Exam III - Lorinda

Question 1

What are the contraindications for HRT?

Answer 1

Severe liver dysfunction
Acute vascular disease
Hyper-coagulability
Severely elevated TGL
Abnormal vaginal bleeding
Any history of current breast cancer

Question 2

General conclusions from the WHI study:

Answer 2

Pretty safe for perimenopausal women to use HRT
Increased risks for older ages
Stroke and breast cancer risk are still increased
Overall reduced death in younger ages with those taking HRT

Question 3

What HRT contains peanut oil?

Answer 3

Micronized progesterone

Question 4

What HRT has an FDA warning about keeping away from children?

Answer 4

Evamist - 17B Estradiol spray

Question 5

What vaginal ring gives you systemic coverage? Non-systemic coverage?

Answer 5

Estring is 17B estradiol = non-systemic

Femring is estradiol acetate = systemic

Question 6

What estrogen product do you have to rub for three minutes into the thigh?

Answer 6

Estrasorb topical gel

One pouch per thigh

Question 7

What SERM can be used for painful sexual intercourse but has a SE of hot flashes?

Answer 7

Ospemifene

Question 8

What SERM + estrogen complex can be used to treat hot flashes or osteoporosis.

Answer 8

Bazedoxifene/Estrogen

Question 9

What non-hormonal options are there for perimenopause?

Answer 9

Megastrol
Venlafaxine
SSRI's (Fluoxetine, Paroxetine, Citalopram)
Clonidine
Gabapentin

Question 10

Risk factors for PCOS

Answer 10

Obesity
DM
Sporatic periods
premature adrenarche/delayed menarche
Family history
Anti-epileptic drugs (valproate esp)

Question 11

PCOS symptoms

Answer 11

Hyperandrogenism
Menstrual irregularities
Obesity
Insulin resistance
Acanthosis nigricans

Question 12

What is the risk associated with developing diabetes if you have PCOS?

Answer 12

2-5x more likely

Question 13

PCOS criteria:
NIH
Rotterdam
Adrogen Excess Society

Answer 13

NIH - Hyperandrogenism, oligo or a-ovulation
Rotterdam - 2/3 requirements
Adrogen Excess Society - hyperandrogegism and one more

Question 14

Longterm risks of PCOS

Answer 14

Hypertension
Dyslipidemia
Infertility
Sleep apnea
Endometrial hyperplasia and caner

Question 15

PCOS treatment

Answer 15

First line: non-pharm (spearmint tea, shaving/waxing, vaniqa cream)

Second line: Treat to goal

• Infertility: clomiphene, metformin, gonadotropins, ovarian drilling, aromatase inhibitors
• Androgen symptoms (no pregnancy): combined oral contraceptives and metformin, spironolactone (monitor potassium)

Question 16

When should you take clomiphene if you are trying to get pregnant?

Answer 16

Take for 5 days starting on the 5th day of the cycle

Do not use for more than 6 cycles (increases ovarian cancer risk)

Question 17

What could you use if you are trying to get pregnant but don’t want cancer side effects?

Answer 17

Aromatase inhibitor like Letrozole
Take on days 3-7 of cycle
Similar efficacy to clomiphene

Question 18

What is dexamethasone used for in conjunction with clomiphene?

Answer 18

Use on days 3-12 to increase ovulation rate to 75% from 15%, and pregnancy to 40% from 5%.

Question 19

How is endometriosis diagnosed?

Answer 19

Only with surgery, where a camera is used laparoscopically.

Question 20

What are some of the signs of endometriosis?

Answer 20

Infertility (if endometrial tissues grows in the ovaries)
Gi complications like constipation
Menorrhagia and anemia

Question 21

What are treatments for endometriosis?

Answer 21

Treat pain with COC (continues use), GnRH agonist, Levonogestrel IUD.
Treat infertility with GnRH analogs and antagonists, surgery, IVF.

Question 22

How do you differentiate PMS from PMDD?

Answer 22

They both include a set of symptoms that appear cyclically before menses and disappear. When work or lifestyle is affected, then it progresses to PMDD.

Question 23

How do you diagnose PMDD?

Answer 23

They need at least 5 symptoms from the PMS symptom list, including one that has to do with mood, anger, anxiety, or tension. These symptoms have to be affecting the work or lifestyle of the woman.

Question 24

What do the guidelines say for treating PMS/PMDD?

