Exam 3 Flashcards

Question

What are some principles of menopausal hormone therapy?

Answer 1

The treatment should be tailored to the individual pt and will vary according to age, symptom severity, medical profile, risk/benefit ratio, etc. There should be a shared decision-making approach.

Answer 2

First, determine if there's evidence of moderate/severe menopausal symptoms. Moderate/severe vulvovaginal atrophy: consider hormonal therapy. - If yes, use vaginal estrogen prep (endometrial monitoring if uterus is intact) or ospemifene or prasterone; Use estradiol acetate ring or systemic estrogen (plus progesterone) if also vasomotor symptoms - If no, use nonhormonal vaginal moisturizer Moderate/severe vasomotor symptoms: consider hormonal therapy. - If yes, use oral or transdermal estrogen or estradiol acetate intravaginal ring (plus progesterone if uterus intact); Use bazedoxifene/conjugated estrogens (only if uterus is intact) - If no, use SSRI or SNRI antidepressant, gabapentin/pregabalin, or clonidine; If taking tamoxifene, avoid paroxetine or fluoxetine or other moderate or strong CYP2D6 inhibitors.

Answer 3

Hypothalamus: - GHRH: Growth hormone releasing hormone - SST: Somatostatin - TRH: Thyrotropin releasing hormone - CRH: Corticotropin releasing hormone - GnRH: Gonadotropin releasing hormone Pituitary: - GH: Growth hormone (acts on many peripheral tissues) - TSH: Thyroid stimulating hormone (acts on thyroid) - ACTH: Adrenalcorticotropic hormone (acts on adrenal cortex) - FSH, LH: Follicle stimulating hormone, luteinizing hormone (acts on gonads)

Answer 4

Stimulators of the hypothalamus: GHRH, TRH, CRH, GnRH Suppressors: DA, SST

Answer 5

Anterior pituitary: - Growth hormone (activate JAK/STAT pathway) - Prolactin (activate JAK/STAT pathway) - TSH, FSH, LH (activates GPCRs, have common α chain) - ACTH (activates GPCRs) Posterior pituitary: - Vasopressin - Oxytocin

Answer 6

GH - Small protein with 2 disulfide bonds. Similar to prolactin. It's an α-helix bundle. Thyroid stimulating hormone, FSH, and LH all have that same α chain, so you end up differentiating by the beta strand.

Answer 7

GH (growth hormone): Required to attain adult size. Increases lean body mass, reduces central adiposity (increases metabolism of fat), reduces insulin sensitivity. IGF-1 (insulin-like growth factor 1): GH stimulates IGF-1 which is what promotes the growth in the liver, bone, cartilage, and muscle.

Answer 8

rhGH (somatotropin) - recombinant GH, α-helix bundle rhIGF-1 (mecasermin) - Used in the treatment of IGF-1 deficiency (ex. if GH doesn't bind to its receptor) . Its structure is a complex with an IGF-1 binding protein to increase the half life.

Answer 9

FSH - directs ovarian follicle development in women, regulates spermatogenesis in men, and stimulates the conversion of testosterone to estrogens in both. LH - stimulates androgen production in the follicular phase and controls est/prog production in the luteal phase for women, stimulates androgen production in men. hCG - produced in the placenta during pregnancy, controls est/prog production during pregnancy. The structure is nearly identical with LH. FSH, LH, and hCG are all heterodimeric proteins that have the same α chains, but different β chains (LH and hCG are nearly identical tho).

Answer 10

Menotropins - Mixture of FSH and LH taken from urine of postmenopausal women. This is the most commonly used ones. Urofollitropin (uFSH) - Only FSH from postmenopausal women; The LH activity is removed during purification. Follitropin α & β - Recombinant forms of FSH. Lutropin α - Recombinant form of LH. Used for stimulation of follicular development in infertile women with LH deficiency, but it was discontinued due to cost. hCG - extracted from pregnant women and has the same activity as LH. Choriogonadotropin α (rhCG) - recombinant hCG Uses: - Ovulation induction: This is usually for patients that fail to respond to other treatments like Clomiphene. - Male infertility

Answer 11

Pulsatile - stimulates the production and release of LH and FSH. Continuous - it would suppress FSH and LH due to desensitization (or down regulation).

Answer 12

Only 2 amino acids are different: AA 3 and 8. There's some cross-activity, so if oxytocin levels are high, it's not uncommon to see vasopressin effects.

Answer 13

- Increases reabsorption of water from tubular filtrate by increasing water permeability in the cells in renal collecting tubes (antidiuretic activity). - Constricts blood vessels to raise blood pressure (vasopressor activity). - Increases levels of Von Willebrand factor and coagulation factor VIII.

Answer 14

Desmopressin is a long-acting synthetic analog of vasopressin due to the modification at AA 1 and 8. Desmopressin has very minimal V1 receptor activity, meaning it doesn't have much vasoconstriction activity. It much more of a selective antidiuretic than vasopressin.

Answer 15

Vasopressin: - coagulopathy in hemophilia A (clotting defect) - von Wilderbrand's disease (low clotting) Desmopressin: - pituitary diabetes insipidus - nocturnal enuresis

Answer 16

- Water intoxication (can lead to hyponatremia, drowsiness, headache, etc.) - Abdominal cramping - Allergic reaction Use with extreme caution in person with cardiovascular diseases

Answer 17

- Uterine contraction in labor and delivery (contracts uterine smooth muscle, stimulates the release of prostaglandins and leukotrienes that augment uterine contraction) - Milk ejection in lactating women (contracts myoepithelial cells surrounding mammary alveoli) - Acts through a GPCR to increase cytosolic Ca2+ levels resulting in smooth muscle contraction - Improves social bonding and trust

Answer 18

- Induction and stimulation of labor - Control of uterine hemorrhage after delivery - Enhancement of milk ejection

Answer 19

- Excessive stimulation of uterine contraction before delivery (can cause fetal distress, placental abruption, uterine rupture, and trauma to the birth canal) - Activation of vasopressin receptors by overdose of oxytocin (can cause fluid retention, water intoxication, and hyponatremia)

Answer 20

- Fetal distress - Abnormal fetal presentation - Cephalopelvic disproportion

Answer 21

1. FSH precautions during follicular phase - to prevent premature surge in LH, the effects of endogenous GnRH need to be blocked by continuous administration of GnRH or GnRH receptor antagonist. 2. Administration of hCG leads to ovulation which leads to insemination or oocyte retrieval. 3. Hormonal support during the luteal phase (typically by exogenous progesterone).

