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79 Cards in this Set
- Front
- Back
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PB 337
What % of U.S. women will use hormonal contraception during their reproductive years |
80
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PB 337
Examples noncontraceptive benefits of hormonal contraception include |
menstral cycle regularity, treatment of menorraghia, dysmenorrhea,amenorrhea for lifestyle,premenstral syndrome,menstral migranes (prevention), acne or hirsutism, improved bone mineral density,bleeding due to leiomyomas, pelvic pain due to endometriosis, decrese in cancers of endometrium, ovary and colon.
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PB 337
In OCP's what is role of the progestins and estrogen combination? |
progestin provide contraceptive effects and an estrogen stabilizes the endometrium to reduce unwanted spotting.
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PB 337
What is progestins mechanism of action (MOA) |
1.Progestin component inhibits release of LH from anterior pituitary, preventing ovulation
2. Progestin dominates in effect on the endometrium leading to decidualized lining, atrophied glands, not receptive to implantation 3. Progestin increases viscosity of cervical mucus, making sperm penetration more difficult |
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PB 337
What is estrogens MOA? |
1. Estrogen component inhibits release of FHS from anterior pituitary, preventing selection of dominant follicle
2. Estrogen provides stability to endometrium, decreases rate of breakthrough bleeding, thins cervical mucus 3. Estrogen increases concentration of progestin receptors, thus allowing for decreased dosage |
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PC 337
What is Biologic classification: 2 main families of progestins? |
1. Estranes (19-nortestosterone derivatives): norethindrone, norethindrone acetate, ethynodiol
diacetate 2. Gonanes: a. "older" : norgestel, levonorgestrel b. "newer" :desogestrel, gestodene, norgestimate 3. "Even newer" progestin: drosperinone (derived from 17 a spironolactone) |
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PC 337
What is MOA of Drosperinone ? |
1. is analogue of spironolactone, biologic action more similar to progesterone
2. Has both anti-mineralocorticoid activity and anti-androgenic activity 3.In open label study found to have acceptable efficacy, safety, and cycle control (similar to other low-dose OCs, 1% breakthrough bleeding, 9.3% spotting, 3.2% amenorrhea) 3 # Patients reported decreased subjective symptoms of water retention and negative affect # Also mean decrease in weight, no significant change in lipid profiles after 13 cycles |
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PC 337
Progestin Only Pills (POPs) are less or more efficaeous than combination? why? |
1. Mechanism related more to effect on cervical mucus & endometrium, only inhibits ovulation about 40% of time
2. Efficacy slightly less than combination OCs- typical failure rate 5% for 1st year of use 3.. Effect on cervical mucus lasts only about 22 hrs, must take pill at same time each day (>3 hr delay = missed pill, use back up for 7 days) |
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PC 337
Why does the WHO say no OCP or POP (progestrone only pills) until 6 weeks if breastfeeding? |
Used commonly by breast feeding women, due to some evidence that combined OCs lead to decreased breast milk production. There is also theoretical concern that exposure to steroids in breast milk in 1st 6 weeks postpartum can lead to growth restriction in neonates, thus the WHO suggests avoiding progesterone-only OCs during 1st 6 wks post-partum
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PC 337
What are the current formulations Progestin Only Pills? |
Micronor-Norethindrone 0.035 mg
Nor-QD-Norethindrone acetate 0.35 mg Orvette-Norgestrel 0.075 mg |
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PC 337
What are Side effects of Oral Contraceptives Estrogen? |
Bloating, headache, nausea, mastalgia, leukorrhea, hypertension, melasma/telengectasia
* Can be decreased by use of 20 mcg EE pills , which still have good contraceptive efficacy |
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PC 337
What are Side effects of Oral Contraceptive Progestin? |
Mood swings, cyclic mastalgia, depression, fatigue, decreased libido, weight gain
* These side effects tend to decrease with continued use |
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PC 337
What "less androgenic" progestins exist? |
Third generation progestins such as desogestrel, and also norgestimate (technically a newer 2nd generation progestin
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PC 337
ARE ALL COMBINATION OCs ARE ANTI-ANDROGENIC? Why? |
YES
WHY- 1. OCs inhibit LH and thus decrease ovarian production of testosterone 2. Estrogen leads to increased sex hormone binding globulin (SHBG) production by liver, progestin decreases SHBG, but overall effect of OCs is to increase SHBG 3. 3rd generation progestins increase SHBG more than monophasic older preparations 4. Increased SHBG leads to decrease in free testosterone * 3rd generation progestins compete less for binding with SHBG 5. # Progestin mediated inhibition of 5- a reductase leads to decreased DHT * Formation of DHT necessary for any cellular effects on skin/hair follicles |
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PC 337
Do all OCs should help treat acne & hirsutism? |
Yes but 3rd generation pills (containing desogetsrel, norgestimate) may be of more benefit (this is not clinically proven though).
