women's health Flashcards
(162 cards)
1
Q
hypothalamus releases _______ onto anterior pituitary. AP releases ______ and ______
A
GnRH; gonadotrophs LH and FSH
2
Q
what two cells does FSH work on? what does it do in each cell?
A
1) . stimulates development of ovarian follicles (granulosa cells)
2) . regulate spermatogenesis in testes (Sertoli cells)
3
Q
what three things does LH do?
A
1) . causes ovulation and formation of corpus luteum in the ovary
2) . stimulates production of estrogen and progesterone by the ovary
3) . stimulates testosterone production by the testes
4
Q
DHEA turns into ______________ by 3beta-hydroxysteroid dehydrogenase
A
androstenedione
5
Q
androstenedione turns into _____________ (testes) and then that turns into ________ (ovaries)
A
testosterone; 17 beta-estradiol
6
Q
in the ___________ cell, cholesterol turns into pregnenolone and then ____________
A
granulosa; progesterone
7
Q
progesterone travels from the ____________ cell to the ________ cell to make ___________
A
granulosa; theca; androgens
8
Q
androgens in the ________ cell travels to the __________ cell to be converted to ________
A
theca; granulosa; estrogens
9
Q
what is the enzyme that converts androgens to estrogens?
A
aromatase
10
Q
what enzyme is lacking during menopause? this causes lack of what hormone?
A
aromatase (bc granulosa cells are lacking); estrogen cant be made, only progesterone
11
Q
estradiol is secreted by ______ and is ______ potent. this is the _________ estrogen in _____________ women
A
ovary; most potent; primary; pre-menopausal
12
Q
what are the three types of estrogens?
A
estradiol (17 beta-estradiol), estrone, estriol
13
Q
estrone is a __________ of estradiol; it has the __/___ potency of estradiol
A
metabolite; 1/3
14
Q
estriol is a ____________ of estradiol. it is the primary estrogen after __________
A
metabolite; menopause
15
Q
estrogen increases levels of what four clotting factors? what does this increase for pts?
A
2, 7, 9, 10; increases risk of blood clots
16
Q
estrogen _________ HDL and _________ LDL
A
increases; decreases
17
Q
estrogen decreases rate of bone ___________: _________ osteoblast activity (____________ osteocyte survival) and decreases number and activity of ___________. this effect on bone is important for _______________
A
resorption; increases and increases; osteoclast; homeostasis
18
Q
estrogen is important for closure of what plates in males and females? starts closing upon 2 years of puberty in what sex?
A
epiphyseal; females
19
Q
estrogen promotes __________ and _____ atherogenesis (in terms of blood vessels)
A
vasodilation; slows
20
Q
estrogen binds to receptors in the ___________. when receptors are activated, they increase or decrease ____ __________
A
nucleus; gene transcription
21
Q
what are the two types of estrogen receptors? does it matter which one we are targeting with drugs?
A
alpha and beta; no
22
Q
where are ER alpha receptors found?
A
female reproductive tract, mammary gland, hypothalamus, endothelial cells, and vascular smooth muscle
23
Q
where are ER beta receptors found?
A
highly expressed in prostate and ovaries; lower expression in lung, brain, bone, and vasculature
24
Q
what two hormones share the same MOA?
A
estrogen and progestin
25
natural estrogens are derived from what two sources?
plant: saw palmetto or soybeans
animal: pregnant mares are a major commercial source of estrogen
26
what is the type of synthetic estrogen used for hormone replacement/contraception? what is different about this compared to estrogen the body normally makes?
ethinyl estradiol (prolonged DOA and higher potency)
27
micronized products have a large surface area for rapid absorption. what does this do for a drug?
increases its bioavailability
28
what does the ethinyl component in estrogen do to metabolism?
it inhibits first-pass metabolism (cleared more slowly)
29
estrogens undergo _______ hepatic metabolism and _____________ recirculation
rapid; enterohepatic (liver will see these substances twice)
30
what are estrogens highly protein bound to?
sex hormone binding globulin
31
what two ways is estrogen excreted? in what form is it excreted?
in the urine as estradiol, estrone, and estriol; in breast milk too, decreases the quality/quantity of human milk
32
estrogen has what impact on blood pressure?
increases it, because increases angiotensinogen synthesis and increases angiotensin II
33
why can estrogen cause thromboembolic disorders and gallbladder disease?
thromboembolic- increase hepatic synthesis of clotting factors
GB disease- increase cholesterol excretion in bile leading to gallstones
34
what are five contraindications to estrogens?
