NR i566 iFinal iExam iStudy iGuide

NR i566 iFinal iExam iStudy iGuide

Week ifive: iChapter i50, i51, i52, i53, i82

Hormone iReplacement iTherapy ➢ Selective iEstrogen iModulators iare idrugs ithat iactivate iestrogen ireceptor imodulators iin isome itissues iand iblock ithem iin iothers

• By iblocking iestrogen ireceptors itamoxifen iprotects iagainst ibreast icancer iand

ipostmenopausal iosteoporosis iand ihas ia ifavorable ieffect ion iserum ilipids i( i i i↓ LDL)

• Hormone ireplacement itherapy iincreases irisk ifor iendometrial icancer iand

ithromboembolism

• HRT iin iwomen i>65 iyears iold iincreases ithe irisk ifor idementia
• Ex. iTamoxifen, iToremifene, iRaloxifene, iBazedoxifene

▪ Raloxifene idoes inot iblock iERs i(estrogen ireceptors) iin iendometrium iso idoes inot ipose irisk ifor iuterine icancer ▪ Bazedoxifene irecommended ifor iprevention iosteoporosis iin ipostmenopausal iwomen iwith ia iuterus

• What iare icommon ivasomotor isymptoms iassociated iwith imenopause ithat iHRT ihelps

ireduce? ihot iflashes, i(menopause iS+S) ▪ When ido ithey iappear iafter istopping iHT? i4 idays ▪ those iwith isevere isymptoms ibefore istarting iHRT iare iat ihighest irisk ifor iintolerable isymptoms iwhen ithey istop

• What ifactors iincrease irisk ifor iharm iwith iHRT? ipersonal ior ifamily ihistory iof ibreast

icancer, icardiovascular idisease

• To ikeep irisk ilow, iHT ishould ibe iused iin iLOWEST idosage iand ifor iSHORTEST itime

ineeded i(often i<5 iyears) ito iaccomplish itreatment igoals. iLong-term iHRT ishould ibe iavoided ias imost irisks ioutweigh ibenefits.

Chapter i50: iEstrogens iand iProgestins

➢ Hormone ireplacement itherapy: iestrogen, iprogestin

• Do inot ineed ito iread/study iManagement iof ifemale isex iinterest-arousal idisorder

Progestins ➢ What iare isome inon-contraception iuses ifor iprogestin? imenopausal ihormone itherapy, idysfunctional iuterine ibleeding, iamenorrhea, iendometrial ihyperplasia iand icarcinoma, icorpus iluteum ideficiency isyndrome, iearly ipregnancy, iin ivitro ifertilization ➢ Hydroxyprogesterone iacetate i(Makena) iis iapproved ifor ipreventing ipreterm ibirth iin iwomen iwith isingleton ipregnancy iand isomething ipreterm idelivery i- iBOOK ➢ If iestrogen ilevels iare iadequate, itreatment iwith iprogestin ifor i5-10 idays iwill ibe ifollowed iby iwithdrawal ibleeding iin iwomen iwith iamenorrhea. iIf iestrogen ilevels iare ilow, imay ineed ito iinduce iendometrial iproliferation iwith ian iestrogen ibefore igiving ithe iprogestin.

• before iprogestin itreatment, iestrogen ilevels imust ibe iadequate

➢ Excessive idysfunctional iuterine ibleeding ican ibe istopped iby iadministering iprogestin ifor i10-14 idays ➢ How ido iwe iestablish iregular imonthly icycle iin idysfunctional iuterine ibleeding? iTwo imethods: icyclic itherapy- ioral idosing i10-14 idays iafter iperiod ifor i10 idays iOR iprogestin ifirst i10 idays iof ieach imonth ➢ What iis ionly iapproved iindication ifor ilong-term iprogestin iuse? iendometrial iCA ➢ When iare iprogestins icontraindicated? iundiagnosed iabnormal ivaginal ibleeding, icoag iissues, iactive ithrombophlebitis, ibreast iCA, iliver idx ➢ What iare isome iside ieffects iof iprogestins? iirregular ibleeding, ispot imore, iamenorrhea, idifferent ivolume iand icycle ilengths

