of combined contraceptive pill contain how much ethinylestradiol?When would you use this?
20 micrograms If risk factors for circulatory disease are present
81
Standard strength preparations of combined contraceptive pill contain how much ethinylestradiol?
30 or 35 micrograms
82
Phased preparations of the combined contraceptive pill is appropriate for what individuals?
Who
- either do not have withdrawal bleeding
- who have breakthrough bleeding with monophasic products
83
Can progesterone only contraceptives be used during surgery?
Yes
84
Women taking oral contraceptives are at an increased risk of deep vein thrombosis during long periods of travel over how many hours?
Over 3 hours
85
At what part of the cycle can you start combined oral contraceptive?When would you need to have additional barrier method and for how long for?
If reasonably certain woman not pregnant, first course started on any day of cycle
If starting on day 6 of cycle or later, additional precautions (barrier methods) necessary during first 7 days.
86
If a patient is on combined oral contraception and is changing to another combined oral contraception containing a different progesterone, how is this done?
If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start the first active tablet of new brand immediatelyMay need additional precautions but depends on specific preparations
87
If a patient is on a progesterone only tablet and is changing to a combined oral contraception, how is this does and are additional precautions needed?
If previous contraceptive used correctly, or pregnancy can reasonably be excluded, start new brand immediately, additional precautions (barrier methods) necessary for first 7 days.
88
If a patient wishes to start combined oral contraception after childbirth (not breastfeeding), how is this done?When would additional precautions be needed?
Start 3 weeks after birth (increased risk of thrombosis if started earlier); later than 3 weeks postpartum additional precautions (barrier methods) necessary for first 7 days (9 days for Qlaira®).
89
What is the risk of starting combined oral contraception before the recommended 3 weeks postpartum?
Increased risk of thrombosis
90
If a patient has had an abortion or miscarriage, when can they start combined oral contraception if they want to?
Start same day
91
What is the advice surrounding a patient being started on combined oral contraception if breastfeeding?
Avoid until weaning Or Avoid for 6 months after birth (adverse effects on lactation).
92
What are the 6 risk factors for VTE for combined oral contraception?How many risk factors would deem the patient unsuitable for combined oral contraception?
1. Fhx of VTE in 1st-degree relative aged under 45 years
2. Obesity; BMI ≥ 30 kg/m2 (avoid if body mass index ≥ 35 kg/m2 unless no suitable alternative)
3. Long-term immobilisation e.g. in a wheelchair, leg in plaster
4. History of superficial thrombophlebitis
5. Age over 35 years (avoid if over 50 years)
6. Smoking.
Use with caution if any of following factors present but avoid if 2 or more factors present
93
What are the 7 risk factors for arterial disease for combined oral contraception?How many risk factors would deem the patient unsuitable for combined oral contraception?
1. Family history of arterial disease in first degree relative aged under 45 years2. Diabetes mellitus (avoid if diabetes complications present)3. Hypertension4. Smoking (avoid if smoking 40 or more cigarettes daily)5. Age over 35 years (avoid if over 50 years)6. Obesity (avoid if body mass index ≥ 35 kg/m2 unless no suitable alternative)7. Migraine without aura - avoid if with aura
94
At what blood pressure would you avoid initiating combined oral contraceptives in?
Above systolic 160 mmHg or diastolic 95 mmHg
95
You would avoid initiating combined oral contraceptives in patients smoking how many cigarettes a day?
40
96
What is the patient advice surrounding combined oral contraceptives and headaches?
Women should report any increase in headache frequency or onset of focal symptoms (discontinue immediately)
97
Combined oral contraceptives increase the risk of what types of cancer?
Breast and cervical
98
What is the patient advice surrounding combined oral contraceptives and vomiting/diarrhoea?When is it advised to take additional precautions?
If vomiting occurs within 2 hours of taking a combined oral contraceptive another pill should be taken as soon as possibleIn cases of persistent vomiting or severe diarrhoea lasting more than 24 hours, additional precautions should be used during and for 7 days after recovery
99
Patient taking combined oral contraceptives:If vomiting and diarrhoea occurs during the last 7 tablets, what is the advice?
The next pill-free interval should be omitted (in the case of ED tablets the inactive ones should be omitted).
100
Combined oral contraception:A missed pill is one that is more than how many hours late?
24 hours
101
If a woman forgets to take one dose of her combined oral contraceptive pill, what is the advice?
If a woman forgets to take a pill, it should be taken as soon as she remembers, and the next one taken at the normal time (even if this means taking 2 pills together).
102
If a woman misses 2 or more oral combined contraceptive pills, what is the advice?
