OB/GYN: Blueprints Ch 24

early age at menopause risk factors

1. hx of cigarette smoking 2. short menstrual cycles 3. nulliparity 4. T1D 5. family hx of early menopause

Ads/Disads of Nexplanon

1. implantable 2. 3 yrs uninterrupted contraceptive coverage 3. no maintainence - no interruption of sexual spontaneity disads 1. need for insertion/removal by dr 2. unpredictable bleeding profile 3. device migration into deeper tissue (rare) -> imaging -> surgical removal

Key factors to maintaining CV health

1. improvement in lifestyle and diet 2. optimal BP 3. weight control these decrease morbidity and mortality

What is assoc. w/ OCP use (2)

1. increased incidence of gall bladder disease 2. benign hepatic tumors

IUD MOA

1. introduced into endometrial cavity using cervical cannula 2. 2 monofilament strings that extend thru cervix where they can be checked to detect expulsion or migration -strings also help w/ removal 3. MOA not completely understood -kill sperm (spermicidal) -prevent fertilization -elicit a sterile inflammatory response (results in sperm being engulfed, immobilized, and destroyed by inflammatory cells) -reduce tubal mobiliy (inhibits sperm/blastocyst transport) -DO NOT affect ovulation (NOT abortifacients) -presumed MOA augmented by LNG in Mirena, Skyla, Liletta, and Kyleena IUDS and copper in ParaGard IUD -progresterone (in LNG devices) thickens cervical mucus and atrophies the endometrium to prevent implanation -copper in Paragard thought to hamper sperm motility and capitation (sper rarely reach fallopian tube and unable to fertilize ovum)

What other kinds of pills are avialble?

1. iron and folic acid supplementation are also available 2. chewable tablets

side effects of POPs

1. irregualr ovulatory cycles 2. breakthrough bleeding 3. increased formation of follicular cysts 4. acne 5. breast tenderness 6. irritability

Side effects of Nexplanon

1. irregular and unpredictable light bleeding 2. 75% have lighter bleeing, require less proetction 3. irregular bleeding reason for 15% of discontinuation, followed by headaches (12%)

Side Effects of Depo-provera

1. irregular menstrual bleeding ->70% experience spotting and irregular menses during 1st year -primary reason for discont. 2. depression 3. weight gain 4. hair loss 5. headache 6. 50% of DMPA users will have amenorrhea after 1 year of use and 80% after 5 yrs of DMPA use

in who is the rate of sterilization higher?

1. married 2. divorced 3. >30 yrs 4. African American

PE for menopause

1. may be decrease in breast size and change in texture 2. increases in abdominal circumference and upper adominal weight gain 3. VVA may be present b/c lower estrogen levels result in thining of superficial vaginal eptihelium 4. vagina will be pale and smooth and shows a loss of rguation 5. Vaginal pH levels are elevated (>5 to 6), and there is a decrease in lactobacillus 6. Increase in BMI (approx 5lb weight gain) 7. skin changes -rpaid onset of loss of elasticity of skin -loss of thickness and collagen in skin 8. Hair changes -loss of pubic hair -female pattern baldness -androgenic alopecia -excessive growth of terminal facial hair 9. complaints of dry eyes and increase in periodontal disease

Side Effects of EC

1. nausea (50%) 2. vomiting (20%) 3. headaches 4. dizziness 5. breast tenderness most are 2* high doses of estrogen in combined regimens progesterone-only has less severe SEs than combined

advantages and disadvantages of NuvaRing

1. one size of ring fits all women, does not need to be fitted 2. women place for 3 continuous weeks then remove for 1 week 3. left in place continuously -> provides low,s teady release of hromone with lower total hormone expsoure 4. douching w/ ring discouraged, use of antifungal agents and spermicides permitted dis ads 1. woman's (or partner's) concern w/ having foreign body in vagina and potential for expulsion -studies show women do not feel it once in vagina, and ring does not need to be removed for intercourse 2. if it is removed, it should be rinsed in cool to lukewarm water and replaced w/in 3 hours 3. reasons for discontinuation= discomfort, headache, vaginal discharge, recurrent vaginitis

Progesterone-only contraception forms + MOA

1. oral 2. injectable 3. implantable 4. intrauterine options (LNG IUDs) all function primarily using same mechanisms: 1. thickening cervical mucus 2. inhibiting sperm motility 3. thinning the endometrial lining not as suitable for implantation

In whom are IUDs especially indicated?