Answer 22

Stimulation: Pulsatile GnRH - Female infertility: uses pump to give pulsatile dosing. - Male infertility: Uses pump to give pulsatile dosing. Used for men with hypothalamic hypogonadotropic hypogonadism. This isn't the preferred treatment. Suppression: continuous GnRH - Controlled ovarian hyperstimulation to suppress LH surge - Endometriosis (reduces production of est/prog) - Prostate cancer (reduces testosterone levels) - Central precocious puberty

Answer 23

These act as competitive antagonists (Genirelix, Cetrorelix, Abarelix, etc.) - Controlled ovarian hyperstimulation: Produce an immediate antagonist effect. - Advanced prostate cancer

Answer 24

They antagonize eachother. As dopamine goes up, prolactin goes down, and vice versa. Hyperprolactinemia can be treated pretty well by dopamine agonists.

Answer 25

- Growth and development: It's essential for brain development (without T3, cretinism can happen) and promotes protein synthesis - Metabolic effects: Increases basal metabolic rate (BMR) and oxygen consumption - Thermogenesis: Increases resting heat production - Cardiovascular effects: Increases catecholamine sensitivity

Answer 26

T3 - Has 3 iodines; More potent T4 - Has 4 iodines; Produced 10x more than T3

Answer 27

A. Get iodine (I2) from diet and it converts to I- iodide in the stomach B. Iodide active transport into thyroid follicular cell by Na+-I- symporter (NIS) C. Iodide passively passes down into the follicular colloid through the pendrin transporter. Then it's oxidized by thyroid peroxidase to I^0 at the apical membrane. D. Iodide-free thyroglobulin is transported to the apical membrane E. Thyroglobulin is iodinated by thyroid peroxidase at one or two positions, forming the hormone precursors MIT and DIT F. MIT + DIT = T3 and DIT + DIT = T4. This coupling is dependent on thyroid peroxidase G. Thyroid hormone-containing thyroglobulin is retrieved back into the cytosol as colloid droplets by pinocytosis H. Lysosomal exopeptidases cleave T3 or T4 from thyroglobulin and the hormones are released into circulation where T4 can be converted to T3 by 5'deiodinase.

Answer 28

Deiodination is when T4 or T3 is conjugated to form glucuronide or sulfate with the phenolic group. It is then excreted in the bile.

Answer 29

A goiter is an enlargement of the thyroid gland due to a persistent rise in TSH (this means that TSH is low, so there's no negative feedback, which causes a rise in TSH) Toxic - Diffuse toxic goiter is seen in Graves' disease. Toxic uninodular goiter and toxic multinodular goiter is seen with an adenoma producing excess T3 Nontoxic - Thyroid enlargement that may be seen in hypothyroidism

Answer 30

The symptoms are exactly opposite from each other. Hypo slows everything down, hyper speeds everything up. Hypothyroidism - Deficiency of thyroid hormones - Decrease in metabolic rate presented by fatigue, mental dullness, lethargy, inattention - Defective thermoregulation - Nontoxic goiter - Dwarfism and mental retardation (cretinism) in infants and children - Myxoedema coma Hyperthyroidism - Excessive levels of thyroid hormones - Excessive metabolism presented by poor thermoregulation and weight loss - Increased heart rate and cardiac output

Answer 31

Hashimoto's thyroiditis - Autoimmune disease that destroys the thyroid gland leading to hypothyroidism Graves' disease - Autoimmune disease that involves thyroid-stimulating IgG. This can result in enlargement of the entire thyroid gland (diffuse toxic goiter)

Answer 32

Levothyroxine (T4) - Converted to T3 intracellularly. Slow onset with long half life. Takes 6-8 weeks to reach steady state. Liothyronine (T3) - Rapid onset, short duration of action, requiring multidosing. Only used in emergency situations. Liotrix (4:1 mix of T4 and T3) - More expensive and not more effective than T4 administration.

Answer 33

- Antithyroid drug therapy - Thioamides - Thyroidectomy - requires lifetime thyroid supplementation - Destruction of the gland with radioactive iodine - Anion inhibitors (competitive inhibitor of iodide, ex. SCN-) - Symptom treatment: Propranolol to slow heartbeat, Diltiazem for tachycardia, Barbiturates lower T4 levels and act as sedatives, Bile acid sequestrants lower T4 levels.

Answer 34

Ca2+ channel is responsible at first K+ channel is responsible last

Answer 35

Norepinephrine - (released by sympathetic nerve) Binds to β-adrenergic receptor, which increases cAMP, which activates the HCN channel. This activation increases diastolic Na+ conductance, which shortens the time until the next spike. So this increases heart rate. Acetylcholine - (released by vagal nerve) Binds to M2, releasing Gβγ from Gα. Gβγ activates GIRK channel, which causes hyperpolarization leading to delayed time until the next spike. So this decreases heart rate.

Answer 36

T3 increases the transcription of the β-adrenergic receptor and HCN channel, which are both involved in increasing the heart rate.

Answer 37

Thioamides inhibit thyroid peroxidases. They block iodine organification and block the coupling of the iodotyrosines. Ex. Methimazole, Propylthiouracil

Answer 38

Large doses of I- inhibits its own uptake, organification, release of thyroid hormones, and it decreases vascularity of the thyroid gland. However, these are only used short-term, like in prep for a thyroidectomy.

Answer 39

KI solution antithyroid drugs beta blockers

Answer 40

TSH test - This measures pituitary TSH level. This is the gold standard and is the most sensitive index for hyperthyroidism. Low TSH level indicates hyperthyroidsim, high TSH level indicates hypothyroidsm. Free T4 test - Measures free thyroxine. This is the most accurate test. AtgA test - Measures antibodies to thyroglobulin. It's + in autoimmune thyroid disease. TPO-Ab test - Measures thyroperoxidase antibodies. TRAb test - Measures thyroid receptor stimulating antibody. This is used to confirm Graves' disease.

Answer 41

1. Thiomides: Take about a month to kick in. Ex. Propylthiouracil (PTU), Methimazole; PTU has a much shorter t1/2, is preferred in the first trimester of pregnancy, has black box warning of hepatic failure. Methimazole is preferred during 2nd and 3rd semester of pregnancy, is more potent, and doesn't have a black box warning. Methimazole is typically preferred. 2. Radioactive iodine (RAI): Causes slow destruction of thyroid gland. It's contraindicated in pregnancy. There's a very high change of causing hypothyroidism with this. 3. Surgery (thyroidectomy): Used as a last resort for large glands, cancer, multinodular goiter, medical failure, 2nd trimester pregnancy, etc. Adjunct treatment - 1. β-blockers: Used short term to alleviate symptoms. Use in patients with HR > 90bpm. Only use cardio-selective ones like propranolol, metoprolol, or atenolol. 2. Calcium channel blockers: Use if contraindicated to β-blockers.