➢ First igeneration iprogestins i(ethynediol idiacetate, inorethindrone) ihave ilower irisk ifor ithrombosis ithan iwith iother iprogestins ilike idrospirenone iand idesogestrel iwhich ihave igreatest irisk ifor ithrombosis Estrogen ➢ What iside ieffects ican ioccur iwith iestrogen iuse? ihigher ipulse- iHA, inausea, iincreased irisk ifor ithromboembolism

• take iwith ifood iand iat inight
• nausea idiminishes iover itime i(try itaking iin iAM iafter ia ibit)
• estrogen idose ican ibe ichanged i(high ito ilow idose)

o combined ioral icontraceptives: iHTN i(lower iestrogen idose)

➢ What iis ithe iblack ibox iwarning ifor iestrogen?

• Endometrial icancer irisk iis iincreased iin iwomen iwith ia iuterus iwho itake iunopposed

iestrogen ▪ IF iyou ihave ia iuterus- ineed iprogestin ito iget irid iof ilining

• Estrogen imay iincrease ithe irisk ifor iDVT iand istroke iand iPE
• Estrogen iis inot iindicated ifor icardiovascular idisease ior idementia iand imay iincrease ithe irisk

ifor idementia iin iwomen iaged i65 iyears iand iolder ➢ Endometrial icancer ievaluation ishould ioccur iif ipatient ihas iwhat isymptom? ipersistent ior irecurrent ivaginal ibleeding ➢ What ieducation ido iprovide ito ireduce icardiovascular irisk iwhen itaking iestrogen?

• Avoid ismoking, iperform iregular iexercise, idecrease iintake iof isaturated ifats, iand itake

iappropriate idrugs ito itreat ihypertension, idiabetes, iand ihigh icholesterol ➢ Why imay itransdermal iestrogen itherapy ibe ipreferred ifor isome ipatients? iless inausea ➢ When iare iestrogens icontraindicated? iIn ipregnant iwomen. iEstrogens imay idecrease imilk isupply iif iused iin ibreastfeeding iwomen.

• also iin iDVTs, iMI, istroke ihistory, igeriatrics

➢ Avoid iuse iin iwomen iwho ihave ibreast icancer ias ican ipromote ithe igrowth iof iexisting ibreast icarcinoma.➢ Relative icontraindication iCOC iif ihave imigraines, iepilepsy, iHTN, icardiac idisease, idiabetes, igallbladder idisease.➢ Estrogens iare iinappropriate ifor igeriatric ipatients.iHormone iTherapy ➢ How ido iCOC ireduce ifertility? i(Estrogen ivs iprogestin iMOA)

• Estrogen isuppresses ithe irelease iof ifollicle istimulating ihormone ifrom ithe ipituitary iand

ithereby iinhibits ifollicular imaturation

• Progestin iacts iin ithe ihypothalamus iand ipituitary ito isuppress ithe imidcycle iluteinizing

ihormone isurge, iwhich inormally itriggers iovulation. iProgestin ialso ithickens ithe icervical imucus i(creates ibarrier ito ipenetration iof isperm) iand ialteration iof ithe iendometrium i(keeps iit ifrom ibuilding iup/thickening), imaking iit iless ihospitable ifor iimplantation ➢ What iis irecommended iHT ifor iwomen iwith iintact iuterus ivs. ihysterectomy? iIntact iuterus: icombination i(estrogen iand iprogestin- inot ijust iestrogen iby iitself); iHysterectomy: iuse iestrogen i(don’t ihave ito iworry iabout ieffects iof iestrogen ion iuterus) ➢ Which iare ipreferred ifor icontraception iduring ilactation i(early ion) iand imigraines? iMigraines: progestin i(higher ipulse- iHA, ihigher irisk ifor iembolism iwith iestrogen) ➢ estrogen iearly ion idecreases imild isupply ➢ What iis ithe idifference ibetween idose itapering iand iday itapering iof ihormone itherapy?