RCT of ethinyl estradiol-norgestimate (Ortho-Tri Cyclen) showed greater improvement in acne after 6 mo of therapy in treatment group compared to placebo (83% vs. 62%) |
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OCP
Review pill warning signs with patients: ACHES |
A: Abdominal pain
C: Chest pain H: Headaches- severe E: Eye problems- blurred vision, loss of vision S: Swelling or severe leg pain |
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OCP
Which progestin has the least and most Anti-Estrogenic Effect |
least Anti-Estrogenic Effect
1.Norethynodrel (2.5mg) (Enovid) 2.Ethynodiol diacetate (1mg) (Demulen and Ovulen) 3. Norethindrone (1mg) (Norinyl and Ortho-Novum) Most Anti-Estrogenic Effect 1. Norgestrel (0.5mg) (Ovral) 2.Norethindrone acetate (1mg) (Norlestrin, LoEstrin) |
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OCP
Which progestin has the least and Estrogenic Effect? |
Least Estrogenic Effect
1.Norgestrel (Ovral, Lo/Ovral, Nordette, Levlen, Tri-Levlen) |
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OCP
Which progestin has the most Androgenic Effect? The least Androgenic Effect |
The progestin has the most Androgenic Effect?
1.norethindrone (loestrin) 2.The least? norethindrone acetate (ovicon) |
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OCP
What are Absolute contraindications to OCP use? |
1. Smoking greater than age 35
2. History of CVA or MI or multiple risk factors for coronary artery disease (older, smoker, hypertension, DM) 3. Moderate or severe hypertension ( baseline BP > 160/100), should also avoid in patients who have more adequately controlled hypertension as risks usually outweigh benefits 4. Diabetes with significant vascular complications 5. Complicated valvular heart disease 6. Thrombophilia or Thromboembolic disorder (history of DVT/PE) 7.Major surgery with prolonged hospitalization 8.Known or suspected pregnancy 9. Undiagnosed vaginal bleeding 10. Known or suspected breast cancer (or history of breast cancer) 11. Markedly abnormal liver function, active viral hepatitis, malignant liver tumor 12. Avoid in patients with symptomatic gall bladder disease current or treated 13. Migraine with focal neurologic symptoms (flashing lights, loss of vision, weakness, slurred speech, dizziness, cranial nerve abnormalities) |
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OCP what is best for Acne/hirsutism?
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Technically, all OCP’s decrease acne, but "newer progestins" possibly less androgenic Ortho-Tri-cyclen *FDA approved for acne indication
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OCP what is best for Amenorrhea?
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Do nothing except r/o pregnancy, but if pt is anxious, can increase estrogen
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OCP
Why does one have Break through bleeding? |
1. Highest in 1st few cycles
2. Higher rate in smokers 3. After many months, is a consequence of progestin-induced decidualization |
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OCP
What are suggestion for breakthrough bleeding? |
1. confirm compliance, reassure, smoking cessation
2. r/o cervicitis, other causes 3. if precedes menses- try triphasic, or can shorten pill cycle, stop x 7 d when bleeding starts and then start new pack 4. if follows menses, increase E/P ratio in beginning 5. if midcycle bleeding, increase E/P ratio mid-cycle Consider supplement w/ Premarin 1.25 mg or Estrace 2mg qd x 7 d |
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OCP
What are suggestion of OCP changes if Breast tenderness? |
Lower the estrogen dose
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OCP
Which medicine affects OCP and why? |
Most do not affect efficacy of OCs (except rifampin) *
Can affect hepatic P450 system, increasing metabolism of synthetic steroids |
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OCP
What OCP if Dysmenorrhea? |
Higher progestin component Desogen
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OCP
What OCP is desired when endometriosis |
Higher progestin, low estrogen, consider continuous OCs i.e. Loestrin Demulen
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OCP
What OCP is desired when fibroids |
Higher progestin Nordette LoEstrin
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OCP
What OCP is desired when Headaches ( not migraines) Menstrual migraines |
Low estrogen dose
Eliminate hormone free interval Alesse Mircette |
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OCP
What OCP is desired when lipid concerns |
Newer generation progestins ie Ortho-cyclen
Or Low dose older progestinsie ie. Ovcon-35 |
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OCP
What OCP is desired when ovarian cysts |
High estrogen dose
look CI for DVT |
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OCP
What OCP best Perimenopausal |
Minimize cardiac risks with low estrogen pill, third generation progestin
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OCP
What best weight gain |
Low estrogen, low progestin
i.e Alesse, |
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OCP
How do you tell someone |