Answer 42

Drugs that... - Lower T4 absorption: Bile aid sequestrants, ferrous sulfate, calcium supplements, etc. - Raise serum TBG concentration: Estrogen - Raise T4 requirement: Enzyme inducers like phenytoin, rifampin, carbamazepine, phenobarbital - Disease-drug interaction: Warfarin

Answer 43

Thyroid supplements 1. Levothyroxine (T4): 1.6mcg/kg/day for uncomplicated adult; Dosing varies on patient characteristics. - Liothyronine (T3): Main use is short term hormone replacement or as a diagnostic agent. - Desiccated thyroid: No justification to use this... so don't

Answer 44

Hyper - - Iodinated compounds (ex. potassium iodide) - Amiodarone - Interferons - Lithium Hypo - - Amiodarone - Lithium - Interferons

Answer 45

PTH - Parathyroid hormone: Increase serum Ca2+ levels. PTH secretion is triggered by low serum Ca2+ levels There is a negative feedback system where if Ca2+ goes up, PTH should shut off. It causes increased Ca2+ reabsorption from collecting tubules and bone, increases PO4 loss in the urine, increased 1,25(OH)2 D3 production by the kidney. Vitamin D - Increases Ca2+ and PO4 absorption from the small intestine, increases Ca2+ and PO4 reabsorption, indirectly slows effects on cells (calbindins, vitamin D binding protein), and inhibits PTH. FGF23 - Fibroblast growth factor 23: Secreted in response to elevated serum phosphate. It stimulates phosphate excretion, inhibits PTH secretion, and inhibits 1,25(OH)2 D synthesis. Calcitonin - Negative regulator of serum Ca2+. it inhibits osteoclastic bone resorption and increases Ca2+ and PO4 loss in urine. It's stimulated by high serum calcium levels.

Answer 46

Biosynthesis: 1. Provitamin D -> Vitamin D3 (cholecalciferal) through UV irradiation of skin. 2. Vitamin D3 converted to 25 hydyoxyvitamin D3 after being transported to the liver by Vitamin D binding protein 3. In the kidney, 25 hydyoxyvitamin D3 is converted to either 1,25 Dihydroxy Vit D3 (calcitriol) when phos, and Ca2+ are low or 24,25 Dihydroxy Vit D3 (secalciferol) when phos. and Ca2+ are normal. Use of Vit D3 in osteoporosis and vitamin D deficiency: - Increases absorption of Calcium and phosphate from the intestines - Increases reabsorption of calcium and phosphate

Answer 47

Estrogens & SERMs: second line treatment for osteoporosis. Goal is to prevent and control postmenopausal bone resorption. MOA: Increases the activity of osteoblasts and may decrease the activity of osteoclasts. Ex. Micronized estradiol, conjugated estrogens, raloxifene

Answer 48

Calcitonin - Second line treatment of osteoporosis. Stimulated by high serum Ca2+ levels to reduce Ca2+ serum levels. Disease states: - Paget's disease - Hypercalcemia 2º to malignancy - Postmenopausal osteoporosis MOA: It inhibits osteoclastic bone resorption and increases Ca2+ and PO4 loss in the urine. Cons - loses efficacy over time, can cause urticaria, hand swelling, and nausea.

Answer 49

Vitamin D - Includes cholecalciferol Vit D3 (OTC), Calcifediol, Calcitriol. Disease states: - Osteoporosis - Hypocalcemia/Hypoparathyroidism - Hyperparathyroidism (suppresses PTH) MOA: Increases Ca2+ and PO4 absorption from the gut, increases Ca2+ and PO4 reabsorption in renal tubules. Cons - May OD, may cause hypercalcemia resulting in coma or death.

Answer 50

Cinacalcet & Etelcalcetide MOA: PAM. Brings PTH levels down by binding to CaR, which is a GPCR on PTH gland. This decreases both serum PTH and Ca2+ levels. Disease state: - 2º Hyperparathyroidism (from CKD with dialysis or parathyroid carcinoma) Cons of Etelcacetide - Injection (Cinac. is oral)

Answer 51

Bisphosphonates: First line of therapy for osteoporosis. MOA: Inhibits bone resorption, reduces the formation and dissolution of hydroxyapatite crystals (50% of the absorbed dose ends up in the bone), inhibits farnesyl pyrophosphate synthase, thus inhibiting the signaling pathway of osteoclasts. Cons - May lead to hypocalcemia, may cause gastric irritation, need to stay upright after taking it. For Paget's and cancer: Pamidronate, Etidronate For osteoporosis: Zoledronate, Alendronate, Risedronate, Ibandronate

Answer 52

Teriparatide and Abaloparatide acts as PTH hormone. Disease states: - Osteoporosis in patients with high risk of fracture MOA: At a low dose everyday, it preferentially stimulates osteoblast activity. Its receptor is a GPCR on osteoblasts that activates Gs and Gq. Pros (compared to bisphos.) - May be more effective at preventing fractures, builds bone mass faster, may allow better bone healing after fracture. Cons - Must be injected daily, not recommended beyond 2 years, black box warning of bone cancer.

Answer 53

Deniszumab: Humanized mAb against RANKL Romosozumab: mAb against sclerostin Disease state: - Postmenopausal osteroporosis MOA Deniszumab Rinds to RANKL to prevent activation of RANK on osteoclast precursors, thus preventing differentiation of osteoclasts. MOA of Romosozumab: Inhibits sclerostin, which would normally decrease OB and increase OC. Cons of Romo.: Major adverse cardiovascular events

Answer 54

High PTH levels decreases Ca2+ levels, so we want to inhibit this. Patients with CKD on dialysis have lost 1,25(OH)2 Vit D3 production. Zemplar - Inhibits secretion of PTH with less effect on serum Ca2+ levels Hectorol - Inhibits secretion of PTH with less effect on serum Ca2+ levels Cinacalcet - PAM of CaR to increase calcium sensitivity, inhibit release of PTH and decrease serum PTH and Ca2+ levels. Etelcacetide - PAM of CaR to increase calcium sensitivity, inhibit release of PTH and decrease serum PTH and Ca2+ levels.

Answer 55

Phosphate binders - Complex with dietary phosphate and prevent absorption from GI. They are used to treat hyperparathyroidism and hyperphosphatemia. In CKD, it's common to lose phosphate excretion in response to PTH and FGF23, so we need to get rid of this excess phosphate. Fosrenol - (Lanthanum Carbonate) Forms insoluble LaPO4 salts in the GI tract, thus decreasing serum PO4 AND Ca2+ levels Renagel - (Sevelamer) Binds PO4 in the GI tract, selective decreases only serum PO4 levels.

Answer 56

Uncontrolled osteoclastic bone resorption and secondary bone formation, but the secondary bone formation is poorly organized. This can cause bone pain, bone deformities, and loss of hearing.