• dose itapering: idaily idose ibut ithe idosage iamount iis igradually ireduced i(gradual ireduction

iof ithe idose)

• day itapering: idaily idose ithat iis ithe isame ibut ithe idays ibetween ithe idoses iis igradually

ireduced i(gradual ireduction iof ithe idays ibetween idoses)

• Only itaper idown iestrogen idosage ibecause ilowering iof iprogestin imight ipermit iestrogen ito

istimulate iendometrial igrowth iwhich iincreases irisk ifor iendometrial ihyperplasia i(pre- icancerous ipotentially) ➢ What iare isymptoms iof iexcess iestrogen ivs iprogestin?

o estrogen: inausea, ibreast itenderness, iedema

o progestin: iappetite iincreases, idepression, ifatigue

➢ COC ishould ibe iavoided iin iwomen iolder ithan i35 iyears iold iwho ismoke. iWhat iis ipreferred itx ithen?progestin ionly ipills, iIUD ior idiaphragm

• NO iestrogen ior icombined ioral icontraceptives i(have iestrogen)

➢ What iare isome iother icontraindications ifor iCOC? ipregnant iwomen, ibreast icancer, iabd iliver ifunction, ithrombophlebitis ➢ What iis ithe iblack ibox iwarning ifor iestrogen iand iprogestin itherapy? iMay iincrease irisk ifor ibreast icancer.

• NOT iindicated ifor icardiovascular idisease ior idementia iand imay iincrease irisk iof idementia

iin iwomen iaged i65 iand iolder.➢ How ilong iis iNexplanon ieffective iand iwhen iit ishould ibe iremoved? iFDA iapproved ifor i3 iyears ibut ican ibe iused iup ito i5 iyears

• subdermal iprogestin

Chapter i51: iBirth iControl

➢ Monotherapy ➢ Combination itherapy

• Do inot ineed ito iread/study iemergency icontraceptives ior idrugs ifor imedical iabortion

iBirth iControl ➢ High iestrogen ioral icontraceptives iare ireserved ifor iwomen itaking idrugs ithat iinduce iCYP450 ior iP3A4

• CYP450 imeds imay iinclude iAmiodarone, iFluoroquinolones, iDiltiazem, iValproic iAcid,

ietc. iThose idrugs ican idecrease ieffectiveness iof ioral icontraceptives iby idecreasing ihormone ilevels. iMay ibe inoted iif ibreakthrough ibleeding ioccurs.

• OC imay idecrease ieffectiveness iof iwarfarin ileading ito idecreased iINR ilevels iso imay ineed

ito iincrease iCoumadin idosage.

• OC imay iincrease iglucose ilevels iso imay ineed ito iincrease idosage iof idiabetic imedications.
• OC ican iimpair ihepatic imetabolism iof itheophylline, itricyclic iantidepressants, idiazepam,

iand ichlordiazepoxide ileading ito ireduces i(hepatic iand irenal) iclearance iwhich iincreases irisk iof itoxicity.➢ How idoes imonophasic idiffer ifrom ibiphasic, itriphasic, ietc. iregarding ihormone ilevels?

• monophasic: idoses iof iestrogen iand iprogastrin iremain iconstant ithroughout icycle
• others ifluctuate ito imatch iour inormal ihormone ilevels
• triphasic: ihave idifferent icolors i(not iplacebos) ibecause iof ithe ichanging ilevels

➢ How ieducate istart idate iof ihormone itherapy i(28-day iregimen) iif ipatient iwants ito iavoid igetting iperiod ion iweekend ivs ipatient iwho iwants ito istart ion idate iwhich ipregnancy iprotection iconferred iimmediately?

• weekend: iavoid iperiod ion iweekend: istart ion ia iSunday i(first iperiod iusually iTuesday iand

ifinish iby iFriday)

o avoid iadditional iprotection: i1

st iSunday iafter iyour iperiod- ino ibackups ineeded ithen i(you iaren’t iclose ito iyour iovulation) ➢ How ieducate ipatient ihow itake ibirth icontrol iif ionly iwants ione iperiod ievery ithree imonths? i(HINT iextended iuse)

• Use ifour i28-day ipackets iof imonophasic ipills iand itake iactive ipills ionly, idiscard iplacebo

ipills iin ithe ifirst i3 ipackets iand icontinue ito ithe inext ipacket. iDo inot itake iplacebo ipills itill ireach i4 th ipacket.