1. oral contraceptives contraindicated 2. at low risk for STIs 3. monogamous women of any age

Natural contraceptive methods

1. periodic abstinence 2. coitus interruptus 3. lactational amenorrhea least effective, should not be used if pregnancy prevention is high priority

Ads/Disads of Vasectomy

1. permanent, highly effective, few side effects 2. generally safe, less expensive and can be perfomred as OP under local anesthesia 3. leaves woman w/o contraception if she leaves relationship

The low dose OCPs contain ___ to ____ mcg of ethinyl estradiol.

10-20 mcg of EE rather than 30-35 mcg

Recommended Calcium intake

1000-1300 mg/day use of dietary Ca preferred of supplement due to potential contribution to coronary artery calcification

IUDs (5 available in US + Use)

4 are Levonorgestrel (LNG) intrauterine systems: 1. Mirena 2. Skyla 3. Liletta 4. Kylena 1 is hormone free and contains copper 1. TCu389A or ParaGard IUDs = most widely used method of reversible contraception in the world (has grown from <2% to just over 10% in past decade)

early menopause

5% of women 40-45 years increased risk with hx of: 1. hysterectomy 2. tubal ligation Thought to be due to decreased vascular supply to ovaries after these procedures

late menopause

5% of women >55 years

Average age of menopause in US

51 yrs (45-55 yrs)

Gold standard for diagnosing osteoporosis

DXA (Dual-energy X-ray absorptiometry) of lumbar spine and hip

Injectable Progeserone-Only Contraception MOA

Depo-Provera (Depot medroxyprogesterone acetate, DMPA) (150 mg/1 mL, intramuscular "IM") injected IM every 3 months in vehicle that allows slow release of progestin over 3-month period low-dose DMPA (104 mg/.65 mL, subcutanoues "SC") also available, not widely used yet -benefits: lower progestin levels but same efficacy acts by: 1. suppressing ovulation 2. thickening the cervical mucus 3. making endometrium unsuitable for implantation 4. reducing tubal motility after injection, ovulation does not occur for 14 weeks, pts have 2 wk grace period in their every every 12-week dosing

Effectiveness of tubal ligation

FR= 0.3% , but varies by method, pt age, and surgeon experience

When are symptoms of menopause often most intesnse?

during late perimenopause phase gradually, most women will see reduciton in severity of these symptoms over time avg medial duration of reported VMS symptoms is 7.5 yrs

When do women achieve maximum bone density?

20-25 yrs t/f achieving max bone density is critical to the care for female pts at all ages -low vit D can result in osteomalacia in adults and rickets in chidlren -diets low in Ca assoc. w/ low bone mineralization

traditional combination pill

conains both estrogen and progestin - taken for 1st 21 days out of 28-day monthyl cycle during last 7 days of cycle, placebo pill or no pill is taken bleeding should begin within 3-5 days of completion of 21 days of hormones

Duavee

conjugated equine estrogen (CEE) 0.45mg and bazedoxifene (BZE) 20 mg), the first TSEC approved to treat VMS and prevent osteoporosis in women with intact uterus doesn't require addition of progesterone SERMs have unique pattern of both agonistic and atnagonistic effects on other tissues, including heart, bone, uterus, and breast only BZE has been shown to have an adequate antagonistic effect on uterus; therefore; it does not require additional progesterone therapy when paried with an estrogen

Once the diagnosis of osteoporosis is made, what should be done? what is recommended for them?

consider 2* causes and work up prior to initiating tx women w/ OP and those at risk for OP should be encouraged to make lifestyle changes to decrease their risk weight-bearing exercise (walking, hiking, stair climbing) and muscle-strengthening exercise have been found to decrease risk of falls and fractures counsel for adequate Ca and Vit D intake reduce active and passive smoking and alcohol intake (<3/day) use fall prevention strategies to limit risk of falls and fxs

With which option are highest success rates acheived?

1. PPS 2. Essure tubal occlusion

MOA of transdermal patch (Estrogen exposure + increased risk of?)

(Ortho Evra Patch, Xulane) contains both P and E releases 150 mg/day of progestin, norelgestromin, and 35 mg/day of EE overal avg estrogen exposure is 60% higher in patch user compared w/ women taking standard 25 mcg OCP t/f these pts should be made aware of increased risk of thromboembolism, specifically DVT and PE in Ortho Evra users compared w/ women taking standard OCPs there does not appear to be increased risk of heart attack and stroke in these pts 1. women apply one patch on same day each weak (patch change day) for 3 consecutive weeks by a 1-week patch-free period where they will have a withdrawal bleed can be worn on upper outer arm, abdomen, buttock, or back in a location that would not be disturbed by clothing patch should NOT be placed on breasts primary MOA is suppression of ovulation by decreasing endogenous FSH and LH levels, thickening ervical mucus, and thinning the endometrium (like combined OCPs)