1) . estrogen dependent tumor (breast cancer or high risk of it)
2) . undiagnosed vaginal bleeding (could be due to CA)
3) . liver disease
4) . thromboembolic disease (anyone with hx of clots)
5) . heavy smokers (inc risk of blood clots)
35
clinical use of estrogen (weeds):
```
Contraception
Dysmenorrhea
Acne
Primary hypogonadism
Postmenopausal hormonal therapy
Relieves genitourinary atrophy
Relieves vasomotor instability
Osteoporosis
Insomnia and fatigue
Mood changes
Sexual function
```
36
what is the natural form of progestogen? what is this produced in response to? what secreted this in both males and females?
progesterone; LH
males: secreted by the testes
females: secreted by corpus luteum mostly during second half of menstrual cycle and placenta
37
what body organ synthesizes a small amount of progesterone in males and females?
adrenal cortex
38
MOA of progestogen?
same as all other steroid hormones
39
what is the main goal of progestogen?
promotes development of secretory endometrium to support implantation and embryo development
40
what does progestogen inhibit?
production of gonadotropin, preventing further ovulation
41
if conception occurs, does progestogen continue to be secreted?
yes, it maintains endometrium and reduces uterine contractions
42
what happens to progesterone production if there's no conception?
corpus luteum progesterone production stops quickly and menstruation starts
43
what are the 7 progestogens?
```
Progesterone
Medroxyprogesterone
Levonorgestrel
Norethindrone
Norgestrel
Norgestimate
Drospirenone
```
44
what are the uses of progestogen: (5)
1) . contraception- alone or in combo with estrogen
2) . Hormone replacement therapy along with estrogen
3) . vasomotor symptoms- postmenopausal women who can't use estrogen
4) . dysmenorrhea
5. endometriosis and infertility
45
ADRs of progestogens
HAs, inc appetite, inc weight gain, depression, fatigue, hair loss, acne/oily skin
46
breast fullness/tenderness is a sign of an ADR from what drug/hormone?
estrogen
47
acne and hirsutism are signs of ADRs for what drug/hormone?
progestin
48
cyclic weight gain and cyclic headache are signs of ADRs for what drug/hormone?
estrogen
49
what are the types of hormonal contraception? (7)
1) . minipill (progestin only)
2) . implant
3) . long acting IM injection
4) . combined oral pill
5) . 91-day oral combo
6) . combination patch
7) . contraceptive vaginal ring
50
what are the types of contraception (in general)? (6)
1) . periodic abstinence
2) . mechanical barriers
3) . hormonal contraception
4) . IUD
5) . sterilization (female/male)
6) . emergency contraception
51
what are the top four BEST contraceptive methods (two reversible/two irreversible)
reversible: Nexplanon/implant (0.05%), IUD (0.2-0.8%)
irreversible: vasectomy, female sterilization
52
what five methods of contraception are the middle tier in terms of effectiveness? what are their percent chance of pregnancy?
injectable, pill, patch, ring, diaphragm (6-12%)
53
what six things are categorized as the least effective contraceptive methods? what are their percent chance of pregnancy?
male condom (18%), female condom (21)%, withdrawal (22%), sponge, fertility awareness based methods, spermicide (28%)
54
what is the pharmacologic effect of hormonal contraception- estrogen and progestin?
estrogen/progestin inhibit LH/FSH and prevent estrogen surge (no estrogen surge = no LH surge = no ovulation
55
factors in selecting contraception (7)
1) . personal preference
2) . effect on menstrual pattern/bleeding
3) . childbearing plans
4) . pattern of sexual activity
5) . partner influences/concerns
6) . ability to acquire/use effectively
7) . tolerance for the medication
56
Nexplanon: rod coated with _________, provides contraception for ___ years. once pts get it removed, they return to ovulation _______ (usually within _______)
progestin; 3; return to ovulation quickly; 3 weeks of removal
57
what is the IM injection for contraception? how many days does it last? what hormone does it use?
