Reproductive
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| Forms of estrogen in birth control | Ethinyl estradiol most common
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| Mestranol | another form of estrogen that is coverted to ethinyl estradiol (50 mcg mestranol equivalent to 35 mcg of ethinyl estradiol)
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| Estradiol cypionate | for monthly IM injection (Lunelle)
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| True or False, there are not many forms of Progestin | False, there are MANY!!!
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| Estrogen mechanism | Supresses gonadotropin releasing hormone (GnRH)and Luteolysis
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| What does suppression of GnRH do? | decreases FSH and LH, supresses ovulation, and requires relatively constant levels (20-30mcg/d)
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| What does Luteolysis do? | decrease progesterone production and inhibit implantation
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| Progesterone Mechanism | Thickens cervical mucus, capacitation, slowed ovum transport and may inhibit ovulation
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| What does thickened cervical mucus do? | inhibits sperm penetration
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| What does capacitation mean? | Decreases sperm enzymes that facilitate fertilization
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| What does slowed ovum transport contribute to? | increased tubal pregnancies
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| How does progesterone inhibit ovulation | alters LH, FSH preovulatory surge
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| Major complications with estrogen | Venous thromboembolism, MI, Breast Cancer, Stroke, Hypertension, Hypertriglyceridemia, cholestasis, and liver disease.
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| Which BC pill is least likely to cause spotting | Ovral/Norgestrel (0.5)
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| Which BC pill is most likely to cause spotting | Demulen 50/Eth. Diacetate (1)
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| As you lower estrogen, the incidence of breakthrough bleeding increases, true/false | True, lower than 20mcg EE causes significantly increased bleeding. Most common reason women quit taking BC pills.
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| Pills with low bleeding | 30-35 mcg estrogen and neutral progestin (norethindrone, norethindrone acetate, or norgestimate) Examples of these: Ortho Novum 1/35 or 1/50 + generics, Ovcon 35, Ortho-Cyclen, Modicon + generics, and Ortho-Novum 7/7/7, give 3 month supply
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| Who should you give low dose estrogen pills to? | Patients at risk of thromboembolism, women over 40, obese women, <35 and heavy smokers > 1PPD, diabetic
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| patients on older anticonvulsants should receive? | 50 mcg estradiol because these medications will chew up some of the estrogen and make it ineffective. Ex dilantin, tegretol and phenobarbital
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| Side effects that will go away with time? | nausea, breakthrough bleeding, cramping, cyclic weight gain, breast tenderness
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| Excess estrogen problems | Hyper- or dysmenorrhea, bloating, cyclic weight gain, nausea, ad thrombotic events
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| estrogen deficiency problems | minimal or absent withdrawal bleeding, early spotting/bleeding (days 1-9), vasomotor symptoms, irritability
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| Progestin excess problems | increased appetite/non-cyclic weight gain, dereased flow duration, depression, hypertension
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| Progestin deficiency problems | Late spotting/bleeding (days 10-21), hyper or dysmenorrhea, bloating/nausea
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| Androgen excess | acne, hirsutism, cholestatic jaundice, and increased appetite, non/cyclic weight gain
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| Anti-mineralocorticoid ADEs | can cause hyperkalemia and orthostasis
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| Patient instruction for birth control pills | -start on first day of menses or first Sunday following menses
-try to take at same time every day
-use additional form of birth control for first cycle
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| If you miss three days of BC pill | take make up dose and use alternate birth control for 1 week
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| If miss three days in first week of pills | consider emergency contraception
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| If miss three days of BC pills in third week | just start a new pack
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| Emergency contraception | take within 72 hours, can be combined or progestin only
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| Plan B 0.75 mg Levonorgestrel, how far apart | 2 doses 12 hours apart
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| Combined | 100mcg EE, 0.5 mg levonorgestrel, 2 doses 12 hours apart
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| Missed period | if missed doses get pregnancy test, if none missed, get test on 2nd missed period
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| Seasonale, Seasonique, and Lybrel | Take these for very infrequent periods
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| Hormone replacement therapy HRT estrogen only | increase chance of uterine cancer
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| HRT estrogen plus progestin | decreases chance of uterine cancer
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| HRT androgen therapy | improves bone density, may increase energy and libido due to androgen effects
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| Be weary of prescribing which hormone with a long history of depression? | Progestin
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| Androgen side effect not reversible | deepening of the voice, will also worsen good cholesterol
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| If a woman has a uterus and requests HRT | you must use progesterone combination therapy, do not use estrogen alone.
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| If using estrogen for osteoporosis use | 0.625 mg of premarin
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| Transdermal estrogen good for compliance or: | hypertriglyceridemia
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| How long should you treat with HRT | 2-5 years because that is usually how long hot flashes last, going past this increases adverse side effects
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| Osteoporosis modifiable risk factors | Low calcium diet, high phosphate, caffeine, smoking, sedentary, medications (steroids, older anticonvulsants, levothyroxine, SSRIs, PPIs)
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| Osteoporosis non-modifiable | female, post-menopausal, age, race, family or personal history, small body frame
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| Anyone with a DEXA score less than this is considered osteoporotic | -2.5
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| Osteopenia is defined by DEXA score of | -1.5 to -2.4
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| Initiate therapy with FRAX score of higher than or equal to | 20% or greater than 3% risk for hip score
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| Calcium supplement | 1200 mg/d for prevention
1500 mg/d for treatment
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| Calcium sources | Calcium carbonate
Calcium citrate
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| Calcium facts | Acidic pH increases absorption
Addition of Vit. D (800 IU) increases absorption
Maximum of 600 mg/dose absorbed
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| Calcium carbonate | 40% elemental calcium
Most common OTC form
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| Calcium carbonate side effects | constipation, nausea
Taking with food increases absorption
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| Calcium citrate | 21% elemental calcium
more expensive
side effects similar to carbonate
Can be taken without regard to meals
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| Bisphosphonates | Alendronate (Fosamax)
Risedronate (Acotonel)
Ibandronate (Boniva)
Zoledronic acid (Reclast)
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| Bisphosphonates pharmacology | inhibit bone resorption (osteoclast function)
exact mechanism unknown
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| Bisphosphonate efficacy | increases bone mineral density by roughly 4-5% in one year
rate of increase slows but continues for at least 10 years
decrease vertebral fractures by 40-50%
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| Bisphosphonate side effects | GI discomfort, esophageal erosions, osteonecrosis of the jaw, atypical fractures
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| Bisphosphonate contraindications/warnings | Avoid in patients with esophageal abnormalities, caution with renal impairment, correct hypocalcemia or hypophosphatemia before initiation
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| Zoledronic acid (Reclast) | 5mg IV annually for treatment
5mg IV every other year for prevention
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| Denosumab and renal function | Tolerated slightly better than bisphosphonates with impaired renal function.
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| Denosumab major side effects | Dermatologic reactions
infections, especially cellulitis
correct hypocalcemia before initiation
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| positive of calcitonin | provides analgesia for bone pain
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| negative of calcitonin | does not help prevent hip fractures
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| Bisphosphonates gold standard because | most researched and most effective
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| Raloxifine good choice with | family history of breast cancer
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