Male / Female Health Flashcards

Question

*Contraceptive Brand Names:* 1. Amethyst 2. Camila 3. Nora-BE 4. Opill 5. Depo-Provera

Answer 1

1. Levonorgestrel/EE 2. Norethindrone 3. Norethindrone 4. Norgestrel 5. Medroxyprogesterone injection

Answer 2

-*Nausea, breast tenderness*/fullness, *bloating, weight gain, increased BP* (usually about 5-8mmHg), melasma (dark skin patches often on face) -Serious AVEs: *thrombosis* (heart attack, stroke, DVT, PE) --> increased risk w/ age, smoking, HTN, DM, or overweight -Symptoms to recognize for thrombosis: *ACHES* A: Abdominal pain that is severe --> can indicate mesenteric or pelvic vein thrombosis C: Chest pain - sharp, crushing, or heavy pain, SOB H: Headaches --> sudden and severe w/ vomiting or weakness/numbness on one side of body E: Eye problems: blurry vision, flashing lights, or partial/complete vision loss --> blood clot in eye S: Swelling or sudden leg pain

Answer 3

-Breast tenderness, HA, fatigue, and depression -*Drospirenone: slightly higher risk of clotting, incresaed K levels (do NOT take w/ kidney, liver, or adrenal gland disease or those w/ high K baseline) -Injectable depot medroxyprogesterone acetate: loss in BMD (vitamin D and calcium supplementation recommended)*

Answer 4

1. Medroxyprogesterone injection (Depo-Provera) 2. 2-3 months; 3-6 months 3. -Check adherence -Wait at least 3 cycles before switching; if early or mid-cycle spotting, estrogen dose may need to be increased; if later in cycle, progestin dose may need to be increased -Currently taking <30 mcg estrogen QD --> increase estrogen dose -Currently taking >/=30 mcg estrogen QD --> try different progestin

Answer 5

CIs: -*Hx of DVT/PE, stroke, CAD*, thrombosis of heart valves or acquired hypercoagulation -*Hx of breast, ovarian, liver, or endometrial cancer* -Liver disease; uncontrolled HTN (>160/100mmHg); severe HAs or *migraines w/ aura* (especially if >35 yo of age); DM w/ vascular disease; unexplained uterine bleeding * BBWs:* -ALL CHC products (pills, ring, patch): do NOT use in women >35 yo who smokes due to serious CV events -Estrogen + progestin transdermal patch: do NOT use in BMI >/=30 kg/m2 --> increased risk of thromboembolism -Depo-Provera: loss of BMD w/ long-term use

Answer 6

1. Use COC w/ lower-androgenic activity (ex. norgestimate - Sprintec 28; desogestrel; dienogest) OR no adrogenic activity (ex. drospirenone - Yaz, Yasmin) 2. Progestin-only (POPs) or nonhormonal method 3. Progestin-only (POPs) or nonhormonal method 4. If with aura, progestin-only or nonhormonal method; if no aura, any method

Answer 7

1. Monophasic COC - extended or continuous w/ drospirenone preferred 2. Take at night with food, consider decreasing estrogen dose or switching to POP, vaginal ring, or nonhormonal method (ideally after 3 month trial) 3. Any method - counsel on possibility of reduced effectiveness w/ patch (do NOT use patch in obesity) -Do NOT use DMPA (depot medroxyprogesterone acetate) if trying to avoid weight gain 4. Do NOT use CHCS for 3 weeks or 6 weeks if additional VTE risk factors --> can use progestin-only or nonhormonal method during this time

Answer 8

1. Choose product containing drospirenone, SSRI may be needed 2. Extended or continuous formulations; alternative: monophasic 28-day formulatio and skip placebo pills 3. Choose product containing drospirenone 4. Natazia (COC), Mirena (levonorgestrel-releasing IUD) are indicated; COCs w/ only 4 placebo pills, continouous, or extended regimens 5. If uncontrolled, progestin-only or nonhormonal method

Answer 9

*Injectables bypass first-pass metabolism, decreasing DDIs* DDIs that decrease hormonal contraceptive efficacy: 1. Some ABXs and antifungals - *rifampin (induction can be prolonged and back-up contraception needed for 6 weeks after D/C), rifabutin*, rifapentine, and griseofulvin 2. Anticonvulsants - *carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate*, perampenel 3. *St. John's Wort 4. Smoking tobacco 5. Ritonavir*-boosted PIs, bosentan, mycophenolate 6. Colsevelam: separate by at least 4 hours 7. Mounjaro (for COCs): use back-up contraception (non-PO or barrier) for 4 weeks after initiation and dose increases Risks w/ Hepatitic C TX: *Mavyret* NOT recommended with any formulation containing >20mcg of EE due to *risk of liver toxicity* -Check any new hepC drugs Drospirenone: *additive hyperkalemia* (ex. aldosterone antagonists, potassium supplements, salt substitutes, ACEis, ARBs, heparin, canagliflozin, calcineurin inhibitors)

Answer 10

1. *7; 5* 2. -*Start today ("Quick start"): best practice recommendation --> maximizes time protected from unintentional pregnancy -Sunday start: starts Sunday after onset of menstruation for pts that prefere menstraution occur during the week and is complete before the following weekend ---> can lead to missed doses if pt runs out of refills over weekend -First day start: starts first day of menses --> since started within 5 days after start of period, no back-up method of birth-control needed, protection immediate* 3. *At any time*; use backup for first 48 hours unless started within 5 days of menses; all active pills (NO placebo)