Answer 57

There's an imbalance of osteoblastic/osteoclastic activity. - Decrease in estrogen levels causes a decreased bone mass. - The shift in bone remodeling balance toward resorption, meaning more osteoclasts - Causes spontaneous or minimal trauma fractures Risk factors: Physical inactivity, age, low Ca2+ intake in early years, long term glucocorticoid therapy

Answer 58

Hyper: - Hyperparathyroidism: Causes increased bone resorption and decreased Ca2+ excretion. - Malignant tumors that produce a peptide with PTH activity Hypo: - Hypoparathyroidism - Vit D deficiencies Rickets: Vitamin D deficiency - Can see weight bearing bone deformities in children - Hypocalcemia in adults

Answer 59

1. Bisphosphonates 2. Estrogens 2. Calcitonin Severe osteoporosis: Bone anabolics and monoclonal antibodies Supplement: Vitamin D

Answer 60

The decreased bone density, bone strength, and deterioration of bone micro-architecture results in an increased bone fragility and increased risk of fracture. The main sites of fracture are vertebral (spine), and non-vertebral (wrist and femur/hip).

Answer 61

Atraumatic fracture of the spine, femur, and/or distal radius OR WHO bone mineral density interpretation by DXA. WHO DXA criteria: - Normal = >0 to -1 - Osteopenia = -1.1 to -2.4 - Osteoporosis = ≤ -2.5 - Severe osteoporosis = ≤-2.5 + ≥ 1 fragility fracture

Answer 62

- Glucocorticoids - more than 5mg of prednisone a day for 3 months or equivalent - Anticonvulsants - Medroxyprogesterone acetate depot - Thyroid supplements - Warfarin - Proton pump inhibitors

Answer 63

Indications - Treatment and prevention of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, and to increase bone mass (from osteoporosis) in males. Contraindications - Hypocalcemia, renal insufficiency, esophageal abnormalities if it gets stuck in the esophagus, if the pt can't stand or sit for 30 minutes, risk of aspiration (alendronate oral solution), bariatric surgery (bisphosphonate), pregnancy/breast feeding Fracture prevention efficacy - Alendronate, Risedronate, and Zoledronic acid are all broad spectrum and reduce all three types of fractures significantly. Ibandronate is only indicated for vertebral fracture risk. Adverse effects - Esophageal irritation/ulceration, abdominal pain, headache, nausea, atypical thigh fracture, osteonecrosis to the jaw, etc.

Answer 64

Indications - Treatment of osteoporosis in men and postmenopausal women who are at high risk for fractures (like Hx of osteoporotic fracture). Treatment of glucocorticoid induced osteoporosis. Contraindications - Hypocalcemia Fracture prevention efficacy - 68% vertebral, 44% hip, 20% non-vertebral. Impressive! Adverse effects - Common ones are back pain, high cholesterol, musculoskeletal pain, bladder infections. Serious ones are osteonecrosis of the jaw, hypocalcemia, dermatitis, etc. Dosing - For postmenopausal osteoporosis treatment, GC-induced treatment, and in men: 60mg SQ every 6 months.

Answer 65

Indications - Raloxifene for prevention and treatment of postmenopausal osteoporosis and breast cancer prophylaxis for postmenopausal women at high risk; Bazedoxifene for prevention in postmenopausal women with a uterus. Contraindications - Active or history of venous thromboembolic events, pregnancy/lactating Fracture prevention efficacy - Only for vertebral risk reduction. Raloxifene is 41% and Bazedoxifene is 39%. Adverse effects - Raloxifene has black box warnings of DVT and pulmonary embolism and stroke. Also side effects include hot flashes, leg cramps, weight gain, and edema Dosing - - Raloxifene (postmenopausal only) prev and treat: 60mg PO daily - Bazedoxifene/estrogen (only postmen prevention): 1 tablet PO daily

Answer 66

Indications - Treatment of postmenopausal osteoporosis in women who are more than 5 years post menopause. Contraindications - Allergy to salmon-calcitonin Fracture prevention efficacy - Only vertebral 35% and nothing else. Adverse effects - Intranasal: rhinitis, epistaxis, increased cancer risks. SQ: flushing, nausea, rash, allergic reaction Dosing - Only postmenopausal osteoporosis treatment. - 200 units intranasally in one nostril once daily OR 100 units SQ/IM once daily

Answer 67

Indications - For women, it is for treatment of postmenopausal osteoporosis if at very high risk of fractures. Teriparatide can be used for men to increase bone mass and GC-induced osteoporosis for men and women. Contraindications - Paget's disease of bone, unexplained elevations of alkaline phosphatase, pre-existing hypercalcemia Fracture prevention efficacy - Really good for vertebral, pretty good for non-vertebral, but not for hip. Adverse effects - Increased incidence of osteosarcoma. Dizziness, orthostatic hypotension, hypercalcemia Dosing - - Teriparatide (1st choice) for treatment of postmenopausal, GC-induced, and for men: 20mcg SQ daily. - Abaloparatide (2nd choice) for only treatment of postmenopausal: 80mcg SQ daily

Answer 68

Indications - Treatment of osteoporosis in postmenopausal women who are at high risk for fractures. Contraindications - Uncorrected hypocalcemia Fracture prevention efficacy - Significant efficacy for vertebral, hip, and non-vertebral!! ** d/c of romosozumab results in bone loss and return to pre-treatment levels, so consider subsequent treatment with bisphosphonate or denosumab ** Adverse effects - Increased risk of myocardial infarction, stroke, or CV death. Headache, hypocalcemia, arthralgias Dosing - Only for postmenopausal treatment: 210mg (105mg x 2 injections) SQ monthly - Max lifetime duration is 12 months

Answer 69

Oral bisphosphonates - Must be taken on an empty stomach with a full glass of plain water. Pt can't lie down for at least 30 minutes after ingestion and until after the first food of the day. Also wait at least 30 minutes before eating, drinking, or taking other meds. (60 minutes for these for ibandronate). Do not chew.

Answer 70

First, we want to look at the risk for the patient. If risk is low/moderate, we will just reasses every 2-4 years. Maybe start bisphosphonates if we want to. At high-very high risk: use bisphosphonates and then consider denosumab, teriparatide, or abaloparatide. If that treatment all doesn't work, maybe consider a SERM, then hormonal therapy depending on vasomotor symptoms, and if over 60, then maybe calcitonin, then Calcium + Vit D. For glucocorticoid-induced osteoporosis, we want to treat with an oral bisphosphonate. For pregnant women, teriparatide is 2nd choice.

