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Pharm III > Lecture 10 (GYN)-Exam 5 > Flashcards

Lecture 10 (GYN)-Exam 5 Flashcards

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1
Q

Cervical Dysplasia Summary: AGC
* What are they?
* Common or rare?
* Associated with what?
* What do you need to do?

A
  • Abnormal cells that original from the endocervix or endometrium
  • Rare - < 1% of cervical cytology
  • Associated with premalignant or malignant disease in 30% of cases
  • Colposcopy and endometrial biopsy
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2
Q

Polycystic ovarian syndrome (PCOS)
* Often presents as what?
* Too much of what?

A

Often presents as abnormal uterine bleeding
* Too much LH in follicular phase of menstruation (≥ 2x FSH secreted)

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3
Q

Polycystic ovarian syndrome (PCOS)
* Theca cells produce too much what? What does that cause?

A

Theca cells produce too much androstenedione
* Cannot all get converted to estradiol
* Some gets converted to estrone in fat cells
* Increases estrogen negative feed back stopping the release of FSH
* Continuous high levels of LH and no LH surge – NO OVULATION

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4
Q

Polycystic ovarian syndrome (PCOS)
* Why too much LH?

A

Why anterior pituitary produces too much LH not well known -> possible association with insulin resistance

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5
Q

PCOS
* What does high levels of androstenedione cause? (3)
* What does insulin resistance cause? (2)

A

High levels of androstenedione
* Hirsutism
* Male pattern baldness
* Acne

Insulin resistance
* Obesity
* Acanthosis nigricans

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6
Q

PCOS
* What happens because of lack of ovulation? (2)

A
  • Amenorrhea or oligomenorrhea
  • Heavy menstrual bleeding
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7
Q

PCOS
* How do you dx it?

A
  • High LH:FSH ratio
  • High androstenedione
  • Diagnostic imaging: ± ovarian follicles
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8
Q

Pcos - treatments
* Why weight lost?(4)

A

Goal: 5 to 10%
* Decreases insulin resistance
* Reduces hirsutism
* Regulates menstrual cycles
* Improved response to fertility treatments

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9
Q

Pcos - treatments
* Why metformin?

A

Improves insulin sensitivity and weight loss
* Regulates menstrual cycles
* No longer recommended as first-line for all patients

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10
Q

Pcos - treatments
* What is first line for androgen excess? How does it work?

A

CHC or progestin only contraception
* Provides progestin / suppress ovarian hormones
* Increases the concentration of sex hormone binding globulin (SHBG)
* Decreases concentration of circulating androgens
* Cycle regulation

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11
Q

Pcos - treatments
* What is second line of androgen excess? What does it not do? CI?

A
  • Spironolactone
  • Does not regulate the menstrual cycle
  • CI: pregnancy
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12
Q

Metformin in PCOS
* Can produce what? Alters what?
* Positive effect on what?
* How does it effect weight?

A

Can produce ovulatory cycles
* Alters insulin’s effect on ovarian androgen synthesis to allow return of ovulation

Positive effect on blood glucose and hyperinsulinemia
* Weight loss (10lbs)

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13
Q

Metformin in PCOS
* Inhibits what? What does that cause?
* Not as effective as what?

A

Inhibits ovarian gluconeogenesis and androgen synthesis
* Less androgens to convert into estrone that persistently promotes LH release

Not as effective as CHC therapy

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14
Q

Metformin in PCOS
* Recommended for patients with what?

A

Recommended for patients with
* Unsuccessful weight loss with diet and exercise
* Continued symptoms of high androgens after 6 months of CHC therapy

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15
Q

Pcos – Women not seeking pregnancy
* What is first line? What does it cause? (4)

A

CHCs first-line
* Provides daily progestin
* Antagonizes endometrial proliferative effects of estrogen
* Decreases effects of high androstenedione
* Provides contraception

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16
Q

Pcos – Women not seeking pregnancy
* What is the dosing guidelines for CHC?