Answer 11

*Always check package insert - very specific instructions per product* COCs: -1 late or missed pill (<48 hours since last dose): *take ASAP and take next dose as scheduled (even if that is 2 pills/day), NO back-up contraception required*, emergency contracption (EC): NOT usually needed (consider if missed doses earlier in same cycle or in week 3 of previous cycle) -2 missed pills (>/=48 hours since last dose): *take most recent pill ASAP (discard other missed pills) and take next dose as scheduled (even if 2 pills/day); if during week 3, omit hormone-free week and start next pack of pills right after finishing current pack; back-up contracption for 7 days*; EC: consider if unprotected sex in last 5 days on week 1 or consider during week 2 or 3 POPs (if >3 hours past scheduled dose): -*Take pill ASAP and take next dose on schedule -Back-up contraception for 48 hours* -EC: consider if unprotected sex in last 5 days

Answer 12

1. *Patches; Brands: Xulane*, Zafemy, Twirla 2. *198 lbs* 3. Annovera 4. *Opill* 5. -*Fixed dose of norethindrone: Errin, Camiliar, Nora-BE* -Drospirenone-only: Slynd

Answer 13

1. *Hormonal interuterine devices containing levonorgestrel: Mirena*, Skyla, Kyleena, Liletta -Cause lighter menstrual bleeding or amenorrhea and minor or no cramping -Can be left in place from 3-8 years 2. Copper-T IUD (Paragard) -Can be used for up to 10 years, but can cause heavier menstrual bleeding and cramping -*Can be used for emergency contraception or regular birth control* 3. Implant (Nexplanon) -Plastic rod placed subdermally in arm -*Releases etonorgestrel for three years*

Answer 14

*Copper IUD (Paragard): most effective, within 5 days -Considerations: must be placed by HCP and lasts up to 10 years* *Ullipristal acetate* 30mg *(Ella): more effective than levonorgestrel, ASAP within 5 days* -Considerations: *Rx required, must be taken after every episode of unprotected sex, less effective if >195 lb or BMI > 30*, progestin-containing contraceptive should NOT be used in combo or within 5 days of administratoin (decreased efficacy of ullipristal concern) -*MOA: chemically related to mifepristone, but works differently --> prevents or delays ovulation and may alter endometrium to impair implantation (contraversal for some pts)* -AVEs: HA, nausea, abdominal pain, sometimes changes in menstrual cycle timing *Levonorgestrel 1.5mg tablets (Plan B One-step): least effective from above options, ASAP within 3 days -Considerations: OTC and can purchase multiple doses, must be taken after every episode of unprotected sex, less effective if >165 lbs or BMI >25 -MOA: preventing or delaying ovulation, thickens cervical mucus -AVEs: primarily nausea (if easily nauseated, take OTC antiemetic --> if vomits within 2 hours of taking medication, consider repeat dose)*

Answer 15

1. Consider OTC antimetic - if vomit after taking dose, contact HCP or take another dose if OTC 2. If you do NOT get your period in three weeks or it is more than a week late, take a pregnancy test 3. *You may wish to get a package of EC for future use*. 4. Regular hormone contraceptives should be started on same or following day (except: ulipirstal: start hormonal contraception after 5 days) 5. Only use one type of oral EC pill. Do NOT use different types together.

Answer 16

1. Wash hands thoroughly. Place one tablespoon of spermicide in diaphragm and disperse inside and around the rim. 2. Pinch ends of cup and insert the pinched end into vagina 3. Leave in for 6 hours after intercourse. Should NOT be placed greater than 24 hours. 4. Reapply spermicide if intercourse repeated or diaphragm is in place for more than 2 hours before sex by inserting jelly with applicator. 5. Wash with mild soap and warm water after removal. Air dry. 6. Can be used for 2-5 years depending on material. Check frequently for holes between uses.

Answer 17

Foams, creams, suppositories, jellies: -Place deep into vagina 10-15 minutes before intercourse where they melt (except for foam: bubbles) -Reinsert if more than 1 hour passes before intercourse Sponge: -Wet the sponge and squeeze to activate -Place deep in the vagina right before intercourse -Leave in for at least 6 hours after intercourse up to 24 hours. Remove and discard. Patches: -Apply to clean, dry skin of *buttocks, stomach, upper arm, or upper torso* weekly for 21 of 28 days. Do NOT apply to breasts. -*Start on either day 1 (no-back up needed) or Sunday (back up 7 days if not day 1)* -If patch becomes loose or falls off for >24 hours during three weeks of use or if >7 days have passed during fourth week wher no patch required, risk of pregnancy --> use backup contraception for one week starting new patch

Answer 18

1. *To prevent period; confirm no pregnancy, insert new ring, and use back-up contraception for 7 days* 2. True 3. *Insert first day of menstrual bleeding (if inserted on day 2-5 of cycle, use back-up contraception for the first 7 days* 4. -Week 1 and 2: if ring out >3 hours, rinse with cool/lukewarm water and reinsert and use back-up contraception for 7 days while ring in place. Consider EC if intercourse within last 5 days. -Week 3: discard and insert new ring and use back-up contraception for 7 days 5. Refrigerate prior to dispensing, but store up to four months at room temperature