Answer 71

Asses BMD changes with DXA - 3-5% changes are significant. Successful treatment - Stable or increasing BMD with no evidence of new fractures Duration of therapy needs to be individualized

Answer 72

Variable for prevention vs. treatment. Ibandronate (only postmenopausal) - Prevention 150mg PO monthly - Treatment 150mg PO monthly OR 3mg IV every 3 months Alendronate (postmenopausal and treatment for glucocorticoid-induced osteoporosis and men) - Prev. 5mg PO daily - Treat. for all: 10mg PO daily OR 70mg PO weekly Risedronate (postmenopausal, GC-induced, and men) - Prev. 5mg PO daily OR 35mg PO weekly, or 150mg PO monthly - Treat. 5mg PO daily OR 35mg PO weekly, or 150mg PO monthly Zoledronic acid (PM, GC-induced, and men) - Prev. 5mg IV every 2 years - Treat. 5mg IV once yearly - GC and for men is always 5mg IV once yearly ** bisphosphonates are the most problematic in CKD due to renal excretion, so if eGFR is < 35, they are contraindicated **

Answer 73

Notable events: - Ovulation: Due to estrogen increasing which causes spike in LH and FSH. - Start of menses: Progesterone drops after the egg isn't fertilized, which causes the period to start over. The menses is the uterine lining shedding.

Answer 74

- HPV is responsible for almost all cases of cervical cancer in women. Also high prevalence in vaginas, vulvar, anus, and oropharynx. It's important to be vaccinated! - The admin schedule if less than 15yo is once now, and once 6-12months later. If more than 15yo, one now, one @ two months, and one @ 6 months. Side effects: Local reactions/pain, redness, pyrexia, erythema, complex regional pain syndrome, and postural orthostatic tachycardia syndrome.

Answer 75

Estrogen - Suppresses FSH production, which prevents the dominant follicle from forming, so ovulation doesn't occur. Progestin - Prevents LH surge to inhibit ovulation, thickens cervical mucus to inhibit sperm penetration/transport, changes the motility of fallopian tubes to impair transport of sperm/ova, causes atrophy of the endometrium to impair implantation.

Answer 76

- Implant: most efficacious. Only progestin. Left in place for 3 years. Use backup method if inserted more than 5 days after the start of the period. Spotting in the beginning is normal. - Levonorgestrel IUD: Only progestin. Left in place for 3-6 years. Use backup for 7 days after insertion. Spotting in the beginning is normal. - Shot: Only progestin. Administered every 3 months. Use back up for 7 days after admin. Do not use for more than 2 years due to bone density issues. - Combined Pill: Progestin & estrogen. Very low dose is 20-25 mcg EE, low dose is 30-35 mcg EE, high dose is 50 mcg EE. If more than 5 days after period, use backup for 7 days. Theres also bi, tri, and four phasic ones. - Mini-pill [Norethindrone]: (progestin). Take within 3 hours of the same time (important). If more than 5 days after period, use backup for 2 days. This one may cause heavier bleeding. - Mini-pill [Drospirenone]: Progestin. If more than 5 days after period, use back up for 7 days. If 2 or more pills missed, use backup for 7 days (like COC). - Vaginal ring: Progestin + estrogen. If more than 1 day after period, use back up for 7 days. - Patch: Progestin + estrogen. New patch each week for 3 weeks, then one week with no patch. If started more than 5 days after period, use a backup for 7 days. - Emergency contraception

Answer 77

Drug interactions - Be mindful of antibiotics For the combined pill, you want to start it within 5 days of the period and if a dose is missed, take it as soon as possible. If 2 or more is missed, take 1 ASAP and use backup for 7 days. For mini-pill, if dose is more than 3 hours late you want to take the dose ASAP and use a back up for 2 days. Start the ring on the day of the period. If not, use back up for 7 days. Can reinsert if it fell out for more than 3 hours, but use a back up for 7 days.

Answer 78

There are certain side effects that are due to too much/not enough estrogen and/or progestin. We can look at these things and adjust the dosing accordingly. Too much estrogen: Bloating, mood changes, fibroid growth, vision changes, cyclic weight gain, headache. Not enough estrogen: Breakthrough bleeding early in the cycle, light menses, vaginal dryness, spotting, no withdrawal bleeding. Too much progestin: Yeast infections, acne, hirsutism, decreased sex drive, noncyclical weight gain, etc. Not enough progestin: Breakthrough bleeding late in cycle, no withdrawal bleeding, heavy menses.

Answer 79

Combined: - Migraine with aura - Smoking more than 15 cigarettes per day and being older than 35 years old. - Hx of stroke - Currently has breast cancer Progestin only: - Current breast cancer We also need to be sure that the patient is not pregnant (there's a series of questions to ask).

Answer 80

It's a chart with lots of conditions indicating the risk of different types of birth control due to that condition. Lower risk means we should use that type of contraception. We don't want to use one that's in category 3-4.

Answer 81

- Copper IUD, Ulipristal acetate, or levonorgestrel pill. This can be used within 5 days of unprotected sex to prevent pregnancy. Copper IUD is best, Ulipristal is next, then Levonorgestrel. Side effects: Nausea, vomiting, headache, dizziness, breast pain, stomach pain, next period may start late, may have spotting

Answer 82

- Dysmenorrhea: Pain with perios; Cramping. 1º is within 6 months of 1st period, pain resolves in 48-72 hours. 2º is onset in 20-30s, involves heavy/irregular bleeding. - Amenorrhea: Absence of menstruation for more than 6 months. It's usually due to some other conditions (disorders of uterus/outflow tract, ovary, anterior pituitary gland, hypothalamus/CNS) - Oligomenorrhea: Menstrual cycle is longer than 35 days long. Causes include anovulation, heavy exercise, eating disorders, thyroid disease, etc. - Polymenorrhea: Menstrual cycle is shorter than 21 days. Causes include anovulation, adolescent age, perimenopause, STIs, etc. - Menorrhagia: Heave menstrual bleeding of more than 80mL per day. Can be caused by hormonal imbalance, infection, fibroids, and coagulopathy. - Metrorrhagia: Bleeding in between periods. Can be caused by hormone imbalance, fibroids, medications, IUDs, infections.

Answer 83

Dysmenorrhea: - Non-pharm: Heating pad, exercise atleast 3x per week, nutritional supplementation with omega-3 fatty acids, vitamin B, and ginger, smoking cessation, acupuncture. - Pharm: NSAIDs & oral contraceptives are 1st choice; Danazol and Leuprolide acetate (GnRH) are 2nd choice. Menorrhagia: - Non-pharm: Target the underlying cause. - Pharm: NSAIDs, Hormonal contraceptive, iron supplementation. Acute menorrhagia - Tranexemic acid, medryoxyprogesterone, high dose estrogen

Answer 84

Endometriosis therapy: Goal is to minimize endometrial lesions, prevent disease progression, minimize pelvic pain, and prevent/correct infertility. - Non pharm: Exercise, acupuncture, massage, cognitive behavior therapy to help with anxiety, surgical treatment. - Pharm: NSAIDs are first line for symptomatic management (Ex. ibuprofen, naproxen); Hormonal options can help through atrophy of endometrial tissue. Not only contraceptives, but also androgens or GnRH agonists for short term use before surgery. Fibroids: - If patient wants to preserve fertility: NSAIDs, OCs, LNG IUD, Tranexamic acid, GnRH agonist, SPRM, myomectomy - Preserve uterus: LNG IUD, GnRH agonist, SPRM, Embolization, ultrasound surgery, myomectomy - Neither: Embolization, ultrasound surgery, hysterectomy.