If a woman misses 2 or more pills (especially from the first 7 in a packet), she may not be protected. She should take an active pill as soon as she remembers and then resume normal pill-taking. In addition, she must either abstain from sex or use an additional method of contraception such as a condom for the next 7 days. If these 7 days run beyond the end of the packet, the next packet should be started at once, omitting the pill-free interval (or, in the case of everyday (ED) pills, omitting the 7 inactive tablets).
103
In patients taking oral combined contraceptives, when would EHC be recommended?
Emergency contraception is recommended if 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a packet and unprotected intercourse has occurred since finishing the last packet.
104
What is the MHRA warning with IUD contraception?
Uterine perforation most often occurs during insertion, but might not be detected until sometime laterSigns and symptoms include:- Severe pelvic pain after insertion (worse than period cramps)- Pain or increased bleeding after insertion which continues for more than a few weeks- Sudden changes in periods;pain during intercourse-Unable to feel the threads
105
The main risk of infection with copper IUD occurs within the first how many days after insertion?
Within 20 daysBut believed to be linked with STIs
106
What does the BNF say about the progesterone only pill and risk of breast cancer?
The risk of breast cancer in users of POCs is possibly of similar magnitude as that associated with COCs, however the evidence is less conclusive.
107
What antidepressant can be used for moderate to severe stress incontinence in women?
Duloxetine
108
What is a common electrolyte disturbance side effect of desmopressin?
Hyponatraemia (and associated convulsions)
109
What is the patient advice for desmopressin if taking for primary nocturnal enuresis?
To reduce the risk of Hyponatraemia (and associated convulsions):Should be warned to avoid fluid overload (including during swimming) and to stop taking desmopressin during an episode of vomiting or diarrhoea (until fluid balance normal).Should not have anything to drink for 1 hour before they take desmopressin, and then for 8 hours after they have taken it.
110
What is the patient advice needed with tamsulosin?
May affect performance of skilled tasks e.g. driving.
111
What is the patient counselling with finasteride?
Rare cases of male breast cancer- report any lumps, nipple discharge
112
What is the contraception advice with finasteride?
Use condoms as it is excreted in semenWomen of child-bearing potential should avoid handling crushed tablets
113
The combined contraceptive pill is not for women above what age?
50
114
At what point of the menstrual cycle should you start the progesterone only pill? If this is not possible, how many days of additional precaution do you need?
Start on Day 1If started after day 5, additional precaution is needed for 2 days
115
After how many hours is classed as a missed pill for progesterone only?What is the exception?How many days will you will you need additional precaution?
3 hours Desogestrel - 12 hours 2 days of additional precaution needed
116
When would you need EHC if taking the progesterone only pill?
If you miss a dose and unprotected sex occurs before 2 pills are taken correctly
117
What is the advice around the progesterone only pill ad vomiting?
If you vomit within 2 hours of taking the pill, take another one ASAPIf you have been unable to take the pill within 3 hours of normal time (12 hours for desogestrel) then additional protection is needed until 2 days after
118
True or false:It is not advised to remove an IUD mid cycle
TRUE
119
What is the MHRA advice with contraceptive implants?
Implants may reach the lung via the pulmonary artery
120
What is the pharmacological management of benign prostate hyperplasia?
Alpha blocker eg tamsulosin
121
What is doxazosin used for?
Hypertension or benign prostate hyperplasia
122
What are drugs that can induce hepatic enzyme activity? CENOPPPRSTRR
CarbamazepineEslicarbazepineNevirapineOxcarbazepinePhenytoinPhenobarbital PrimidoneRitonavir St John's WortTopiramateRifabutinRifampacin (possibly also griseofulvin)
123
Women using combined hormonal contraceptive patches, vaginal rings or oral tablets who require enzyme-inducing drugs or griseofulvin should be advised to change to a reliable contraceptive method that is not affected by enzyme-inducers such as:
1. Parenteral progestogen-only contraceptives (medroxyprogesterone acetate and norethisterone) 2. Intra-uterine devices (levonorgestrel).
124
Women using combined hormonal contraceptive patches, vaginal rings or oral tablets who require enzyme-inducing drugs or griseofulvin should be advised to change to a reliable contraceptive method that is unaffected by enzyme-inducers, such as some parenteral progestogen-only contraceptives (medroxyprogesterone acetate and norethisterone) or intra-uterine devices (levonorgestrel; see also Contraceptives, non-hormonal). This should be continued for how long?
The duration of treatment and for four weeks after stopping.
125
What are the parenteral progestogen-only contraceptives which are not impacted by enzyme-inducers?
Medroxyprogesterone acetate and norethisterone.