Answer 19

Infertility: *unable to get pregnant after one year or longer of unprotected sex* Female TX options: 1.* Clomiphene - selective estrogen receptor modulator (SERM) - agonists and antagonists of estrogen in certain tissues, causes LH and FSH to surge to trigger ovulation 2. Letrozole - aromatase inhibitor - estrogen negative feedback (estrogen production suppressed to result in initial FSH surge) 3. Gonadotropins - act as LH, FSH or HCG; often used after poor response to clomiphene or letrozole or to spur egg release for procedures (ex. intrauterine insemination, in vitro fertilization)* -Brand names contain parts of words of reproduce, men(strual), follicle, gonadotropin, pregnancy, and ovary: Menopur, Follistim AQ, Gonal-f, Pregnyl, Novarel, Ovidrel 4. Leuprolide (Lupron) - gonadotropin releasing hormone agonist (GnRHA) or exogenous HCG --> more commonly used in breast or prostate cancer Risks: *Clomiphene: hot flashes from LH surge, clotting risks -Clomiphene, gonadotropins: can cause multiple eggs to be released (risk of multiple births)*

Answer 20

1. *American College of Obstetricians and Gynecologists (ACOG) 2. First trimester (weeks 0-12): where most organ development occurs* 3. -Gravida (G): number of times pt has become pregnant -Para (P): number of times pt has given birth 4. *Lifestyle modifications* including behavioral interventions, smoking cessation, and reduction of alcohol and tobacco use

Answer 21

1. -Dietary folate of 600mcg/day or folic acid supplementation -Calcium: 1000mg/day and Vitamin D 600IU/day --> without proper amounts, mother's bone health will be sacraficed to provide for baby 2. Inactivated influenza vaccine any trimester, single dose of Tdap every pregnancy between weeks 27-36, RSV vaccine if weeks 32-36 during September to January -ALL live vaccines CI 3. -Preclampsia: elevated BP and evidence of oragn damage that typically occurs after 20 weeks of gestation (only cure is delivery of baby) -Add low-dose ASA at end of first trimester of pregnancy for at risk pts (ex. DM, renal disease, hx of preclampsia, chronic HTN)

Answer 22

*Old Classification:* -A: studies in amimals and women had NO risk in first trimester, risk of fetal harm remote -B: animal studies have NOT demonstrated fetal risk, but NO well-controlled studies in pregnant women -C: animal studies have shown harm to fetus, but NO well-controlled studies in pregnant women (use only if benefit outweighs risk) -D: positive evidence to risk of human fetus, but benefits may outweigh risk w/ life-threatening or serious diseases -X: studies in animals or women should fetal abnormlaities and risk clearly outweighs benefits --> CI in pregnancy New classifciation: sections updated in package insert 1. Pregnancy section - *includes risk of adverse developmental outcomes*, drug's pharmacology (dose adjustments, AVEs, disease risks), pregnancy exposure registry information (encourage women to participate - information collected while pregnant, breastfeeding, newborn baby) 2. Lactation section -* includes whether drug/metabolites are present in human milk*, effects on infants, and effects on milk production 3. *Females & Males of Reproductive Potential - any effects on infertility and requirements for preganncy testing and contraception *

Answer 23

Acne: isotretinoin, topical retinoids ABXs: quinolones, tetracyclines Dyslipidemia, HF, and HTN: statins, RAAS inhibitors (ACEIs, ARBs, aliskiren, Entresto) Hormones: most, including estradiol, progesterone (including megestrol), raloxifene, Duavee, testosterone, contraceptives Migraine: dihydroergotamine, ergotamine Others: hydroxyurea, lithium, methotrexate, misoprostol, NSAIDs, paroxetine, ribavirin, thalidomide, topiamate, warfarin, weight loss drugs, valproic acid/Divalproex

Answer 24

Morning Sickness, N/V: -First line: *lifestyle* (avoid an empty stomach, eat smaller and more frequent meals, drink plenty of water, avoid spicy or odorous foods, avoid environmental triggers) -*If lifestyle measures fail: pridoxine (vitamin B6) +/- doxylamine* (RX: doxylamine/pyridoxine - Bonjesta, Diclegis) -*Ginger listed as "possibly effective" for morning sickness* -Hyperemesis gravidarium: severe N/V causing weight loss, dehydration, and electrolyte imabalances --> seek medical attention GERD/Heartburn: -*First line: lifestyle (eat smaller and more frequent meals, avoid foods that worsen GERD, if when sleeping: elevate head of bed and NOT eating 3 hours prior to sleep) -If lifestyle measures fail: antacids (calcium carbonate --> can also help supplement calcium)* -If heartburn NOT relieved by antacids, can consider H2RA or PPI for add-on

Answer 25

Flatulence: *simethicone* (Gas-X, Mylicon) Constipation: -First line: *lifestyle* (fluid intake, fiber intake, and physical activity) -If lifestyle measures fail: *fiber (psyllium, calcium polycarbophils*, methylcellulose) w/ fluids preferred, alternative: docusate or PEG -Many prenatal vitamins contain iron which can worsen constipation Cough, Cold, and Allergies: -*First line: cromolyn* -Second line: *first-generation anthistamines (DOC: chlorpheniramine)*, second-generation antihistamines now often recommended too, *if nasal spray for chronic allergy needed budsonide is DOC* -*Avoid: liquid formulations that contain alcohol*; dextromethorphan and guaaifenesin have limited safety data; oral decongestants should (ex. pseudophedrine) should be avoided during first trimester

Answer 26

Pain: -Non-pharm: hot/cold packs, light massage, or physical therapy can limit or avoid use of analgesics -*First line: APAP for mild pain -Avoid: NSAIDs including ASA* (except low-dose for preeclampsia) especially at 20 weeks or later --> premature closure of fetal ductus arteriosus and kidney problems -Opioids should ONLY be used if there are NO alternatives Asthma: -*Rescue therapy: ICS-formoterol or albuterol* -Maintenance therapy: *budesonide DOC*, but all ICS are considered safe (LABAs can be continued w/ ICS if needed) Iron Deficiency Anemia: supplemental iron, prenatal vitamins with iron

