Gynecology
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| Higher estrone:estradiol ratio with: | Oral estrogen; Higher doses than systemic therapies
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| More physiologic estradiol:estrone ratio with: | systemic (parenterally) estrogen; lower doses than PO estrogens
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| Most appropriate for urogenital symptoms | vaginal estrogen
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| All approved for vasomotor symptoms | Transdermal estradiol gels (all are QD dosing)
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| In women with a uterus who receive estrogen, a progestin must be given: | for ≥ 10 days per cycle to prevent endometrial hyperplasia
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| In woman without a uterus who receive estrogen, give: | estrogen only (don’t need progestin)
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| Most effective tx for hot flashes | Hormone therapy (no effect of progestins on sx)
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| Most effective tx for sx of urogenital atrophy (vaginal dryness and sexual discomfort): | Hormone therapy; may worsen urinary incontinence
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| Estrogen tx: osteoporosis benefit seen: | primarily within >5 yrs of therapy; max protection requires ≥ 10 yrs tx
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| Reevaluate HRT every: | 3-6 months for possible taper or discontinuation
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| Alt tx for hot flashes | Venlafaxine, paxil, Prozac, clonidine, gabapentin
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| In postmenopausal women, testosterone can improve: | Libido, sense of well-being, energy
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| Women should be on the lowest HRT dose that controls sxs & re-evaluated every __ for possible taper or d/c | 3-6 months
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| HRT indications | Tx mod-severe vasomotor sxs assoc w/menopause, mod-severe sxs of vulvar / vaginal atrophy assoc w/menopause, prevent postmenopausal osteoporosis
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| Benefits of HRT | Alleviation of vasomotor symptoms, relief of vaginal dryness/atrophy, raised HDL/lowered LDL, alleviation of mood swings and fatigue, reduced risk of fractures, reduced risk of colon cancer, reduced risk of diabetes
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| Alt options to HRT to tx menopausal sxs | herbal/complementary, bio-identical estrogens, antidepressants, neuroendocrine agents, lifestyle and behavioral modifications
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| Most studied herb for menopausal sxs: somewhat effective for tx of hot flashes | Black Cohosh (Remifemin)
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| Gabapentin has shown some effect on __ | Hot flashes
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| __ has the highest percent of elemental calcium | Calcium carbonate
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| Nonsteroidal compounds with estrogenic activity derived from plants (phytoestrogens)= | soy isoflavones
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| Tx of cervical abnormalities | Cyrotherapy of Cervix; LEEP; Laser; Cervical Conization
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| Endometrial hyperplasia w/o atypia: tx | Provera; Micronized Progesterone; if HRT is resumed, resume at higher dose progestin for longer time, repeat bx 3-6 mos
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| endometrial ca tx | TAH w/BSO
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| Adenomyosis tx | D&C, GnRH agonist, mifeprostone, or TAH (definitive)
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| ovarian cyst tx | small (<8 cm): monitor x1-2 cycles; large: lap exploration
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| CIN tx | electocautery, laser tx, conization, or LEEP; poss TAH for severe dz
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| vulvar/vaginal ca tx | excision; topical 5-FU; laser tx
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| hydatidiform mole tx | benign: chemo; high-risk: chemo +/- adj xrt & surg (curettage or hysterectomy)
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| Painful bladder syndrome tx | Dietary restrictions (Low oxalate diet)
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| endometritis tx | 1stline: clinda + gent; if refractory by 24-48 hr, add amp; Flagyl if sepsis
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| PCOS Tx options | OCP. Metformin. Anti-androgen ( if NOT PG): spironolactone (for hirsutism), finasteride or flutamide. Clomiphene for infertility. Dexamethasone for high DHEA.
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| Contraceptive methods: most vs least effective | Most: IUD, implants, sterilization; Least: diaphragms, condoms, withdrawal/rhythm
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| OCP CIs | PG. AUB. Hx of VTE/CVA/CAD. Estrogen-dependent tumor. Liver dz. Smoker if >35 yo
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| OCPs MOA | inhibition of midcycle LH/FSH surge: inhibits ovulation, thickens cervical mucus, alters endometrium
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| Gonorrhea tx | CTX 250mg IM or Cefixime 400mg PO. Also give Azithro 1gm PO to empirically tx likely co-infection with CT
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| Chlamydia tx | Azithro 1gm PO x1, or doxy 100mg PO BID x7d. Tx partners from within last 60 days. Avoid sex for 7 days after tx.
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| LGV tx | Doxy 100mg PO BID x21 days
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| HSV tx | Ast episode: acyclovir 40mg PO x7-10d (or 200mg 5x/day), vs famciclovir or valaciclovir. Suppression tx for >6 outbreaks/yr
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| syphilis tx | TOC Benzathine PCN 2.4M U IM x1 (latent >1 yr & tertiary: Q week x3 wk. Neurosyphilis: aq PCN q4h x14d
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| chancroid tx | azithromycin 1gm x1 (or CTX 250mg IM x1, or erythro 500 PO TID x7d, or cipro 500 BID x3d)
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| HPV tx | Podophyllin 10-25% topical. Trichloroacetic acid 80-90% Q week. Podofilox gel BID. Imiquimod TIW. Cryotherapy for internal lesion.
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| fibroid mgmt | Asx: bimanual exam Q6 months. Sx: progestin for AUB. Pre-op GnRH agonist -> temporary menopause (fibroid shrinks in absence of estrogen). Mirena.
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| Endometriosis mgmt | Prevention of ovulation. OCP. Danazol x4-6 months. GnRH analogs x6 months. Progestins. Lap ablation of lesions vs BSO
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| PMS mgmt | Tx sxs. Breast pain: danazol, bromocriptine. Bloating: spironolactone, CaCO3. Mood: SSRI, monophasic OCP. Exercise, diet
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| OCP: use with caution if pt has: | DM, HTN, HLD, hx of biliary dz
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| OCP approved for OMDD | Combo pill with progestin drosperinone (diuretic for water retention). CI in renal/liver/adrenal dz
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| Plan B OCP | 2 tabs of 0.75mg levonogestrel (taken together vs 12h apart), within 72h of intercourse
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| Depo-Provera = | injectable progesterone, Q3 months (AE: wt gain, irregular menses)
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| Implanon = | single rod implant that releases 68 micrograms etonorgestrel daily
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| Ortho Evra = | transdermal patch: 150 micrograms norelgestromin & 20 micrograms ethinyl estradiol daily. 3 weeks on & 1 week off
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| Nuva Ring = | 120 micrograms etonogestrel & 15 micrograms ethinyl estradiol daily. 3 weeks in, 1 week off (withdrawal bleeding)
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| Essure = | transcervical (chemical or coils) used to scar proximal portion of fallopian tubes or cornua.
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| IUD types | ParaGard (copper) for 12 years. Mirena (releases levonorgestrel) for 5 years.
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| most effective reversible means of contraception | OCP: (ethinyl estradiol or mestranol) + (norethindrone or levonorgestrel or norgestimate)
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| minipill OCPs | progesterone only; 1/2 as effective as combo pills; best for lactating F or >40 yo
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| depot contraception | usually medroxyprogesterone, 150mg q90 days; 0.3% fail rate in 1st year
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| infertility tx | clomiphene; artificial insemination;assisted repro (IVF)
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