Answer 85

Non-pharm: Aerobic exercise, relaxation techniques, supplements (calcium carb, vit B6, vit D, vit E), reduced caffeine, alcohol, etc., increase complex carvs, have a structured sleep schedule. Pharm: 1. SSRIs (try 3 different SSRIs), NSAIDs, Spironolactone 2. Venlafaxine, Duloxetine -> COCs -> Clomipramine -> Alprazolam Last. GnRH agonist, Surgery Complementary. Ginkgo, St. John's Wort

Answer 86

Orgasmic disorder - Cognitive behavioral therapy, EROS-CTd, Non-FDA bupropion, Apomorphine SL Interest/Arousal: Hormone therapy (est. or test.), Addyi, Vyleesi Genito-pelvic pain/penetration disorder: Hormone therapy (est or test), Ospemifene, lubricants, cognitive behavioral therapy, pelvic floor exercises, botulinum toxin, mechanical devices

Answer 87

Increase 300-400 extra calories per day. Limit: Artificial sweeteners, dairy, raw eggs, unwashed fruits and vegetables, herbal teas, undercooked meats, caffeine (<200mg/day). Supplements: - Folate (Folic acid): reduce risk of neural tubal defects. 400-600mcg daily - Calcium: Can decrease risk of maternal bone loss, HTN, and preeclampsia. 1000-1300 mg daily. - Iron: Helps with blood oxygenation. 27-30mg daily.

Answer 88

1. Inactivated flu before the end of october. 2. Tdap between 27-36 weeks of pregnancy. 3. Covid mRNA AVOID - HPV, MMR, Live flu, Varicella, Yellow fever, Thyphoid fever

Answer 89

Sections on the package insert: 8.1 Pregnancy (includes labor and delivery); 8.2 Lactation (includes nursing mothers); 8.3 Females and Males of reproductive potential Teratogens - Warfarin, Lisinopril, Lithium, Methotrexate, Alcohol, Isotretinoin, Statins

Answer 90

Nausea and Vomiting - 1st line is non pharm like avoiding triggers, eating smaller, dryer meals, avoid spicy foods, keep stomach from being completely empty. 2nd line is pharm: Pyridoxine -> Doxylamine and Pyridoxine -> Meclizine, Dimenhydrinate, Diphenhydramine -> Ondansetron Metoclopramide Heartburn and constipation - - Heartburn: Non pharm like smaller, more frequent meals, avoid foods and liquids before bed, elevate head of the bed; Pharm treatment like antacids, sucralfate, H2RAs, PPIs. - Constipation: Non pharm like increase high-fiber foods, increase fluid intake to 8 glasses of water per day, regular exercise; Pharm: Osmotic laxatives, stool softeners, bulk laxitives. Pain, fever, and headache - Non-pharm: Cool compress, manage stress, get 8 hours of sleep; Pharm: Acetaminophen (avoid NSAIDs after 32 weeks) Cough and cold - make sure they are vaccianted against flu and covid. Treat based off symptoms with single agents. Ex. congestion treated with sudafed, runny nose and sleeplessness with diphenhydramine or chlorpheniramine. Urinary tract infections - Non-pharm includes hydration, proper wiping and voiding before and after sex, wearing cotton underwear; Pharm treatment is antibiotics (1st gen cephalosporins like Cephalexin, Nitrofurantoin, Amoxicillin, Ampicillin)

Answer 91

1. Induction of labor (stages 2 and 3) - Low dose is 1-2 milliunits/min every 15-60mins; High dose is 4-6 milliunits/min every 15-30mins. 2. Postpartum hemorrhage - IV: 20 units/L over 1 hour; IM: 10 units. 3. Medical termination - 50 units/500mL over 3 hours + 1 hour rest, then repeat, adding another 50 units per cycle.

Answer 92

Mother - What medication, what dose, how long of duration, effect on milk supply, are there safer alternatives? Infant - Age, weight, preterm vs. term, other health conditions, % of diet composed of breastmilk Antidepressants - Paroxetine, Sertraline

Answer 93

Relevant infant dose (RID): If the RID is over 10% then a large amount of it transfers to milk and there are risks of the effect in the infant. Ex. ASA 10.8% or Doxycycline 13.3% Hale's lactation category: L1 is the safest (ex. APAP and amoxicillin) -> L5 is the worst, meaning it's contraindicated (ex. Amiodarone, chemotherapy agents)

Answer 94

Breast shield Pump Milk container

Answer 95

Levonorgestrel - ++++ progestin, ++++ androgenic. LNG is the progestin with the most progestin activity. Drospirenone and segesterone - +/- progestin, none for the others; These act differently. They aren't very selective. They can cause potassium related issues for some people.

Answer 96

A - Abdominal pain C - Chest pain (from pulmonary embolism or myocardial infarction) H - Headache (from HTN, stroke, migraine) E - Eye problems (stroke, HTN) S - Severe leg pain (DVT)

Answer 97

Need to have at least 5 symptoms and at least one from each section: 1. Affective lability, irritability, depressed mood, anxiety 2. Decreased interest in usual activities, difficulty concentrating, change in appetite, lethargy, hypersomnia or insomnia, feeling overwhelmed or out of control, physical symptoms

Answer 98

Irregular bleeding from pill - Ibuprofen, Mefenamic acid, change pill formulation. If implant/IUD, could also use combined pill for 1 cycle or used EE for 21 days. Heavy/prolonged bleeding - Ibuprofen, EE for 21 days, Tranexamic acid Headaches - Ibuprofen, acetaminophen, etc., if during hormone-free week, consider extended use. Nausea - Take pill with food or at bedtime, if at beginning of cycle, consider continuous use. Breast tenderness - Supportive bra, hot/cold compress, ibuprofen, APAP, maybe lower dose of estrogen. Acne - Topical treatments, different pill formulations, switch from IUD/implant to combined pill. Mood changes - Continuous cycle if the changes are during the hormone-free week. Pain - Ibuprofen, acetaminophen, etc.