Answer 24

1. Lifestyle changes (1200mg calcium, vit B6, stress reduction and management, exercise)
2. SSRI’s (fluoxetine, sertraline) - luteal phase
3. OC’s (may increase symptoms)
4. GnRH agonists - Leuprolide

Spironolactone 25mg TID x10 days prior to menses for bloating

Question 25

What folic acid dose is recommended?

Answer 25

400mcg/day

Question 26

What percent of women experience unintended pregnancy in their lifetime?

Answer 26

48%

Question 27

What are the contraceptive choices available?

Answer 27

``` Permanent LARCs COC Other hormonal methods Barrier Other ```

Question 28

What is the only thing that is used for STD prevention?

Answer 28

Condoms

Question 29

What would you talk about when assisting in choosing a contraceptive method for someone?

Answer 29

``` Most effective options first If they want to have children Medical history/age Patient's preference of options Lifestyle/risk of STDs Ability to pay Partner support ```

Question 30

What contraceptive method is first line now?

Answer 30

LARCs

Question 31

What did the Contraceptive Choice Project in St. Louis find?

Answer 31

That LARCs were preferred and the most effective for preventing pregnancy if the access to care was provided for. There was a reduction in abortions and teenage births. Save $17 for every $ spent. And these are spendy devices.

Question 32

What is in the implant?

Answer 32

Etonogestrel Effective for 3 years SE irregular periods, but sometimes no periods Use backup for 48 hours afterward CI with breast cancer, cirrhosis, undiagnosed vaginal bleeding

Question 33

What are the levonorgestrel choices for IUDs?

Answer 33

Skyla Mirena Liletta PID risk

Question 34

What is the mechanism for a copper IUD?

Answer 34

``` ParaGard Spermacide EC SE Increased bleeding and cramping. Benefits = non-hormonal No concerns of breast cancer CI - cervical or uterine cancer, recent endoetriosis ```

Question 35

Go to the doctor if you experience these with an IUD: | PAINS

Answer 35

``` Period late/abnormal bleeding Abdominal pain/pain with intercourse Infection exposure/abnormal discharge Not feeling well, fever, chills String missing, shorter or longer ```

Question 36

What are the benefits of COC therapy?

Answer 36

``` Decreased: ovarian cancer endometrial cancer colon cancer ectopic pregnancy anemia benign breast disease ``` Increased: Possibly bone density

Question 37

What type of COC can we use continuously?

Answer 37

monophasic

Question 38

Who is the progestin only pill indicated for?

Answer 38

Breastfeeding women

Question 39

What is the normal starting dose of ethinyl estradiol?

Answer 39

20mcg. Can go down to 10mcg if dose is too high, can go up to 30mcg-50 if breakthrough bleeding is occurring.

Question 40

What doses of estradiol valerate are used?

Answer 40

1, 2, 3mg

Question 41

What is the equivalent ethinyl estradiol to 50mcg mestranol?

Answer 41

35mcg ethinyl estradiol

Question 42

What are estrogen SE's?

Answer 42

``` Breast tenderness Nausea Breakthrough bleeding Headache? Thrombo events ```

Question 43

What are progesterone-related SE's?

Answer 43

Tiredness Mood swings BTB (#1) Lighter flow No risk of clots If SE's occur, switch type of progesterone

Question 44

What lab value needs to be monitored in someone taking drospirinone?

Answer 44

Potassium

Question 45

What are the effects of COC on androgenicity? - LH levels - Ovarian testosterone production - SHBG levels - Free testosterone levels

Answer 45

- LH levels: Decrease - Ovarian testosterone production: Decrease - SHBG levels: Increase - Free testosterone levels: Decrease Decreases acne

Question 46

What are the categories in the CDC US-MEC, and what do they mean?

Answer 46

1. No restrictions for contraceptive use 2. Condition where benefits outweigh risks 3. Condition where risks usually outweigh benefits 4. Unacceptable health risk if contraceptives are taken

Question 47

What age is the cutoff for birth control use if you also smoke?

Answer 47

35

Question 48

What route of administration of HC's gives the highest area under the curve?

Answer 48

The patch

Question 49

When can you start hormonal contraceptives postpartum? Why?

Answer 49

After 42 days. High blood clot risk.

Question 50

Why is there a push to get the pregnancy category X changed on birth control?

Answer 50

because women may think that their children will have birth defects if they got pregnant on the pill, and try to abort them.

Question 51

What hormonal contraceptives have a higher risk of VTE?

Answer 51

Ortho Evra | 2nd and 3rd gen progestins other than levonorgestrel.

Question 52

What are the serious adverse reactions to COC? | ACHES

Answer 52

``` Abdominal pain Chest pain Headaches Eye problems Severe leg pain ```