1. Women with regular menstrual cycles can start OCs within 5 days of starting their period and need no backup
2. Women who start the pill at a time other than their period should be reasonably sure they are not pregnant first, and use back-up for 7 days. 3. Women who are amennorheic can start OCs at any time if they are reasonably sure they are not pregnant, and should use back-up for 7 days. |
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OCP
What do you tell someone if you missed pills? |
1. Miss 1 pill: take missed pill as soon as remembered and continue regular schedule
2. If pack is started late ( > 7 day hormone free interval) should use back-up for 7 days, consider emergency contraception (EC). 3. Missed 2 pills: during week 1- take 2 pills daily for 2 days then finish pack. Use back up for 7 days, offer EC. 4. Missed 2 pills during week 2- take pills daily for 2 days then finish the pack. No back-up needed. 5. Missed 2 pills during week 3- take missed pill as soon as remembered, then continue regular schedule (even if you need to take 2 pills at same time). Skip placebo pills and start a new pack. Use back up for 7 days - OR - start a new pack right away and use back up for 7 days. 6. Missed 3 or more pills- start a new pack and use back up for 7 days. Offer EC. |
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OCP
What emergency contraception is available |
1. Yuzpe method: high dose combination OCs
2. High dose progestin only pills 3. Copper IUD insertion |
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OCP
What is MOA of emergency contraception |
primarily acts as contraceptive, disrupts normal follicular growth, blocks LH surge, inhibits ovulation if taken prior to ovulation. May create deficient luteal phase, have some effect on endometrium. May inhibit tubal transport of sperm/ova. NOT AN ABORTIFACIENT. # Combination OCs (Yuzpe method) lead to 60-75% reduction in pregnancies
# POPs lead to 85% reduction in pregnancies |
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OCP
How do you prescribe EC? |
1. Must use EC pills within 72 hours of unprotected intercourse
2. If using combination OCs, prescribe anti-emetic medication to take 1 hour before 1st dose 3. Take one dose then repeat identical dose 12 hours later 4. If no menses within 21 days should have pregnancy test |
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OCP
What EC are available |
Progestin Only Pills
Plan B 1 white pill $8- 20 Orvette (need 2 packs) 20 yellow tablets Up to $60 Combination OCs PREVEN 2 light blue tablets $ 20-25 Ovral 2 white tablets $20-40 |
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Describe differences gastroschesis versus omphalocle
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omphalocele cong anomalies
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CI place epidural?
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cardiac lesion not reduce bp, hypovolemia
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what nn blocks on c/s analgesia
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t4-s1 c/s nn block
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Epidural fever
Epidural mitral stenosis Epidural preeclampsia Epidural autonomic dysreflexia |
1. Epidural fever can occur from epidural itself
2. 3. 4. Autonomic dysreflexia Spinal or epidural extending to T10 level ◦ Blocks stimuli that arise from pelvic organs |
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Why pt shiver after c/s?
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sympathic block induced vasodilitation
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Causes benign breast disease
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green journal
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Causes galactorrhea
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aaa
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What mm affected
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piriformis
obrturator perineal body bulbocaverosis |
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vestibulitis describe
dyspauraneuria describe causes |
aaaa
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vulvar dystrophy
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aaa
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what is vulvodynia
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Vulvodynia, defined as burning, stinging, rawness, or soreness, with or without pruritus, can be further characterized by the site of the pain, whether it is generalized or localized, and whether it is provoked, spontaneous, or both
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what are causes of acute and cronic vulvar puritis
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In cases of acute vulvar pruritus, common etiologies include vulvovaginal candidiasis and contact dermatitis. Chronic vulvar pruritus should prompt a search for underlying dermatoses, such as lichen sclerosus, lichen simplex chronicus, or psoriasis; neoplasia, including vulvar intraepithelial neoplasia, squamous cell carcinoma, and Paget disease of the vulva; or vulvar manifestations of systemic diseases, such as Crohn disease.