Answer 27

HTN: *labetalol, nifedipine XR, methyldopa -CI: ACEIs, ARBs*, aliskiren, Entresto -Low dose ASA recommended in chronic HTN pt to prevent preeclampsia DM: *insulin DOC* if NOT controlled w/ lifestyle, alternatives: metformin and glyburide -*Low dose ASA recommended in T1DM and T2DM for preeclampsia prevention*

Answer 28

1. *PCNs (including amoxicillin and ampicillin), cephalosporins, erythromycin, azithromycin* 2. *Topical antifungals (Creams, suppositories) x 7 days -Avoid: fluconazole* 3. *Must treat even if asymptomatic (can lead to premature birth and perinatal mortality) -First line: cephalexin or amoxicillin x 7 days* -Alternatives: nitrofurantoin, Bactrim, fosfomycin -*Nitrofurantoin, Bactrim: consider last line during 1st trimester and should NOT be used in last 2 weeks of pregnancy* 4. Since most asymptomatic, test prior with IgM and *IgG test* -Avoid dirty food and water (uncommon in US), *unpasteurized dairy products, and cat feces *

Answer 29

VTE: risk developing increased during first 6 weeks postpartum -TX: *LMWH preferred* over UFH (due to ease of administration) --> monitor anti-Xa levels, drawn 4 hours post-dose or aPTT (UFH) -*Prophylaxis: pneumatic compression devices +/- LMWH > UFH -Warfarin teratogenic, oral factor Xa inhibitors and direct thrombin inhibitors NOT been adequately studied* Mechanical valve: if on warfarin, generally converted to LMWH and may be switched back to warfarin after 13th week of pregnancy then back to LMWH close to delivery

Answer 30

Hypothyroidism: *levothyroxine --> will require 30-50% dose increase during pregnancy* -Do NOT leave untreated (complications: miscarriage, preeclampsia, low birth weight, cognitive impairment, growth retardation) Hyperthyroidism: mild cases will NOT require TX -*First trimester: propylthiouracil (PTU) -Later trimesters: methimazole -Both agents have liver damage risk* -Avoid: radioactive ioidine

Answer 31

1. *Vitamin D (400 IU); Iron (1mg/kg QD)* 2. *LactMed* or Brigg's Drugs in Pregnancy and Lactation -Properties: non-ionized, small molecular weight, low volume of distribution, high lipid solubility -Majority of drugs are safe while breastfeeding 3. -*Codeine and tramadol: risk of excessive sleepiness, breathing difficulty, and/or death (especially in mothers who were CYP2D6 ultra-rapid metabolizers* -Chemotherapy, illict drugs, radioactive compounds -*Avoid if possible: amphetamines, amiodarone, ergotamines, lithium, metronidazole, phenobarbital, statins 4. HIV*

Answer 32

Menopause: last menstraul period over 12 months ago (typically in ages 40-58 yo: average of 52 yo) Induced menopause: both ovaries removed, chemotherapy, or radiation can cause menopause prematurely S/Sx: asymptomatic to severe -Vasomotor symptoms (from decreased estrogen and progesterone levels): hot flashes (flushing and sensation of heat in upper body and face sometimes followed by chills), night sweats (hot flashes during sleep) -Genitourinary symptoms (from decline in estrogen in vaginal mucosa): vaginal dyness, burning, dysparerunia (painful intercourse)

Answer 33

Criteria for hormone therapy: healthy, symptomatic women within 10 years of menopause, -Extending TX beyond age 60 yo may be acceptable (ex. pt w/ osteoporosis) if lowest possible dose used and woman advised of risks -Consider QOL priorities and personal risk factors (ex. age, time since menopause, risk of blood clots, heart disease, stroke, breast cancer) before risk --> use non-hormonal TX in risk factors (ex. SSRIs, SNRIs, fezolinetant) Hormone therapy: -Estrogen: most effective in vasomotor symptoms; if pt has uterus, use combination form of progesterone (unopposed estrogen increases risk of endometrial cancer); local formulations preferred for vaginal symptoms only; transdermal, local (topical), and low-dose PO estrogen have lower clot risks -Progestin: given as combo w/ estrogen (ex. norethindrone, levonorgestrel, drospirenone) or seperate (most commonly medroxyprogesterone -MPA); micronized progestin (ex. Prometrium) considered safter than synthetic (ex. MPA); can cause mood disturbances and it takien intermittently spotting can occur

Answer 34

1. 17-beta-estradiol, vaginal cream 2. Estradiol, transdermal patch 3. Conjugated equine estrogens, vaginal cream, oral tablet, injection 4. Medroxyprogesterone, oral tablets 5. Micronized progesterone, oral tablet

Answer 35

1. 17-beta-estradiol, vaginal ring 2. estradiol, transdermal patch 3. conjugated estrogens/vazedoxifene, oral tablet 4. 17-beta-estradiol, vaginal tablet 5. Prasterone, vaginal insert - for dyspareunia

Answer 36

1. *Vivelle-Dot*; Minivelle 2. *Climara*; Menostar 3. Micronized progestin (less risk than synthetic) 4. -Patch: lower abdomen, below waistband -Spray (Evamist): inside of forearm (between elbow and wrist) -Gels: Divigel to upper thigh, Elestrin to upper arm and shoulder, Estrogel to entire arm from wrist to shoulder