Answer 99

of symptoms: - normal: 1 or more - PMS: 1 or more - PMDD: 5 or more Severity of symptoms: - Normal: mild/no functional impairment - PMS: Economic or social impairment - PMDD: Significant distress/interference with daily life Time period of symptoms: - Normal: 1-2 days before menses - PMS: 5 days before menses - PMDD: 7 days before menses and resolves within a few days of cycles: - PMS: 3 consecutive - PMDD: at least 2 symptomatic cycles

Answer 100

Depression - Cognitive behavioral therapy or if EPDS score is above 10, then use previous antidepressants, CBT, or pharmacologic agent. Gestational diabetes - Diet and exercise, regular self monitors of blood glucose; Pharm: Insulin is preferred. Thromboembolism - Inferior vena cava filter, compression stockings; Pharm: anticoagulant for at least 6 months (NOT warfarin) Preeclampsia and eclampsia - Prevent with baby aspirin in first trimester. If severe, Use IV therapy because we want to treat immediately (Hydralazine, Labetalol, Nitroprusside, Nifedipine) Preterm labor - - Prevention: Progesterone 200mg vaginal suppository if no history of preterm labor; 250mg IM weekly during weeks 16-36 if history of preterm birth - Treatment: Corticosteroids, antibiotics (apicillin + erythromycin), tocolytics, magnesium sulfate (4-6g IV loading dose, 2g/hr)

Answer 101

Magnesium sulfate 4-6g IV bolus. - This relaxes the blood vessels in the cerebrum to reduce the lack of blood flow. Alternatives include phenytoin, benzodiazepines, and/or immediate delivery.

Answer 102

- Controlled ovarian hyperstimulation: Aromatase inhibitors like Letrozole (starat day 3 of menses, 2.5-10mg x 5days) and anastrozole (start day 3 of menses, 1mg x5 days), w/ or w/o intrauterine insemination (IUI) - Gonadotropins w/ or w/o IUI - Assisted reproductive techniques: IUI (delivering washed sperm into uterine cavity via soft catheter, more successful the more times you do it), in vitro fertilization (IVF, matured eggs are retrieved and fertilized, then transferred back to the uterus, $$), intravaginal culture, intracytoplasmic sperm injection (ICSI, good for male infertility)

Answer 103

Women <35 yo: unable to become pregnant after 12 months of frequent, unprotected intercourse. Women 35-40 yo: unable to become pregnant after 6 months of frequent, unprotected intercourse. Women >40 yo: unable to become pregnant after less than 6 months of frequent, unprotected intercourse.

Answer 104

Hyperandrogenism - - Hirsutism (most common) - Acne - Alopecia Menstrual disturbances - - Amenorrhea - Oligomenorrhea - Anovulation Overweight or obese Diagnosis: Polycystic ovaries, chronic anovulation, and hyperandrogenism.

Answer 105

1. Inappropriate gonadotropin secretion: An increase in GnRH can cause the LH surge to happen too soon, but no rise in FSH, so there's no dominant follicle, leading to no ovulation. Estrogen will be unopposed, the luteal phase with never be entered, and this extra estrogen can lead to elevated levels of androgen. 2. Insulin resistance with hyperinsulinemia: If our body is resistant to insulin, we will compensate by having more insulin in the body, which leads to hyperinsulinemia. Increased insulin sensitivity in the ovarian androgenic pathway can lead to hyperandrogenism, because sex-hormone binding globulin synthesis won't be synthesized anymore. 3. Excessive androgen production: Hypersecretion of LH and insulin leads to more androgen production, leading to higher free testosterone concentrations.

Answer 106

1. Combined oral contraceptive - Lowest effective dose of estrogen for LH suppression (will decrease ovarian androgen production) - Progestin with low androgenic effect, like norgestimate and norethindrone (not desogestrel, drospirenone, etc.) 2. Progestin-only OC 2. Levonorgestrel-releasing IUD 2. Metformin (only endometrial protective if regular menses and ovulation has been established.

Answer 107

1. Combined oral contraceptive 2. Can add Spironolactone if COC doesn't work too well for acne and hirsutism. 2. 5-α reductase inhibitor to prevent conversion of testosterone to DHT (ex. finasteride) 3. Topical Vaniqa (eflornithine); For facial hair only 4. Cosmetic procedures like plucking, waxing, etc.

Answer 108

1. Letrozole - Aromatase inhibitor 2. Low-dose gonadotropin therapy 2. Laparoscopic ovarian drilling 3. In-vitro fertilization

Answer 109

1. Metformin

Answer 110

1. Inappropriate gonadotropin secretion - As GnRH increases, it causes an LH surge too soon with no rise in FSH. There's no dominant follicle, meaning no ovulation and unopposed estrogen. The luteal phase is never entered and now we see elevated levels of androgens. 2. Insulin resistance with hyperinsulinemia - Fat and muscle demonstrate resistance, so the body compensates by making more insulin. Then, the hyperinsulinemia causes an increase in insulin sensitivity in the ovarian androgenic pathway, causing hyperandrogenism (insulin inhibits SHBG that bind testosterone, so now there's too much free T) 3. Excessive androgen production - Androgens are usually produced in the ovary to facilitate follicular growth. But due to hypersecretion of LH and insulin, the androgen production goes up.

Answer 111

1. Combined oral contraceptive (low dose estrogen + antiandrogen progestin) 2. Progestin-only OC (norethindrone 0.35mg) 2. Levonorgestrel-releasing IUD 2. Metformin

Answer 112

1. Combined oral contraceptive (low dose estrogen + antiandrogen progestin) 2. Spironolactone 2. 5. 5 α reductase inhibitor like Finasteride 3. Topical Vaniqa (eflornithine) for facial hair only

Answer 113

1. Aromatase inhibitors (Letrozole) 2. Low-dose gonadotropin therapy 2. Laparoscopic ovarian drilling (ovarian diathermy) Last. In-vitro fertilization

Answer 114

BPH: Restrict fluid, EtOH, and caffeine in the afternoon. Avoid diuretics and nasal decongestants, if possible. ED: Vacuum erection: They are pretty effective, and they aren't a drug, so there's no side effects. They have a slower onset and can be pretty expensive. Penile prostheses is expensive, invasive, and permanent, but it's effective.

Answer 115

5-α reductase inhibitors: 5-α reductase in the prostate coverts T -> DHT, causing prostate enlargement and growth; Best for men with prostate size > 40g α-adrenergic blockers: The prostate is covered with α-1a receptors, and the stimulation of this is what causes smooth muscle contraction. PDE-inhibitors: If the pt also has ED, this would be a good option; Relaxes prostate gland and bladder neck.

