566 Final Exam Study Guide
Week 5
Prevention of osteoporosis with hormone replacement therapy
o Selective Estrogen Receptor Modulators (SERMs)
Tamoxifen (Nolvadex-D), Toremifene (Fareston), Raloxifene (Evista),
and Bazedoxifene (Duavee - postmenopausal women drug)
These drugs provide benefits of estrogen (protection against
osteoporosis, maintenance of the urogenital tract, reduction
of LDL cholesterol) while avoiding its drawbacks (promotion
of breast cancer, uterine cancer, and thromboembolism)
o Prevention of osteoporosis requires lifelong hormone replacement
When stopped, bone loss decreases by 12%.
LIfelong treatment increases health risks.
o All women (and men) should practice primary prevention of bone loss by
ensuring adequate intake of calcium and vitamin D, performing regular
weight-bearing exercise, and avoiding smoking and excessive alcohol use.
- When and when not to use progestin for hormone replacement therapy and why -
When To Use:
o Menopausal Hormone Therapy
Counteracts adverse effects of estrogen on endometrium in women
undergoing menopausal hormone therapy.
o Dysfunctional Uterine Bleeding
Cessation of bleeding can be achieved with 10-14 day treatment.
Withdrawal bleeding can take place when treatment stops.
o Amenorrhea
Progestin helps induce menstrual flow in select women experiencing
amenorrhea.
If endogenous estrogen levels are normal, give progestin for 5-10
days.
If estrogen levels are low, need to induce endometrial proliferation
with estrogen before giving progestin.
o Endometrial Hyperplasia and Carcinoma
Can provide palliation in women with metastatic endometrial
carcinoma - do not prolong life.
Only approved long-term progestin therapy is for protection against
endometrial cancer.
Progestin can suppress endometrial hyperplasia - a potentially
precancerous condition
o Help Support early pregnancy with the corpus luteum deficiency syndrome
and in women undergoing IVF.
o Hydroxyprogesterone Acetate (Makena) - helps prevent preterm birth.
When Not To Use (Contraindications):
o Absolute Contraindications
Undiagnosed abnormal vaginal bleeding.
o Relative Contraindications
Active Thrombophlebitis
Hx of thromboembolic disorders
Active Liver Disease
Carcinoma of the breast
o Do Not Use:
Prepubertal Children
High-dose therapy in first 4 months of pregnancy (birth defects)
Local vs. systemic estrogen options and why one would be chosen over the other -
Systemic Options
o Oral
Most active estrogenic compound - ESTRADIOL
Estradiol is available alone or in combination with
progestins
Popular because of its convenience.
o Transdermal
Four Formulations
Emulsion (Estrasorb), Spray (Evamist), Gels
(EstroGel, Elestrin, and Divigel)
Four Advantages Over Oral Formulations:
The total dose of estrogen is greatly reduced
(because the liver is bypassed).
There is less nausea and vomiting.
Blood levels of estrogen fluctuate less.
There is a lower risk for DVT, pulmonary embolism,
and stroke.
o Intravaginal
Femring
Control hot flashes and night sweats as well as local
effects (treatment of vulval and vagnial atrophy).
o Parental
IV and IM administrations - use of these routes are rare.
Used in acute, emergency control of heavy uterine
bleeding.
Local Options
o Intravaginal
Primarily treatment for vulvar and vaginal atrophy associated
with menopause.
Available as inserts, creams, and vaginal rings
Intravaginal Inserts - Imvexxy, Vagifem, and Yuvafem
Creams - Estrace Vaginal, Premarin Vaginal
Rings - Estring (other vaginal ring, Femring, is
systemic effects)
Transdermal estrogen therapy has fewer adverse effects.
- Management of oral contraceptives (OCs)
o How to change patients from one combination oral contraceptive to another.