A

≤ 35 mcg of ethinyl estradiol/day

Anti-androgenic progestins recommended
* Desogestrel
* Drospirenone
* Norgestimate

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17
Q

Pcos – Women not seeking pregnancy
* What do you give for patients with contraindications to CHCs?
* WHat are the routes?

A

Progestins only

Oral, IM, IUD:
* Oral: medroxyprogesterone 5 or 10mg for first 10 to 14 days every one to two months

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18
Q

Pcos – Women not seeking pregnancy
* How does progestins only work?

A

Antagonizes endometrial proliferative effects of estrogen

Does not decrease effects of high androstenedione
* Drospirenone with some effects

May or may not provide contraception

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19
Q

*

PCOS – Women seeking pregnancy
* What is first line?

A

First-line: weight loss

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20
Q

*

PCOS – Women seeking pregnancy
* What else can be first line besides weight loss? How does it work?

A

First-line: letrozole-> Aromatase inhibitor
* Inhibits the estrogen negative feedback
* Promotes follicle growth
* Stimulates ovulation

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21
Q

PCOS – Women seeking pregnancy: Letrozole
* replaces what?
* Highest what?
* What is the regimen?

A
  • Replaces historic clomiphene
  • Highest cumulative pregnancy and live birth rate (80% vs 30 to 40% with clomiphene)
  • Regimen: 2.5 to 7.5 mg PO daily on days 3 to 7 of the ovarian cycle
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22
Q

When is menarche, menstruation and menopause?

A
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23
Q

Prolactin
* Necessary for what?
* Synthesized and secreted from what?

A
  • Necessary for synthesis and maintenance of milk production
  • Synthesized and secreted from lactotrophs in the anterior pituitary
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24
Q

Prolactin
* How is it regulated?Inhibited? stimulated?

A

Regulated by the hypothalamus
* Inhibited by a constant release of dopamine (prolactin inhibiting factor)
* Stimulated by thyrotrophin releasing hormone (prolactin stimulating factor)