Answer 116

Finasteride - 5-α reductase inhibitor; 5 mg daily; Impotence, decreased libido, etc. Dutasteride - 5-α reductase inhibitor; 0.5 mg daily Terazosin - α1a blocker; 1 mg HS; Dizziness, fatigue Doxazosin - α1a blocker; 1 mg HS; dizziness, fatigue Alfuzosin - α1a blocker; 10 mg daily; dizziness, fatigue Silodosin - α1a blocker; 4 mg daily; dizziness, fatigue Tamsulosin - α1a blocker; 0.4 mg HS; Dizziness, headache, abnormal ejaculation, etc.; Used the most because it's more selective in the urinary tract. Tadalafil - PDE5 inhibitor; 5 mg daily

Answer 117

BPH - Obstructive symptoms include decreased force of stream, hesitancy to initiate voiding, strain or push to urinate, etc. Irritative symptoms include nocturia, increased frequency, urgency, dysuria, incontinence, etc. - Diagnosis is based on AUA symptom score, residual volume >25-30mL, digital exam, and symptoms. ED - Consistent inability to obtain or sustain an erection sufficient for intercourse in at least 50% of attempts. Hypogonadism - - Specific: Reduced libido, gynecomastia, loss of body hair, reduced muscle bulk and strength - Non-specific: decreased energy, feeling sad, poor concentration, etc. - Total testosterone of < 300 ng/dL or free testosterone level <5 ng/dL.

Answer 118

BPH: Drugs with strong anti-cholinergic properties (1st gen antihistamines, tricyclic antidepressants, etc.) Sexual dysfunction: Antidepressants (SSRIs), antihypertensive agents, estrogens/anti-androgens, 5-α reductase inhibitors, and cancer chemotherapy Priaprism: ED drugs, antidepressants, cocaine, antipsychotics, anticoagulants

Answer 119

- Aging - Diseases and conditions like diabetes, HTN, coronary artery disease, MS/Parkinsons/Stroke, low testosterone levels - Physical things like injury, surgeries, radiation - Antidepressants (SSRIs), antihypertensive agents, estrogens/anti-androgens, 5-α reductase inhibitors - Unhealthy lifestyle (esp. tobacco smoking)

Answer 120

For hypogonadism, they must be showing specific symptoms and have free testosterone < 5 ng/dL or total testosterone < 300 ng/dL. Hypogonadism is usually in the younger population. Low T AND Symptoms is hypogonadism.

Answer 121

Testosterone replacement should only be used when hypogonadism is diagnosed (Low T + Sx)

Answer 122

OTC products - mostly derived from natural products. The efficacy and negative impacts of these are unknown. Testosterone injections - Possible mood swings Patch - most similar to physiologic testosterone levels. Solution - 1-4 applications a day Pellets - implanted subcutaneously (hassle). Capsules - (Jatenzo) non-invasive, not messy

Answer 123

Alprostadil injection - Work to increase cAMP, which lowers Ca2+, allowing smooth muscle to relax. The injection technique must be taught. This is the treatment of choice if the patient fails PDE5 treatment. Adverse effects include local irritation, penile pain, risk of priapism and cavernosal plagues or areas of fibrosis. Alprostadil pellets - Work to increase cAMP, which lowers Ca2+, allowing smooth muscle to relax. At least it's not an injection, quick onset. Need to use a device to insert the suppository into the urethra. Oral PDE-5 inhibitors - Promotes smooth muscle relaxation in the penis by inhibiting PDE-5 (inhibits conversion of cGMP to 5'GMP); Enhances development and maintenance of erection & decreases refractory period between erections; NAION (sudden vision loss)

Answer 124

Injection - Inject into one of the two sides of the corpora cavernosa. Pellets - Urinate first, then insert suppository, then role penis for 10-30 seconds. Patches - Apply over skin of back, thigh, or upper arm, away from pressure areas. Gels - Apply over a covered area of non-genital skin like shoulders and upper arms. Wash hands after application. Buccal tabs - Apply to buccal mucosa. Do not chew or swallow. Solution - Applied to arm pics. Apply deodorant prior to application. Wash hands after use.

Answer 125

Dosing: - Sildenafil: 50mg - Tadalafil: 10mg (2.5-5 if daily) - Avanafil: 100mg Side effects: Headache, flushing, NAION (sudden vision loss), etc. Contraindications: If patient is on oral or transdermal nitrates, alpha-blockers, if patient has sever CAD Drug interactions: CYP3A4 inhibitors (grapefruit juice, etc.), food delays absorption Advantages/disadvantages: There's telehealth availability!

Answer 126

Saw Palmetto - The literature is not consistent, so if the patient says it helps them, then let them use it.

Answer 127

Etiology - Drugs, sickle-cell disease, pelvic tumors, infections, but the cause is unknown in about 1/3 of cases. - Drugs: ED drugs, antidepressants, antipsychotics, anticoagulants, cocaine, and more. For non-ischemic (not painful) - treat with cold packs and compression. Ischemic (painful) - treat with blood aspiration and saline irrigation.

Answer 128

Epidemiology - Major type is androgenic alopecia (male pattern baldness). It affects 50% of men. It has a gradual onset. There's also alopecia areata, which is an autoimmune disorder presenting in small round patches of baldness. Also Alopecia universalis, where the patient loses all of their hair (scalp and body). Also traction alopecia and drug-induced alopecia. Patho - Alopecia happens when testosterone is converted to DHT, which shrinks the hair follicle, resulting in shortening and shrinking of the hair. Treatment - - Finasteride (Propecia): Inhibits type II 5-α reductase, which converts testosterone to DHT. Dose: 1mg PO once daily. - Minoxidil (Rogaine): Enlarges miniaturized hair follicles. Dose: apply to scalp twice daily every day.

Answer 129

Prostate cancer - Because the african male population has the highest incidence of prostate cancer, it would be good to target that population for screening. - Yearly screening for men whose PSA is 2.5 ng/mL or higher. - Every 2 years screening if PSA is less than 2.5 ng/mL. - Most men w/o prostate cancer have PSA levels under 4 ng/mL of blood. Testicular cancer - Younger men should do an individual screening regularly to ensure that there are no abnormal growths.

Answer 130

1. Treat or eliminate known causes 2. Oral PDE-5 inhibitors 3. Intraurethral or intracavernous Tx 4. Possible combination therapy 5. Penile prosthesis

Answer 131

Mild - Watchful waiting Moderate - If also ED: α adrenergic antagonist, PDE inhibitor, or both; If small prostate and low PSA: α adrenergic antagonist; If large prostate and increased PSA: 5 α reductase inhibitor OR 5 α reductase inhibitor + α adrenergic antagonist; If predominant irritative voiding symptoms: α adrenergic antagonist + anticholinergic agent. Severe - Complications of BPH, so surgery or prostatectomy.

Answer 132

BPH + OAB: Tamsulosin + Tolterodine BPH + ED: Finasteride + Tadalafil

Answer 133

Chronic anovulation Hyperandrogenism Polycystic ovaries

Exam 3 Flashcards

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