Answer 37

Brand: Osphena MOA: *estrogen agonist/antagonist* ROA: PO TX: *dyspareunia, moderate/severe vaginal dryness (NOT for mild, for short-term)* AVEs: hot flashes, vaginal discharge, hyperhidrosis, muscle spasms Warnings: should NOT be used in severe heaptic impairment BBW/CI: same as other-estrogen containing products (do NOT use in women >35 yo and smokers, hx of CVD, hx of cancers, migraines w/ aura)

Answer 38

Natural products: *black cohosh, evening primrose oil, red clover, soy*, flaxseed, dong quai, St. John's Wort, chasteberry Drugs for Vasomotor Symptoms: -SSRIs and SNRIs: *paroxetine (Brisdelle)* has lower dose than for depression (*CYP2D6 inhibitor: blocks effiacy of tamoxifen*), others (NOT FDA-approved): citalopram, escitalopram, venlafaxine, desvenlafaxine -*Fezolinetant* (Veozah): *neurokinin B antagonist to modulate thermoregulatory center* (CI: cirrhosis, severe renal impairment, use with 1A2 inhibitors) -Gabapentin (NOT FDA approved), oxybutynin (NOT FDA approved) *NOT recommended:* -Fluoxetine, sertraline: lack of evidence -Pregabalin, clonidine: AVEs outweight benefits -Bioidentical hormone therapy

Answer 39

Drugs that lower testosterone: methadone (especially for opioid dependence), chemotherapy (prostate cancer), cimetidine, spirinolactone TX: testosterone -Controversal due to unclear benefits and risks -Risks: CV (use low testosterone levels), clot risk, increase of Hct (polychythemia), noncancereous prostate growth, abuse potential -Restricted use in BPH -Formulations: injections (SC or IM: painful), topical

Answer 40

Formulations: -Topical gels/solutions: *Androgel, AndroGel Pump*, Vogelxo, Testim, Fortesta, Natesta (nasal gel) -Injections: *testosterone cypionate (Depo-Testosterone)*, testosterone undecanoate (Aveed), testosterone enanthate (Xyosted), -Implantable pellets (Testopel) -PO capsules: tesosterone undacanoate (Jatenzao, Kyzatrex, Tlando) Administration: -*Gels: apply at same time each morning,* falmmable until dry -Xyosted: contains sesame oil

Answer 41

AVEs: *increased appetite, acne, edema, hepatotoxicity, reduced sperm count*, increased SCr, sensitive nipple, sleep apnea -*Natesto: nasal irritation*, prime pump ten times then insert actuator into nostril -Injections: pain -Androgel Pump: before first use, prime by pushing down three times -Apply deodorant prior to apply olutions to underarms -For maximal absorption, wait 2-6 hours after apply gels/solutions before showering or swimming Warnings: increased risk of breast cancer, prostate cancer, CV events, VTE, dyslipidemia, gynecomastia, polycythemia, priapism, caution in hepatic impairment, may worsen BPH CIs: breast cancer, prostate cacner, pregnancy, breastfeeding -Aveed: allergy to castor oil or benzyl benzoate -Depo-Testosterone: serious cardiac, hepatic, or renal disease BBW: -*Topical gel/soluation: secondary exposure to testosterone in children can result in virilization* -PO testosterone undecanoate and SC testosterone ethanate: increase BP and increase risk of CV events -Aveed: pulmonary oil microembolism rxns (cough, dyspnea, throat tightening, anaphylaxis) --> observe in healthcare setting 30 minutes after each injection, only available through REMS program Monitoring: testosterone levels, PSA, liver function, cholesterol, Hct (some

Answer 42

1. Alcohol 2. Antidepressants: especially SSRIs and SNRIs (including decreased libido) 3. Antipsyhcotics: first generation (ex. chlorpromazine), prolactin-raising second generation (ex. risperidone, palperidone) 4. BPH medications: finasteride, dutasteride, silodosin (mostly retrograde ejaculation) 5. Anti-hypertensive medications: beta-blockers, clonidine, others Medical conditions: cardiovascular disease (for ED), depression, stress, neurological illnesses (ex. in ED - spinal cord injury, stroke)

Answer 43

Natural Products: *yohimbe, L-arginine, panax ginseng -L-arginine: "possibly effective"*, can cause similar AVEs to PDE5is (flushing, HA, dizziness) -*Yohimbe: insufficient evidence,* causes GI AVEs, anxiety, tachycardia, arrhythmias -*Ginseng: bleeding risk* TX: -*First line: PDE5is --> started low and titrated to effective dose* (TX failure can be due to lack of sexual stimulation, timing of dose, and eating a large meal w/ dose) -Efficacy similar among PDE5is, but can switch to another drug in class -*Tadalafil: indicated for ED, BPH, and pulmonary HTN -Sildenafil: indicated for ED and pulmonary HTN -PDE5is intolerated/CI: alprostadil*

Answer 44

Drugs: *sildenafil (Viagra, Revatio)*, vardenafil (Levitra, Staxyn), *tadalafil (Cialis, Adcirca*, Alya), avanafil (Stendra) MOA: *nitric oxide (NO) --> guanylate cyclase --> increased cGMP --> relaxes smooth muscle in arteria --> blood flows into vessicles -PDE5is prevent PDE from degrading cGMP* ROA: PO TX: *ED, pulmonary HTN (Revatio, Adcirca, Alya, BPH (Cialis)*

Answer 45

-*Take w/ or w/o food --> sildenafil and vardenafil have decreased efficacy when taken w/ high-fat or large meal (common cause of TX failure) -For ED, no more than one dose/day recommended* -Stendra can be taken closest to sexual activity -*Take about 15 minutes (avanafil), 30 minutes (tadalafil when taken PRN), or 1 hour (sildenafil, vardenafil) before sexual activity*