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25
Galactorrhea * What is it? What is the MCC?
* Abnormal lactation * MCC - lesions of hypothalamus, pituitary
26
Galactorrhea: * What are the other causes (besides lesions)(4)
* Drugs – dopamine antagonists (antipsychotics, antidepressants metoclopramide, etc) * Hypothyroidism * Renal dysfunction * Manual stimulation
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*
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* Evaluation of Galactorrhea
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Galactorrhea treatments * What are the different types of txt?(4)
* Patient reassurance * Stopping or switching medications * Dopamine agonists * Surgery: Prolactinomas > 10 mm
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# * Antipsychotic induced Galactorrhea * What are the different treatment options?(3) * MC occurs w/?
Treatment options * Lower the dose * Switch to alternative prolactin-sparing antipsychotic->Not ideal if clinically stable * Add a full / partial dopamine agonist-> Aripiprazole ## Footnote MC with risperiodone
32
Mastitis * MC in what setting? * WHat are initiating factors?
* MC in the setting of breastfeeding * Initiating factor = milk stasis (prolonged engorgement, incomplete or inefficient feeding)
33
Mastitis * What are the sxs?
Warm, erythema, edema, pain to breast plus systemic symptoms * Fever, myalgias, chills, malaise, and flu-like symptoms
34
# * Mastitis * What are MCC? * May be complicated by what?
**MCC Staphylococcus aureus (MRSA / MSSA)** May be complicated by abscess formation
35
# * Mastitis * What is first line? * Rarely requires what? * What is the duration?
**First-line: outpatient antibiotics (ex. Breastfeeding: cephalexin, clinda, augmentin, diclocycline) (No breastfeeding: Bacrtrim and doxy)** * Rarely requires IV antibiotics * Duration – 10 to 14 days
36
Mastitis: * Besides antibiotics, what are the additional txt?(4)
* I and D abscesses * Cold compresses * NSAIDS * Pumping / breastfeeding
37
Breast cellulitis in non-lactating females * Common or uncommon? * What are the sxs? * WHat is uncommon? * What are the MC organisms? * What is the txt?
* Uncommon * Erythema, edema, pain to breast * ± axillary lymphadenopathy * Systemic symptoms uncommon * MC organisms Staph and Strep * Empiric treatment similar to mastitis
38
Breast cellulitis in non-lactating females * What is the imaging?
* ± ultrasound * Mammogram usually recommended
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Fibrocystic Changes * MC what? * Ages? * Thought to be due to what
* Most common benign breast disease - ~50% of women of reproductive age * Most common ages 30-50 * Thought to be due to hormonal imbalance: Estrogen
41
Fibrocystic Changes * What are the sxs?
* Multiple, usually bilateral TENDER mobile masses in the breast * Cyclical bilateral breast tenderness, most prominent just before menstruation
42
Fibrocystic Changes * What are the red flags?
**Red Flags** – recurrent or severe symptoms, solid masses, nipple abnormalities, edema, skin changes, unilateral discharge
43
Fibrocystic breast disease treatment * What is first line?(5)
* Imaging * Patient reassurance * Physical support (bra) * Warm or cold compresses * Acetaminophen or NSAIDs
44
Fibrocystic breast disease treatment * What is second line?
If 6-month trial of first-line therapies unsuccessful * Tamoxifen 10mg PO daily * Danazol * Adjustment of CHC or hormone replacement therapies
45
# * Breast Cancer * MC type and area?
MC ductal carcinoma / upper outer quadrant
46
SERMs vs aromatase inhibitors moa
47
Selective estrogen receptor modulator (Serm): Selective * MC ones? (3)
* **MC tamoxifen, raloxifene, clomiphene**
48
Selective estrogen receptor modulator (Serm): Selective * Antiestrogen effects on the breast decreases what? * Important what? * Estrogenic effects on bone? * Tamoxifen increases risk of what?
* Antiestrogen effects on the breast decrease breast cancer relapse after treatment * Important treatment component of estrogen and progestin receptor positive breast cancers * Estrogenic effects on bone decrease risk of osteoporosis * Tamoxifen increases risk of endometrial cancer
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Selective estrogen receptor modulator (Serm)
50
Selective estrogen receptor modulator (Serm)
* Uterus
51
Serms * What are the MC SEs? (4) * CI?(3)
MC adverse effects: * Hot flashes * Nausea/vomiting * Increased risk of DVT/PE * Abnormal vaginal bleeding (tamoxifen) CI: history of DVT/PE, pregnancy, warfarin therapy (antagonism)
52
Aromatase inhibitors * What is the MOA?
* Blocks conversion of androstenedione to estrogen * Decreases estrogen available for binding to hormone receptor positive breast cancer cells
53
Aromatase inhibitors * What are the SEs? (4) * CI in who?
Adverse effects: * Arthralgias, joint stiffness, bone pain * Sexual dysfunction * Decrease bone mineral density * Hot flashes, flushing CI: pregnancy
54