medroxyprogesterone; 90 day; progestin
58
ADRs for IM injection (5, one main one)
1) . DELAY in return to fertility (6-12 months)
2) . amenorrhea or irregular bleeding
3) . weight gain
4) . HA
5) . acne
59
boxed warning for IM injection
women who have used for at least 5 years have significantly reduced BMD of lumbar spine/femoral neck (particularly after 15 yrs and if started before age 20)
60
is the boxed warning for IM injection reversible?
almost completely reversible, even after 4 or more years of drug
61
what are the two types of oral progestin?
norgestrel or norethindrone
62
a "missed dose of minipill" means you're outside a ___ hr window. what do you do after a missed dose?
three; must use back up method for 48 hours
63
what are combo pills made up of?
estrogen- ethinyl estradiol
progestin- norgestimate, desogestrol, dienogest, ethyodiol (BEST)
-drospirenone (might have hyperkalemia)
-norgestrel, levonorgestrel, norethindrone (more ADRs)
64
what is the monophasic pill formulation? what are the two drug names?
constant dose every day for 21 days (estrogen/progestin), 7 days of no hormones +/- iron; ortho-cyclen, yasmin
65
what is the biphasic pill formulation? what are the two drug names?
amount of hormone may change 1/3 way through cycle; mircette and orthoNovum
66
what is the triphasic pill formulation? what are the two drug names?
amount of hormone changes every week; ortho-novum 7/7/7 or ortho tri-cyclen
67
what is the quadriphasic formulation? what are the two drug names?
four varying amounts throughout monthly pack; natazia and quartette
68
Multiphasic pills have a ______ total hormone dose per cycle; no evidence they cause fewer ADRs or improve bleeding patterns compared to __________ pills
lower; monophasic
69
91-day oral combo pill: combo of ________ and ___________ for ___ weeks and then ____ week of placebo or estrogen only. how many periods per year?
estrogen; progesterone; 12; 1; 4 periods
70
91 day combo pill estrogen kind- _____ spotting and unplanned _________ for 12 weeks while on pill
less; bleeding
71
what are the three start methods for oral contraceptives?
1) . same day: begin taking active pill the 1st day of menses
2) . sunday start: begin taking active pill the first sunday after menses begins (use BUM for at least a week)
3) . quick start: begin taking active pill day given the prescription (use BUM for at least a week)
72
if you miss one pill for OC, when do you take the next one?
take as soon as remembered (no BUM needed)
73
if you miss two OC pills in week 1 or 2 of cycle, how do you correct?
take 2 pills for 2 days plus BUM for 7 days
74
if you miss two OC pills in week 3 of cycle, how do you correct?
finish the pills in the current pack, omit hormone free week and begin new pack (insurance might not cover this)
**if cant start new pack, use BUM until you can take 7 consecutive days from new pack
75
what impact does estrogen/progestin contraceptives have on fracture risk?
decreased postmenopausal hip fracture risk for women using estrogen products in their 40s (use after other agents for osteoporosis)
76
4 non contraceptive benefits of estrogen/progestin contraceptives
helps with:
1) . menstrual cycle disorders
2) . hyperandrogenism
3) . gynecologic disorders
4) . cancer risk
77
OC are substrates of the ________ enzyme. what does this mean?
CYP450; any drug that increases the CYP450 enzyme will increase the clearance/decrease efficacy of oral contraceptives
78
what are the two types of CYP450 inducers? what contraceptive forms are recommended to use with these drugs instead of OCs?
1) . antiepileptic: phenytoin, carbamazepine, topiramate, oxcarbazepine (use 90 day injection)
2) . antibiotics: rifampin- used for TB (other ABX not proven to affect estradiol so BUM isn't required)
79
how do OC impact lamotrigine?