• For ithose ion icombination iOC ithat iuse iextended icycle, iup ito i56 idays ican ibe imissed iwith

ilittle ior ino iincreased irisk ifor ipregnancy iprovided ithat ipills ihad ibeen itaken icontinuously ifor ithe iprior i3 iweeks.➢ Which ibirth icontrol imethods iare ithe imost ieffective? iNexplanon, iIUD, iDepo ➢ What iare ithe iCDC irecommendations ito ieducate ipatient iregarding iif imiss ione ior imore iCOC ipills?

• Refer ito ipackage iinsert ifor iindividual idrugs ias imay ivary, ibut iin igeneral:

o During iFIRST iweek:

▪ If iONE ior iMORE ipills iare imissed, itake i1 ipill ias isoon ias ipossible iand ithe in icontinue ithe ipack. iUse ian iadditional iform iof icontraception ifor i7 idays.

o During iSECOND ior iTHIRD iweek:

▪ If iONE ior iTWO ipills iare imissed, itake i1 ipill ias isoon ias ipossible iand ithen icontinue iwith iactive ipills iin ithe ipack ibut iskip ithe iplacebo ipills iand igo istraight ito ia inew ipack ionce iall ithe iactive ipills ihave ibeen itaken.▪ If iTHREE ior iMORE ipills iare imissed, ifollow ithe isame iinstructions igiven ifor imissing ione ior itwo ipills, ibut iuse ian iadditional iform iof icontraception ifor i7 idays.➢ Taking ia iPROGESTIN ipill ieven i3 ihours ilate ican ireduce itheir ieffectiveness iand iuse iof iback iup iprotection ior iemergency icontraception iis irecommended iif iunprotected isexual iintercourse ioccurred.

• higher ifailure irates iand inot ias ieffective ias icombo ipills
• someone iwho itakes iprogestin ionly: ilactating, imigraines, ilots iof iside ieffects iwith icombo

➢ What iare ithe irecommendations ito ieducate iif imiss iprogestin iOC ipill? itake ias isoon ias iyou iremember iand iuse iback iup ifor iat ileast i2 idays

• If iONE ipill iis imissed, iit ishould ibe itaken ias isoon ias iremembered iand ibackup

icontraception ishould ibe iused ifor iat ileast i2 idays. iThe ipills ishould ibe iresumed ias ischeduled ion ithe inext iday.

• If iTWO ipills iare imissed, ithe iregimen ishould ibe irestarted, iand ibackup icontraception

ishould ibe iused ifor iat ileast i2 idays.

• If iTWO ior iMORE ipills iare imissed iand ino imenstrual ibleeding ioccurs, ia ipregnancy itest

ishould ibe idone.➢ Patch imay ihelp iimprove icompliance ias ionly ineed ito ichange ipatch ionce iweekly ifor ifirst i3 iweeks, ithen ino ipatch i4 th iweek i(to ihave icycle)

• When iis iback-up iprotection ineeded iwhen ipatch iis iused? iIf ithe ipatch ihas ibeen ioff ilonger

ithan i24 ihours.

Chapter i52: iAndrogen

➢ Hormone ireplacement itherapy: itestosterone

➢ Therapy ieffects i(therapeutic ivs iadverse) ➢ Monitoring ineeds ➢ Contraindications iAndrogens ➢ What idoes iandrogen ideficiency ilead ito? iinfertility/sterility. iDoes iandrogen ireplacement irestore ifertility? iNO ➢ Testosterone iis imajor iendogenous iandrogen. iWhat iare inormal inatural ilevels iof itestosterone iin imen ivs iwomen?

• Men iproduce i2.5 i- i10 img itestosterone idaily iby ithe iLeydig icells iof ithe itestes
• Women iproduce i300 imcg iwith ihalf iproduction ifrom iboth iovaries iand iadrenal iglands i(10-

i40x iless itestosterone ithan imen)