Adjunct therapy for hormone receptor positive Breast cancer: Premenopausal women * Low and + what? * What is first line? (how long?, decreased what?, Transition?)
55
Adjunct therapy for hormone receptor positive Breast cancer: Postmenopausal women * Low what? + what? * What is first line? What are the examples? * Inactive in who?
56
Terminology * What is amenorrhea? Primary and secondary?
Amenorrhea - absence of menstruation * Primary Amenorrhea- no menarche by 15 years old * Secondary amenorrhea- amenorrhea for 3 or more months with previously regular menstrual cycles
57
Terminology * What is oligomenorrhea?
Oligomenorrhea - reduction of the frequency of menses: interval being more than 35 days but less than six months
58
Terminology * What is menopause and precocious menstruation?
* Menopause - Amenorrhea for 12 months without other apparent cause * Precocious menstruation - Menarche before 9 years of age
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Amenorrhea etiologies
60
* Amenorrhea evaluation
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* Amenorrhea Treatment:
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Primary ovarian insufficiency * two what? * MCC? * Other causes? (4)
Two serum FSH levels in menopausal rage (taken 1 month apart) MCC – idiopathic Other causes: * Chemotherapy / radiation * Infection * Auto-immune * Abnormal karyotype (e.g., Turners variant)
63
Primary ovarian insufficiency * What is the first line txt? (general) * What does it cause?(3)
First-line treatment = hormone replacement therapy (HRT) * decrease vasomotor symptoms (hot flashes, flushing) * decrease cardiovascular risks * increase bone mineral density
64
Primary ovarian insufficiency * What are the first line choices?
Transdermal estradiol or Oral conjugated estrogens Plus Progesterone 7 to 12 days per cycle
65
Primary ovarian insufficiency * What is second line?
Second-line = CHC * Patients seeking contraception
66
Functional hypothalamic pituitary crisis * What is it? What are the causes? (3)
Chronic anovulation secondary to suppression of the hypothalamus-pituitary axis (HPA) * Stress * Excessive exercise * Body weight loss
67
Functional hypothalamic pituitary crisis * Why do you want to do txt? (4)
* Restore HPA function * Preserve BMD * Restore ovulation * Improve fertility
68
Functional hypothalamic pituitary crisis * What is the first line txt?
Correct under lying cause * Nutritional repletion / weight gain * Stress reduction
69
Functional hypothalamic pituitary crisis * What is the second line txt? * What is not recommended?
Pharmacologic treatment (short course) * **Transdermal estradiol and cyclic progesterone** * Second-line: CHCs (patients seeking contraception) Bisphosphonates not recommended
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# FYI Amenorrhea – specific treatments
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# FYI Amenorrhea – specific treatments
72
Heavy menstrual bleeding (HMB) * What is it?
* Menstrual bleeding > 80mL/cycle or > 7days * Bleeding that impacts quality of life (social, professional, familial, etc)
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Heavy menstrual bleeding (HMB)
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HMB
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HMB treatments
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HMB treatments
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Tranexamic acid * What is it? * MOA?
Synthetic derivative of the amino acid lysine MOA: * High affinity for lysine binding sites of plasminogen * Blocks these sites * Prevents binding of plasmin to the fibrin surface * Antifibrinolytic effect
78
Tranexamic acid * What are the SE? * CI?
Adverse effects: * N, V, D * Myalgias * Abdominal pain * Headache * Venous thromboembolism * Color vision disturbance CI: History of VTE
79
Acute severe bleeding * What do you need to do if hemodynamically unstable?
* Stabilize – Fluids, blood * Emergent dilation and curettage initial treatment of choice * Alternative (patient expected to be stable for 3-4hours)->High-dose conjugated equine estrogen
80
Acute severe bleeding: High-dose conjugated equine estrogen * What is the dose? * What does it cause? (2) * Primary SE?
* 25mg IV Q4-6 hours * Cessation of bleeding approximately 5 hours * Stabilization of endometrium * Primary adverse effect = nausea and vomiting
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Acute severe bleeding * What is the txt of hemodynamically stable?
82
dysmenorrhea * What is it?
Crampy abdominal pain with or just before menses
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* dysmenorrhea
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* dysmenorrhea
85
Dysmenorrhea treatment * What is first line?
* Topical heat * NSAIDs (IBU, naproxen, mefenamic acid) * Start 1-2 days prior to menses onset
86
Dysmenorrhea treatment * What is second line? What does it cause?
87
Dysmenorrhea treatment
88