Answer 46

AVEs: *HA, flushing, dizziness, dyspepsia*, blurred vision, difficulty w/ color discrimination, increased sensitivity to light, epistaxis, diarrhea, myalgia, muscle/back pain (mostly w/ tadalafil which can last up to two days) Warnings: -*Impaired color discrimination* (dose-related): pts w/ retinis pigmentoas may have higher risk -*Hearing loss*, w/ or w/o tinnitis/dizziness -*Vision loss: rare, but due nonarteritic anterior ischemia optic neuropathy (NAION) - risk factors: low cup-to-disc ratio, CAD and other vascular conditions, age >50 yo, Cuacasian --> avoid with retinal disorders* -*Hypotension: due to vasodilation* --> higher risk w/ fluid depletion, resting BP <90/50, or autonomic dysfunction -*Priapism: seek emergency medical care if errection lasts >4 hours* (blood in penis is NOT getting replaced - risk for necrosis/amputation) -CVD --> caution w/ low or very higher BP or recent cardiac events --> *if chest pain occurs, seek immediate medical help* CIs: *use w/ nitrates* or riociguat (guanylate cyclase stimulator)

Answer 47

-*Nitrates (severe hypotension): avoid long-acting nitrates completely; short-acting nitrates shuld not be be used until 12 hours after avanafil, 24 hours for sildenafil or vardenafil, and 48 hours for tadalafil* -Riociguat should NOT be used within 24 hours of sildenafil or within 24 hours before or 48 hours after tadalafil -Additive hypotension w/ alpha-blockers, antihypertensive drugs, and alcohol --> *pt should be stable on alpha-blocker (w/o excessive dizziness/hypotension) before starting PDE5i*; if Cialis being used for BPH, do NOT use alpha-blockers concurrently -*oderate and strong CYP3A4 inhibitors: lower starting dose for PDE5i and/or extended dosing intervals -Strong CYP3A4 inducers: decrease drug levels --> monitor effecitveness*

Answer 48

Starting doses: -sildenafil (Viagra): 50mg PO --> take 1 hour before sexual activity -vardenafil: 10mg PO --> take 1 hour before sexual activity -tadalafil (Cialis): 10mg PO --> take at least 30 minutes before sexual activity -avanafil: 100mg PO --> take 15-30 minutes before sexual activity Dose reduction if: 65 yo or older, using an alpha-blocker, using a CYP3A4 inhibitor, or severe renal or liver disease --> dose reduce by 50% -sildenafil (Viagra): 25mg, vardenafil/tadalafil: 5mg, and avanafil: 50mg Tadalafil: -Daily dose: 2.5-5mg PO QD -On-demand dose: 5-20mg PO PRN

Answer 49

Brand: Caverject, Caverject Impulse, Edex, Muse MOA: *prostaglandin E1, a vasodilator that allows blood to flow into cavernosal arteries* ROA: *injection* (Caverject, Caverject Impulse, Edex), *urethral pellets *(Muse) Administration: *refigerate urethral pellets before insertion* TX: *ED in men who cannot tolerate or have CI to PDE5is* AVEs: *penile pain, pripaism*, HA, dizziness -Intracavernous injection: hematoma, bruising at injection site -Uretheral pellets: urethral burning or bleeding CIs: -Conditions that predispose pt to priapism (ex. sickle cell anemia, multiple myeloma, leukemia) -Intracavernous injection: anatomical deformation or fibrotic conditions of enis, penile implants -Urethral pellets: urethral stricture, balanitis, severe hypospadias and curvature, urethritis, venous thrombosis

Answer 50

Brand: Addyl MOA: *5-HTA agonist and 5-HT2A antagonist* ROA: PO TX: *hypoactive sexual desire disorder in pre-menopausal females only* AVEs: dizziness, somnolence, nausea, fatigue, insomnia, dry mouth Warnings: *hypotension, syncope*, CNS depression -Avoid in pregnancy or breastfeeding BBW: -*CI with alcohol due to increased risk of severe hypotension and syncope (REMS program required) * -CI in combo w/ moderate or strong *CYP3A4 inhibitors* or hepatic impairment DDIs: -Use with CNS depressants can increase risk of hypotension and syncope -Major substrate of CYP3A4 and inhibits P-gp (concurrent moderate/strong CYP3A4 inhibitiors CI)

Answer 51

Brand: Vyleesi MOA: *nonselective melanocortin receptor agonist* ROA: *injection (SC)* TX: *hypoactive sexual desire disorder in pre-menopausal females only* Warnings: increased BP and decreased HR after each dose, skin hyperpigmentation, nausea, delayed gastric emptying -Avoid in pregnancy (effective contraception should be used) CIs: *uncontrolled HTN or known vascular disease*

Answer 52

*Pathophysiology:* -Testosterone converted to dihydrotesterone (DHT) via 5-alpha-reductase increasing number of prostate cells -Explansion causes gland to press/pinch urethra contributing to lower urinary tract symptoms (LUTS) via direct bladder outlet destruction and increased smooth muscle tone and resistance -Irritation causes bladder wall to contract even when it contains small amount of urine, causing frequent urinartion and bladder weakens and loss ability to empty itself Symptoms/Complications: -*Hesistency, intermittent urine flow, straining or weak stream of urine -Urinary urgency and leaking/dribbling -Urinary frequency, especially nocturia* -Incomplete emptying of lbadder -Bladder outlet obstruction -In severe blockage, acute renal failure