OC's increase the clearance of it, reducing plasma concentration up to 60%
80
ADRs of OC
bleeding irregularities, acne, MI, nausea, weight gain, mood swings, breast tenderness, HA, hirsutism, depression, HTN
81
what does bleeding early vs late mean when someone is taking OC?
early- not enough estrogen (inc estrogen)
| late (after day 14)- not enough progestin (inc levels)
82
what is acne a sign of when taking OC? what is the fix for it?
sign of too much progestin; switch to a higher level pf estrogen and/or select a lower androgenic OC
83
when do you have a higher risk of MI when taking an OC?
with estrogen doses > 50 mcg (low risk factor bc most OC only use 30 mcg per day)
84
contraindications to OC (3)
1) . breast cancer (or other estrogen/progestin dependent neoplasm)
2) . hepatic tumors or dz
3) . pt at risk for arterial/venous thrombotic disease- estrogen drives the increased clotting factors
85
what are 6 types of people at risk for arterial/venous thrombotic disease?
CVD, CAD, DVT/PE, uncontrolled HTN, migraine with aura (progesterone OC is best), and women over 35 yrs old who smoke
86
when breastfeeding, you can used combined OC pills but have to wait __-__ weeks after birth to start
6-8
87
what hormone is the preferred one to use in contraceptives when breastfeeding? what are the four suggested contraceptives?
```
progestin
mini pill (micornor, Nor QD, Ovrette), depo Provera, IUD, Nexplanon
```
88
what is the combined hormonal transdermal patch?
Xulane- ethinyl estrogen and norelgestromin
89
how to use the transdermal patch?
place on once a week for 3 weeks and then one week of no patch
90
Missed doses of transdermal patch: what to do if patch is off for less than 24 hrs vs more than 24 hrs
less than 24 hrs- reapply, no BUM needed
| more than 24 hrs- open a new patch, new day 1, must use BUM for 1 week
91
the transdermal patch is less effective for what pt population?
people over 90 kg (198 lbs)
92
NuvaRing: has what type of delivery for systemic effect? how to use? _______ be removed during intercourse
topical delivery; inserted by pt and left in for 3 weeks, and removed with one week off; shouldn't
93
what to do with misses does of NuvaRing: less than or greater than 3 hours
less than 3 hrs: reinsert
| more than 3 hrs: reinsert and use BUM until ring has been used for a week
94
what are the two main forms of IUD? which one is mostly used?
```
levonorgestrel coated- mostly used
Copper coated (ParaGard T)
```
95
how does the levonorgestrel coated IUD prevent pregnancy? (3 things)
1) . thickens cervical mucus which inhibits sperm passage/survival
2) . inhibits ovulation dec LH and FSH
3) . thins endometrium, which decreases implantation
96
how does copper IUD prevent pregnancy? (2)
1) . inhibits sperm motility preventing fertilization
| 2) . prevents implantation
97
what is the copper IUD NOT coated with?
progesterone
98
indications of use for IUD (3)
1) . no hx of PID or ectopic preg
2) . have heavy menses, cramps, anemia, or dysfunctional uterine bleeding
3) . women seeking long term protection (2 yrs or more)
99
what are the three types of levonorgesterel coated IUDs? how long does each last?
1) . mirena- lasts 5 yrs
2) . Skyla- 3 yrs (smaller than mirena)
3) . liletta- 4 yrs
100
how long does the copper IUD last? what can it also be used for besides its primary use?
10 yrs; emergency contraception
101
once removing an IUD, how long does it take to return to fertility?
1-3 months
102
ADRs of IUD
PAINS
P: period late; abnormal spotting or bleeding
A: abdominal pain, pain with intercourse
I: infection exposure, abnormal vaginal discharge
N: not feeling well, fever, chills
S: string missing, shorter or longer
103
contraindications of IUDs (6)
1) . inc susceptibility to infection (DM, AIDS, valve heart dz)
2) . current pregnancy
3) . pelvic infection, PID in past year
4) . CA/distorted uterine cavity
5) . undiagnosed vaginal bleeding
6) . hx of ectopic preg
104
4 types of EC
levonorgestrel, YUZPE, Copper IUD, Ulipristal
105
how do oral EC methods work?
primarily by delaying ovulation
106
if patient has already ovulated what is important to remember about EC?
it doesn't stop the implantation
107
what is the only OTC EC? what is the timing of use? what is % efficacy?