126
For a short course (2 months or less) of an enyme-inducing drug, contraception can be managed how?
Continuing the combined hormonal contraceptive method may be appropriate if used in combination with consistent and careful use of condoms for the duration of treatment and for four weeks after stopping the enzyme-inducing drug.
127
For long-term course (over 2 months) of an enzyme-inducing drug (except rifampicin or rifabutin) or a course of griseofulvin, how should contraception be managed?
1. Use of monophasic combined oral contraceptive at a dose of ethinylestradiol 50micrograms or more daily [unlicensed use] and use either an extended or a 'tricycling' regimen (taking three packets of monophasic tablets without a break followed by a shortened tablet-free interval of four days [unlicensed use]; continue for the duration of treatment with the interacting drug and for four weeks after stopping.
128
What is the minimum dose of ethinylestradiol recommended for contraceptives in patients taking enzyme-inducing drugs?
At least 50microgram ethinylestradiol daily.
129
What is 'tricycling'?
Taking three packets of monophasic tablets without a break followed by a shortened tablet-free interval of four days (unlicensed).
130
For how long after treatment cessation of an enzyme-inducing drug should extra precautions be used?
four weeks.
131
If breakthrough bleeding occurs with use of ethinylestradiol (minimum 50mcg) daily and an enzyme-inducing drug, what is recommeneded?
The dose of ethinylestradiol should be increased by increments of 10micrograms up to a maximum of 70micrograms daily on specialist advice, or to use additional precautions, or to change to a method unaffected by the interacting drugs.
132
What are the two most potent enzyme-inducing drugs, for which an alternative method of contraception (such as an IUD) is always recommended?
Rifampicin and rifabutin. Rifampacin: TB, leprosy and legionnaire's disease. Rifabutin: TB, prevent and treat Mycobacterium avium complex. Alternative to rifampicin in people with HIV/AIDs on antiretrovirals.
133
Is the effectiveness of the etonorgestrel-releasing implant impacted by enzyme-inducing drugs?
Yes
134
What options are there for EHC in people taking enzyme-inducing drugs?
Effectiveness of levonorgestrel and ulipristal acetate is reduced in women taking enzyme-inducing drugs or griseofulvin.A copper intra-uterine device can be offered instead. If copper intra-uterine device is declined or unsuitable, the dose of levonorgestrel should be increased.
135
Regular hormonal contraception should not be newly initiated in a patient until how many days after administration of ulipristal acetate as emergency hormonal contraception?
At least 5 days, can cause reduced effectivness of ulipristal acetate.
136
Which type of EHC can be used more than once in the same cycle?For the one that cant, why is this?
Ulipristal acetate can be used as EHC more than once. The manufacturer advises that the use of levonorgestrel as EHC more than once in the same cycle is not advisable due to increased risk of side-effects.
137
Levonorgestrel should not be used as emergency hormonal contraceptive within how many days of administration of Ulipristal acetate (as emergency hormonal contraception), the contraceptive effect of ulipristal acetate may be reduced by progestogens.
5
138
Ulpristal acetate is not recommended for use in women who have severe asthma treated with what?Why?
Ulipristal acetate is not recommend for use in women who have severe asthma treated by oral corticosteroids, due to the antiglucocorticoid effect of ulipristal acetate.
139
Which SNRI is licensed for moderate to severe stress urinary incontinence?
Duloxetine
140
What are darifenacin and solifenacin?
some of the newer antimuscarinic drugs licensed for urinary frequency, urgency and incontinence
141
What is oxybutinin?
antimuscarinic drug that also has a relaxant effect on smooth muscle. Has many antimuscarinic side effects that limit use and consequently newer ones are taking over
142
A lot of the drugs used for urinary problems are antimuscarinic. what are the antimuscarinic side effects?
Constipationdry mouthskin drynessurinary retentionskin flushing pupil dilation
143
What is tolerodine?
Another antimuscarinic used in this condition
144
What are Flavoxate and Trospium
More antimuscarinics- some of the newer ones
145
Is there any bloody drugs in this condition that aren't antimuscarinic?!
Mirabegron!A selective beta 3 agonist
146
What is first line treatment for nocturnal eneuresis (bed wetting) in children?
An enuresis alarm- an alarm that goes off as soon as the child wets the bed as it detects moisture- the child gradually learns to wake before the alarm and gets to toilet on time.Desmopressin is used if the alarm fails for child over 5 years!!
147
what is Fesoteradine
another antimuscarinic used in this for frequency/ urgency/ incontinence
148
What do we need to warn drivers taking Tamsulosin?
may effect driving and performance of skilled tasks- extra warning label