Premenstrual syndrome vs premenstrual dysmorphic disorder * What happens in both? (4)
* Cyclic pattern of symptoms occurring in the last week of the menstrual cycle (luteal phase) * Resolves with menstruation * Cannot be attributable to other medical problem * Impacts normal daily functioning
89
Premenstrual syndrome vs premenstrual dysmorphic disorder * What is PMS?
At least one moderate to severe somatic or affective symptom must be present for at least 3 months
90
Premenstrual syndrome vs premenstrual dysmorphic disorder * What is Premenstrual dysmorphic disorder?
* At least 5 symptoms must be present; 1 must be an affective symptoms * Occurs with the majority of cycles
91
PMS / PMDD treatment * What is the nonpharmacologic txt?
* Limited efficacy * Mild to moderate PMS * Decrease intake of Caffeine, Refined sugars, Sodium * Increasing exercise * Cognitive behavior therapy
92
PMS / PMDD treatment * What is the first line txts?
* SSRIs or venlafaxine (SNRI) * Combination hormonal contraception
93
PMS / PMDD treatment * What is the MOA of SSRI/venlafaxine? * MOA of CHC?
94
Ssris and SNRIs * What are the dosing options?
Continuous vs Luteal Phase Dosing Luteal: * Start day 14 and discontinue with menses * Decreased side effects * Less effects on libido
95
CHCs * What is for PMDD? PMS?
PMDD * Monophasic recommended * 20mcg EE / 3mg drospirenone FDA approved indication * Other monophasic combinations have similar efficacy PMS * Multiphasic regimens reduce physical symptoms but not mood symptoms
96
What is last line for PMS/PMDD?
* Severe symptoms not responding to first-line therapies * GnRH agonist - leuprolide
97
Menopause * What happens during perimenopause?
* Menstrual cycles anovulatory * Irregular * Less estrogen and progesterone * Less inhibition on hypothalamus and pituitary * More GnRH, FSH, LH * High levels, erratic
98
(PERI)Menopause symptoms * What happens vasomotor? * What happens on genitourinary?
Vasomotor * Hot flashes, flushing * > 25% of women * Mean duration: 7.4 years Genitourinary * > 85% of women * Vaginal dryness / atrophy / dyspareunia * Increased risk of UTIs / urethritis / frequency/urgency
99
(PERI)Menopause symptoms * What happens psychological? * Decreased what? * Increased what?
Psychological * Mood swings, poor memory, anxiety, depression Decreased BMD Increased risk of CVE
100
Menopause treatment * What is the nonpharm txt?
101
Menopause treatment * What is the pharm txt for mod to severe sxs?
102
Menopause treatment review
103
# * Hormonal therapy Contraindications
104
Topical Hormone therapy * What is the topical therapy for? * What are the SE?(4)
Topical therapy * Recommended if vaginal/GU symptoms only complaint * More effective than oral hormone replacement * 80-90% symptom improvement Adverse effects: * Vulvovaginal candidiasis, vaginal bleeding, breast pain, nausea
105
Hormone therapy * What is the oral ospemifene?
* SERM – full estrogen agonist of vaginal epithelium * Decreases vaginal dryness and dyspareunia
106
Menopausal hormone therapy (MHT): Overall consensus recommendations for MHT * Most effective for what? * May decrease what? * **What do you give for hysterectomy and if uterus is still present?**
* Most effective for vasomotor symptoms * May decrease all-cause mortality from heart disease * **Estrogen only appropriate after hysterectomy; addition of progesterone required if uterus present**
107
Menopausal hormone therapy (MHT): Overall consensus recommendations for MHT * Increased risk of what? * Contraindicated in who? * Dose, duration, routes of administration are personalized based on what?
* Increased risk of VTE and stoke with estrogen-containing MHT->Risk is lower with transdermal MHT * Contraindicated in women with a personal history of breast cancer; highest association with progestin use * Dose, duration, routes of administration are personalized based on specific patient needs; age is not a sole indication of discontinuation
108
# FYI Various MHT products
109
Progestin only products * What are the examples?
110
Bioidentical therapy * Personalized therapy based on what? * Patient-specific what? * Adjusted how?
* Personalized therapy based on various hormone levels * Patient-specific doses compounded * Adjusted as needed for hormone fluctuations
111
Bioidentical therapy * Efficacy? * Limited what? * Same risks as what? * Forms?
* Efficacy equivalent to commercial products * Limited literature regarding superiority * Same risks as commercial products * Many dosage forms
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# FYI MHT Summary
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# FYI MHT Summary
114
Ssris and SNRIs: First-line when MHT Contraindicated * What is the continuous dosing effects?(4)
* Decreases vasomotor symptoms * Decreases anxiety / depression * May worsen weight gain * May worsen sexual function
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Monitoring and follow-up

Pharm III (14 decks)

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