Plan B- levonorgestrel; 72-120 hrs; 85% efficacy
108
what is the YUZPE EC? how to use? timing of use? % efficacy
estrogen plus progesterone, Rx only; 100-120 mcg estrogen AND 500-600 mcg progesterone, give together as two separate doses, 12 hrs apart; timing is up to 120 hrs, 99% efficacy
109
when using the copper IUD for EC, when do you have the insert it? what is % efficacy?
inserted within 120 hrs after intercourse; 99%
110
what is the ulipristal/ella timing of use? what is % efficacy? what does this delay?
up to 120 hrs, 98% (Rx, single dose); ovulation
111
what is the abortifacient drug?
mifepristone/mifeprex
112
what is MOA of mifepristone?
binds to intracellular progesterone receptor which blocks effects of progesterone; leads to contraction inducing activity in uterine smooth muscle
113
what is mifepristone given with?
misoprostol- stimulates contractions and induces labor
114
abortifacient is used for termination of pregnancy through ___ days of gestation
70
115
ADRs of mifepristone (2)
vaginal bleeding for 9-16 days, uterine hemorrhage
116
what is the most common reason postmenopausal women seek hormone replacement?
vasomotor symptoms (hot flashes)
117
what are two main symptoms related to estrogen deficiency (menopause)?
vasomotor (hot flashes) and GU
118
what are some GU problems menopausal women have? (4)
1) . Decreased estrogen leads to shrinkage of labia minora and vuvlovaginal atrophy
2) . Loss of lubrication
3) . Vaginal pH becomes more basic – creating favorable environment for bacterial colonization
4) . Thinning of urethra and bladder lining and decreased muscle tone – urinary frequency/urgency & UTI
119
what are the four main menopause tx options?
1) . hormone therapy
2) . SSRI's
3) . prasterone vaginal insert (intrarosa)
4) . Natural products
120
what are the four types of hormone therapy for menopause?
1) . estrogen and progesterone (EPT)
2) . estrogen only (ET)
3) . estrogen-receptor agonists or antagonists (SERM)- osphena
4) . estrogen and Bazedoxifene (Duavee)
121
what are the two types of EPT?
estrogen plus cyclic progestogen and estrogen plus daily progestogen
122
what are the three types of natural products for menopause tx?
1) . soy isoflavones- act similar to estrogen and ADRs
2) . evening primrose oil
3) . black cohosh- some help with hot flashes (but liver toxicity)
123
what is the primary indication of hormone therapy?
moderate to severe vasomotor symptoms
124
which population of women should be getting HT?
women younger than 60 who are within 10 yrs of menopause onset (not at high risk of CVD or breast CA)
125
what can be used in high risk women where hormone therapy isn't recommended for vasomotor symptoms?
SSRIs- Effexor, Prozac, paxil, zoloft
126
what three drugs can help vasomotor symptoms if the pt cant take estrogen?
clonidine, megestrol, and gabapentin
127
when taking hormone therapy, what is important about dose?
use lowest effective dose
128
what hormone therapy is recommended for postmenopausal women with moderate-severe vaginal symptoms?
local estrogen therapy preferred if no vasomotor symptoms
129
stress incontinence: how does systemic vs local hormone therapy impact it?
systemic- may worsen
| local- may help
130
hormone therapy is or is not recommended for sole tx of diminished libido?
NOT
131
what are the two drugs used for menopausal sexual dysfunction?