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Difference sequential and contingent screening?
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1st trimester screen positive test
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Facial hair DDX
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PCOS
Ovarian tumor Idiopathic Secondary ammenorrhea prolatin TSH FSH Testosterone (female 20-80) DHEA (ovarian and adrenal tumors 38-338) |
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Does PP female secrete testosterone
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Yes 5 yrs after menopause
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Cushings
Adult CAH |
adrenal gland tumor
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Define Metabolic syndrome
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Elevated BP 130/85
Elevated glucose >100 Annovulation Oligomenorrhe Inc Abd cirumference >88cm (35inches) TG >150mg/dl decreased HDL 35 |
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Late onset CAH enzyme deficiency
enzyme. How present? |
21 Hydroxylase
Seqelae PCOS, 17OHP greater 1200 |
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Drugs cause hirsitism
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Danazol, Methyltestosterone,
Tx-Spironoloactone 25mg BID to 100mgBID, MOA inhibits 5alpha reductase SE-hypokalemic, orthostatic hypotension, diuresis, breast enlargement, OCP, FLutamide, Finasteride |
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Secondary amenorrhea 31 oDDX
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hypothyroid, premature ovarian failure, pregnancy
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Primary ammenorrhea 13 yo big mass
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TVS, hemocolpos, imperf hymen, Tanner staging
teratoma (squamous compartment can metastasis), wilm tumor, Mesenteric lipoma |
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What are Postoperative Issues of bariatric surgery?
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Rapid Weight Loss
Resolution of Subfertility Nutritional Deficiencies B12, folate, calcium hyperhomocystinemia Dumping Syndrome Postprandial hyperinsulinemic hypoglycemia |
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What is Dumping Syndrome?
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What are nutritional deficiencies of bariatric surgery
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Vitamin B12
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What co morbidity are improved with bipass
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Diabetes 100% (85%)
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What are restrictive or malabsorptive bariatric methods surgery?
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Restrictive procedures:
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Only 1 tube on pathology how handle?
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inform patient
alternate contraception HSG |
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Screen DM
What are cut offs 1 hr 3 hr |
Universal and risk based approach
1 hr 140 3 hr coustan 95/180/155/140 |
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DM Dietary requirement
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CHO 60%
PRO 20% FAT 20% ( unsat/sat) Br 25% L 30% D 30% snacks 15% |
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Hypertrichosis caused by?
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genetic, dilantin, anorexia, hypothyroidism, danazol, serotoli-leydig
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Hypertrichosis what secondary needs ruled out?
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All diagnostic approaches recommend that secondary causes (such as adult-onset congenital adrenal hyperplasia, hyperprolactinemia, and androgen-secreting neoplasms) should first be excluded
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What physical exam features needed in work up of hirsuitism?
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he physical examination should include evaluation of balding, acne, clitoromegaly, and body hair distribution, as well as pelvic examination to look for ovarian enlargement. The presence and severity of acne should be noted. Signs of insulin resistance such as hypertension, obesity, centripetal fat distribution, and the presence of acanthosis nigricans should be recorded. Acanthosis nigricans is a dermatologic condition marked by velvety, mossy, verrucous, hyperpigmented skin. It has been noted on the back of the neck, in the axillae, underneath the breasts, and even on the vulva. The presence of acanthosis nigricans appears to be more a sign of insulin resistance or medication reaction than a distinct disease unto itself.
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PCOS patients need screened for?
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Women with PCOS should be screened for cardiovascular risk by determination of BMI, fasting lipid and lipoprotein levels, and metabolic syndrome risk factors (see Box 2 and Box 3). Women with PCOS should be rescreened periodically for cardiovascular disease risk factors because conversion to impaired glucose tolerance approaches 20% per year
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Umbilical aa gives rise to?
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inferior and superior vesicle aa
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Uterine aa gives rise to?
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vaginal
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What Rx constipation IBS
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fiber, methylcellulose, lactulose, sorbitol
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What Rx diarrhea IBS
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loperimide,cholestrirmanine, 5HT4 receptor antagonist Alosetron
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Term hypergonadotropin hypogonadism refers to
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ovarian function decreased or absent due to negative feedback LH and FSH have increased levels. Disorder at ovarian level dx by FSH greater 40 mIU/ml on 2 readings
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Turners has features of?
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short web neck , low hairline, cardiac defects, shield chest POF
45 X 46 XX 46xy |