Answer 53

-Centrally-acting anticholinergic (ex. benztropine) -Drugs w/ anticholinergic effects (antihistamines, decongestants, phenothiazines, TCAs) -Caffeine -Diuretics -SNRIs -Testosterone products

Answer 54

Natural products: guidelines do NOT recommend, but various products investigated -*Saw palmetto: unlikely to be effective* based on contradictory and incosistent data -Pygeum, pumpkin seed (beta-sitosterol), rye pollen: shown some improvement in symptoms -*Lycopene: used for prostate cancer prevention*, but NO good evidence in BPH Symptom assessment: questionnaires (ex. American Urological Association Symptom Score = AUASS or International Prostate Symptom Score = I-PSS) *TX: * -Mild disease: watchful waiting, annual assessments -Moderate/severe disease: medications or minimally invasive procedures or surgery (ex. transurethral resection of prostate = TURP) -Alpha blockers: first line in moderate/severe symptoms, work quickly, do NOT shrink prostate -5 alpha-reductase inhibitors: delayed onset, shrink prostate size -PDE5is: tadalafil +/- 5 alpha-reducatase inhibitor

Answer 55

Drugs: -*Non-selective alpha-1 inhibitors: doxazosin (Cardura, Cardura XL), terazosin -Selective alpha-1a inhibitors: tamsulosin (Flomax, w/dutasteride - Jalyn), alfuzosin (Uroxatral), silodosin (Rapaflo)* MOA: *inhibit alpha-1 adrenergic receptors, causing relaxation of smooth muscle in prostate and bladder neck, reducing bladder outlet obstruction and improving urinary flow -Alpha-1A receptors: primarily found in prostate -Alpha-1B and -1D: dominant in heart and arteries* ROA: PO *Administration:* -Non-selective: given QHS to minimize initial "first-dose" effect of orthostasis/dizzines (caution especially in nocturia), titrate slowly -Tamsulosin: 0.4mg PO QD -Work quickly, but 4-6 weeks may be required to assess beneficial effects (do NOT shrink prostate and do NOT change PSA levels) -Cardura XL: OROS frmulation, can leave ghost tablet TX: *BPH* -Off-label: bladder outlet obstruction in women

Answer 56

AVEs: *dizziness, fatigue, HA, abnormal ejaculation* (especailly w/ tamsulosin and silodosin; *retrograde ejaculation/sexual dysfunction w/ silodosin)*, fluid retention, rhinitis (tamsulosin) -*Non-selective alpha inhibitors (ex. doxazosin) have more AVEs of orthostasis, dizziness, HA* Warnings: -*Orthostatic hypotension/syncope*, typically w/ first dose, if therapy interrupted for several days, dosage increased too rapidly, or antoher anti-HTN or PDE5i is started -*Intraoperative floppy iris syndrome (IFIS) can occur in cataract surgery* if currently on previously treated -Priapism --> seek medical attention if an errection lasts >4 hours -Angina --> D/C if symptoms begin or worsen CIs: concurrent use of silodosin or alfuzosin w/ strong CYP3A4 inhibitor; hepatic impairment (Child-Pugh class C for silodosin, B/C for alfuzosin); severe renal impairment (silodosin) Monitoring: BP, PSA, urinary symptoms DDIs: -*Caution when co-administered w/ PDE5is (hypotension) --> do NOT use in combo w/ tadalafil for BPH* -Caution w/ other drugs that lower BP -Tamsulosin, alfuzosin, silodosin: majory CYP3A4 substrates --> do NOT use w/ strong inhibitors -Silodosin: cannot use w/ strong P-gp inhibitors (ex. cyclosporine) -Alfuzosin: caution with other QT-prolonging drugs and CVD

Answer 57

Drugs: *finasteride (Proscar, Propecia*, w/ tadalafil - Entadfi), dutasteride (Avodart, w/ tamsulosin - Jalyn) MOA: *inhibits conversion of testosterone to dihydrotestosterone (DHT) -Finasteride: selective 5 alpha-reductase type II enzyme (more prevalent in prostate)* ROA: PO Administration: -*Pregnant women should NOT take or handle these medications* (API can be absorbed through skin from broken or crushed tablets and can be detrimental to the fetus --> NIOSH) -*Delayed onset --> TX for 6 months may be required for maximal efficacy* -Swallow dutasteride whole (do NOT chew or open contents - oropharyngeal irritation) TX: *BPH w/ enlarged prostate (improves symptoms, decreases risk of urinary retention and need for surgery, decreases size of prostate, decrease PSA levels), alopecia (Propecia)*

Answer 58

AVEs: *impotence, decreased libido, ejaculation disturbances, breast enlargement and tenderness*, rash -Sexual side effects decrease w/ time and return to baseline at one year of use in some men Warnings: may increase risk of high-grade prostate cancer CIs: *women of child-bearing potential, pregnancy,* children Monitoring: PSA, urinary symptoms DDIs: -Finasteride and dutasteride: minor CYP3A4 substrates -Do NOT use Proscar if using Propecia for hair loss

Answer 59

*Pathophysiology:* -Detrusor muscle innervated by parasympathetic nervous system (Ach acting on muscarinic receptors) is inappropriately stimulated causing involuntary contractions and feeling of urinary urgency -M3 receptor is responsible for both emptying contractions and involuntary bladder contractions S/Sx: *urinary urgency w/ or w/o incontinence, urinary frequency, nocturia, urinary incontinence (involuntary leakage of urine)* Risk factors: *age >40, obesity, neurologic conditions (ex. PD, stroke, dementia), DM*, prior vaginal delivery, restricted mobility, hysterectomy, pelvic injury