Osphena and
| Intrarosa (vaginal insert)- (both used for moderate to severe dyspareunia)
132
osteoporosis: hormone therapy for __________. estrogen _____ the rate of resorption but ______ restore bone loss
prevention; reduces; doesn't
133
what is a combo product for tx of moderate-severe vasomotor symptoms and osteoporosis prevention?
duavee (estrogen and bazedoxifene)
134
therapy duration for hormone replacement
check after 3 months- year; try to discontinue if asymptomatic; if symptoms recur try to treat an additional 3 months (optimal tx is for less than 5 years)
135
give only estrogen HRT to pts without a ____________. give _________ _______ for women intolerant of oral products. give _______ ______ in women with no vasomotor symptoms
uterus; transdermal patches; topical/vaginal products
136
If pt has a uterus, give low dose _______ AND ________________ to prevent endometrial hyperplasia
estrogen and progesterone
137
what is the estrogen plus cyclic progesterone (sequential therapy)?
daily estrogen with progesterone added for 10-14 days/month (often bleed at end of cycle)
138
what is the estrogen plus continuous progesterone (continuous therapy)?
give both everyday, some bleeding at first but usually tapers off (ie for ppl who don't want a period)
139
two main risks of estrogen hormone therapy
endometrial cancer (10-20 yrs incs risk 8 fold) and breast cancer (risk isnt that large and dec after d/c drug)
140
MOA of danazol
weak androgen, suppresses LH and FSH leading to atrophy of endometrial tissue, inhibits LH/FSH surge
141
2 clinical uses for danazol
1) . endometriosis
| 2) . fibrocystic breast disease
142
boxed warnings of danazol
thromboembolic events, hepatic effects, androgenic effects on female fetus (be careful in preg/BF)
143
ADRs of danazol (4)
weight gain, edema, acne, decreased breast size
144
Unless a pt is having vasomotor symptoms, you aren't going to use _______ to only treat sexual function or osteoporosis
HRT
145
which drug increases the sensitivity of insulin receptors? what menstrual disorder could this help with?
metformin; keeps DM in check for pts with POS
146
what diuretic can help with PCOS symptoms? why does this help?
spironolactone; it is an ant androgen that can help improve symptoms of hirsutism
147
two potential tx for endometriosis are _________ ________ and ________
aromatase inhibitors (affects FSH and LH) amd NSAIDs (anti inflam for pain)
148
SERMS MOA
estrogen related compounds that have selective AGONISM or ANTAGONISM for receptors depending on TISSUE TYPE
(used for a variety of things**)
149
what are the 5 SERMS?
1) . tamoxifen (nolvadex)
2) . toremifene (fareston)
3) . raloxifene (evista)
4) . osphena
5) . clomiphene (clomid)
150
MOA of tamoxifen/nolvadex
binds to estrogen receptors on tumors to inhibit growth (specifically breast tissue)
**negative impact in uterine tissue
151
clinical uses for tamoxifen/nolvadex
metastatic breast CA, tx of breast CA after surgery/radiation, prevention of breast CA in high risk pre-menopausal women
152
boxed warning for tamoxifen (nolvadex)
increased incidence of uterine and endometrial CAs
153
clinical use of Toremifene/fareston
tx of metastatic breast CA in postmenopausal women with estrogen receptor positive tumors
154
boxed warning of toremifene/fareston
prolongs QT interval (avoid use with drugs that do/strong CYP3A4 inhibitors)
155
what are the three aromatase inhibitors?
anastrazole/arimidex
letrozole/femara
exemestane/aromasin
156
moa of aromatase inhibitors
inhibits enzyme which prevents conversion of androgens to estrogen
157
what two things do aromatase inhibitors do to the body?
1) . significant;y reduce plasma estrogen levels
| 2) . increased secretion of FSH from anterior pituitary (induces ovulation with less risk of multiple birth)
158
clinical use of aromatase inhibitors
breast cancer in postmenopausal women- not going to feed tumor
159
what is the off label use of letrozole/femara?
infertility/ovulation: pulsatile use (used for some days and then removed)
160
MOA for clomiphene/clomid
interferes with negative feedback of estrogens on the hypothalamus (causes an increase in GnRH, LH, FSH secretion to stimulate ovulation)
161
two clinical uses of clomiphene/clomid
tx of ovulatory dysfunction (for people who want to get pregnant) and PCOS
162
ADRs of clomiphene/clomid (4)
multiple pregnancies (10%), reversible skin loss, hot flashes, constipation