Go straight from one type to the other, without taking a gap in between. Start the
new pill the day after taking the last active pill in the last pill packet. This also applies
with 'placebo' pills.
o “No gap method”
o How to initiate treatment (when in the cycle is it best to start- may vary based on
type of contraceptive)
OCs: The sequence begins on either the first day of the menstrual cycle or the
first Sunday after the onset of menses. With the first option, protection is
conferred immediately; hence no backup contraception is needed. With a
Sunday start, which is done to have menses occur on weekdays rather than the
weekend, protection may not be immediate; hence an alternate form of birth
control should be used during the first 7 days of the pill pack.
o What teaching needs to be done
Educate pts on proper protocol for missed dose
Women should be informed about the symptoms of thrombosis and
thromboembolism (e.g., leg tenderness or pain, sudden chest pain, shortness
of breath, severe headache, sudden visual disturbance) and instructed to
consult the prescriber if these occur.
o What baseline data is needed?
Assess for hx of HTN, diabetes, thromboembolism, cerebrovascular or cardiovascular
disease, breast CA. Urine pregnancy test.
o Contraindications for OCs
Pregnancy, history of thromboembolism, breast cancer, and women over 35 years of
age who continue to smoke tobacco.
Use with caution in women with diabetes, hypertension, and cardiac disease.
- How to achieve an extended cycle with oral contraceptives
To achieve an extended schedule cycle, the user would simply purchase four packets of a 28-
day product (each of which contains 21 active pills) and then take the active pills for 84 days
straight.
- What behaviors would make one birth control method more effective over another?
Family planning goals, age, frequency of intercourse, Pt capacity for
adherence.
oBe able to evaluate a patient scenario and suggest an appropriate birth control
method (type of prescribed contraception: OC, long-term methods, IUD, etc).
- What effect does CYP450 inhibitors or inducers have on OCs?
o Recall examples of CYP450 inhibitors and inducers from NR565 (Chapter 4 in
textbook)
Inhibitors: Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol,
Ketoconazole, Grapefruit Juice, Quinidine
Inducers: Carbamazepine, Rifampin, Alcohol, Phenytoin, Griseofulvin,
Phenobarbital, Sulfonylureas
o How does this impact prescribing of OCs?
Women taking OCs in combination with any CYP450 inducers and inhibitors should be
alert for indications of reduced OC blood levels, such as breakthrough bleeding or
spotting.
o If these signs appear, it may be necessary to either:
(1) increase the estrogen dosage of the OC
(2) combine the OC with a second form of birth control (e.g., condom)
(3) switch to an alternative form of birth control
- Benefits and drawbacks of progestin-only contraception
Benefits: Do not cause thromboembolic disorders, headaches, nausea, or most of the other
adverse effects associated with combination OCs
Drawbacks: Less effective and are more likely to cause irregular bleeding (breakthrough
bleeding, spotting, amenorrhea, inconsistent cycle length, variations in the volume and
duration of monthly flow). Irregular bleeding is the major drawback of these products and the
principal reason that women discontinue them.
- What are the most effective forms of contraception?
Etonogestrel subdermal implant
o Nexplanon
Surgical sterilization
o Male: Vasectomy
o Female: Tubal ligation
IUD
o Copper T 380A (ParaGard)
o Levonorgestrel T (Mirena)
- Testosterone replacement
o Administration
Transdermal Patches - male hypogonadism
o Applied daily to the upper arm, back, or abdomen.
Testosterone gel is also available.
o Patient Teaching
Transdermal patches:
o good hand washing is required after application
o cover application site with clothing after medication has dried
o wash the application site before skin-to-skin contact with another
person
females and children may experience negative effects from
exposure to testosterone
if cross contamination occurs, wash the affected area with
soap and water to prevent absorption
- Treatment of delayed puberty
o When is it appropriate to initiate androgen therapy (short course and long-term)
Short term: The psychologic pressures of delayed sexual maturation are causing a boy
significant distress. In these cases, a limited course of androgen therapy is indicated.
o Both fluoxymesterone (Androxy, Halotestin) and methyltestosterone (Methitest) are
approved for this purpose.
Long term: If delayed puberty is the result of true hypogonadism
- Androgen therapy
o Effects
▪ Therapeutic
Manage hypogonadism and subsequent testosterone deficiency through
testosterone supplementation
▪ Adverse
Virilization in women, girls, and boys
Premature Epiphyseal Closure
Version | 2021 |
Category | Exam (elaborations) |
Pages | 25 |
Language | English |
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