Answer 60

Urge: *sudden urge to urinate, associated w/ neuropathy* and often in those w/ DM, strokes, dementia, PD, or MS Stress: *urine leaks during any form of exertion* (ex. exercise, coughing, sneezing, laughin) as a result of pressure on bladder Functional: no abnormality in bladder, but may be cognitiviely, socially, or physically impaired thus hindering access to toilet Overflow: leakage that occurs when quantity of urine stored in bladder exceeds capacity often w/o urge to urinarte *(BPH most common cause) Mixed: combination of urge and stress UI*

Answer 61

alcohol, cholinesterase inhibitors, diuretics, sedatives

Answer 62

Non-pharmacological: *behavioral therapy considered first-line* (ex. bladder training, delayed or scheduled voiding, *pelvic floor muscle exercises such as Kegel exercises*, urge control techniques, *fluid management, avoiding bladder irritants such as caffeine*, weight loss) *Urge/Mixed Incontinence:* -First line: behavioral therapy + anticholinergic or beta-3 agonist for 4-8 weeks for adequate trial -Anticholinergics: long-acting (Ex. oxybutynin ER or transdermal) often used initially (less AVEs), selective anticholinergics (darifenacin, solifenacin) have less cognitive AVEs -Beta-3 agonists: similar efficacy to anticholinergics, just different AVEs -OnabotulinumtoxinA (Botox): higher efficacy, but NOT first-line due to cost and injection -Nerve stimulation or surgical TX Stress Incontinence: medications use NOT FDA-approved with minial efficacy -Pseduophedrine, duloxetine *Nocturia: desmopressin (CI: pts w/ increased fluid retention risk, BBW: hyponatremia)*

Answer 63

Drugs: *oxbutynin (Ditropan XL, Oxytrol, Oxtrol for Women*, Gelnique), *tolterodine (Detrol, Detrol LA)*, trospium, *solifenacin (Vesicare)*, darifenacin, fesoterodine (Toviaz) MOA: *"antimuscarinic" drugs that competitively bind to muscarinic receptors and block ACh, preventing contraction of detrusor muscle -More selective for M3 receptors: solifenacin, darifenacin* *ROA:* -Oxybutynin: IR, ER (Ditropan XL), patch (Rx: Oxytrol, OTC: Oxytrol for Women), gel (Gelnique) -Rest: PO Administration: -Decrease dose in renal impairment (CrCl <30) w/ fesoteridine, solifenacin, tolterodine, and trospium (do NOT use tropsium XR) -*Ditropan XL: OROS formulaion, can leave ghost shell* -Oxytrol patch: place on dry, intact skin on abdomen, hips, or buttock; avoid reapplication to same site within 7 days; available OTC for women >/=18 yo; applied twice weekly -Package labeling is NOT clear if metals present in Oxytrol (Rx and OTC) --> consider removing before MRI -Gelnique: apply to dry, intact skin on abdomen, thighs, or upper arms/shoulders; rotate sites -*Trospium XR: take OES*

Answer 64

AVEs: *dizzinss and drowsiness (greatest w/ oxybutynin), xerostomia (dry mouth), constipation*, dry eyes/blurred vision, urinary retention, application site rxns (topical gel/patch) Warnings: -*Agitation, confusion, drowsiness, dizziness, blurred vision*, hallucinations, and/or HA which may impair physical or mental abilities *(caution in performing tasks that require mental alertness, on Beers Criteria)* -Angioedema of face, lips, tongue, and/or larynx CIs: -*Uncontrolled narrow angle glaucoma*, urinary retention, gastric retention, decreased gastric motility -Oxytrol for Women OTC: pain or burning when urinating, blood in urine, unexplained lower back or side pain, cloudy or foul-smelling urine, male sex, age <18 yo, urinary or gastric retention, glaucoma, accidential urine loss only due to coughing, sneezing, or laughing DDIs: -Additive effects w/ medications that have anticholinergic side effects -Lowest dose of tolterodine, solifenacin, darifenacin, and fesosterodine should be used w/ strong CYP3A4 inhibitors -Acetylcholinesterase inhibitors for dementia increase ACh in CNS --> although OAB drugs primarily stay in periphery, some may experience CNS side effects (may worsen dementia symptoms)

Answer 65

-Oxybutynin patch and gel: less dry mouth and constipation than PO forms -Long acting formulations have less AVEs (ex. oxbutynin ER) -Selective anticholinergics (ex. darifenacin, solifenacin): less cognitive AVEs -Non-pharm: avoid mouthwarshes w/ alcohol, use ice chips, water, sugar-free candy or gum -Beta-3 agonists have less incidence of dry mouth and anticholinergic AVEs

Answer 66

Drugs: mirabegron (Mybetriq), vibegron (Gemtesa) MOA: *relax detrusor muscle and increase bladder capacity via beta-3 receptor activation* ROA: PO TX: *in combo or alone for urge/mixed incontinence* AVEs: nasopharyngitis, HA, constipation, diarrhea, dizziness -Mirabegron: UTI Warnings: *urinary retention* in pts w/ BPH and when used w/ anticholingergics -Mirabegron: increased BP, angioedema of face/lips/tongue/larynx DDIs (mirabegron): moderate CYP2D6 inhibitor (caution in NTIs that are metabolized by 2D6 and digoxin), levels of metoprolol may be increased, levels of tamixofen decreased Monitoring: urinary symptoms, BP (mirabegron)

Male / Female Health Flashcards

(90 cards)