3 forms of ECPs

(aka post-coital or morning-after pill) 1. Copper T IUD (ParaGard) -emergently inserted 2. SPRM (selective progesterone receptor modulator, uliprastil or Ella) 3. Mifepristone (RU 486) -approved in US for termination of preg up to 49 days of gestation, not approved for EC

Two-Cell Theory

(aka two-cell, two-gonadotropin theory) Postulates role of both FSH and LH (two gonadotropins) on ovarian follicular maturation and the production of estrogens involving both theca and granulosa cells (two cells) 1. LH stimualtes production of androgens (androstenedione) from cholesterol and prenenolone in theca cells 2. Androgens transported into granulosa cells where FSH stimulates the conversion of androgens to estrogens (estroen) 3. As rising estrogen levels have negative feedback on pituitary FSH secretion, dominant follicle is protected from decrease in FSH by its increased number of FSH receptors

two long-term consequences of menopause

(consequences of estrogen-deficient state) 1. CV -protective benefits of estrogen on lipid profile (increased HDL, decreased LDL and TGs) -protective on vascular epithelium (decreased atherogenesis, increased vasodilation, decreased platelet adherence) -these are lost -increased risk for CAD 2. Low Bone Density -formerly osteopenia, potentially osteoporosis -bone resportion increases

Multiphasic oral contraceptives

(dose varying) differ from monophasic only in that they vary the dosage of estrogen and/or progestin in active hormone pils in effort to mimic menstural cycle advantage=may provide lower level of estrogen and progestin overall, but highly effective at preventing preg

What may women with menstrual-related disorders benefit from?

(endometriosis, heavy menstural periods, anemia, dysmenorrhea, mesntrual irregularity, menstural migranines, PMS, PCOS, ovarian cysts) may benefit from extending # of consec days of hormonal pills taken from 21 days-1, 2, or 3 months, thus increasing length of continuous hormonal suppression and decreasing the # of withdrawal bleeds extended or long-cycle regimens (Seasonale and Seasonique) provide continued suppression of ovulation and decreased menstrual-related symptoms (such as pain, heavy bleeding, cysts, anemia, and headaches for users also good for women who prefer to have fewer withdrawal bleeds while taking OCPs

monophasic combination pills

(fixed dose) combination pills -fixed dose of estrogen (20-35 mcg of ethinyl estradiol EE) -fixed dose of progestin

Perimenopause (aka?)

(menopausal transition) transition from normal ovulatory cycles to menopause b/c of progressive ovarian failure symptoms can begin from 2-8 yrs prior to final menstural period (FMP) time from FMP and beyond is considered postmenopausal menopausal transition and early postmenopausal years are when women have their most significant symptoms

Continuous regimens

(such as Lybrel) with a daily hormone pill and no hormone free interval have been found to be safe and effective

Interactions of OCPs (meds that reduce efficacy of OCPs vs. meds whose efficacies are changed by OCPs)

**only antibiotic that lower effectiveness of OCPs is Rifampin CDHMPTT

thelarche

*usually first phenotypic sign of puberty 1. development of breast buds (around 10 yrs) -occurs in response to increase in levels of ciruclating estrogen 2. coestrogeniation of vaginal mucosa and growth of vagina and uterus 3. further breast development continues thruout puberty and adolesence (Marshall and Tanner)

Side Effects of OCPs

.OCPs w/ estrogen doses >50 mg can increase coagulability -> higher rates of MI, stroke, DVT, and PE, particularly in women who smoke even at lower doses of estrogen (35 mcg or less), women >35 yrs who smoke >15 cigs/day are still at ^ risk of heart attack, stroke, DVT, and PE if they use OCPs

Effectiveness of Transdermal Patch

1% pregnancy rate in actual use -- similar to other combo hormonal methods transdermal patch has been found to have a decreased effectiveness in women weight more than 198 lbs (90kg)

Effectiveness of Depo-Provera

1. 1st yr theoretical failure rate of only 0.3% -one of most effective contraceptions avaialble 2. typical use FRs ~3%, mostly attributed to pts failiing to return at scheduled times for follow-up injections

Medications for Tx of OP

1. Bisphosphonates -leading tx -MOA: inhibiton of osteoclast resorption of bone 2. partial estrogen agonists/antagonists -inhibit bone resorption (aka SERMs) 3. denosumab (Prolia) -human mAb to receptor activator of NFkB ligand, which blocks proliferation and differentation of osteoclasts, resulting in decreased bone resorption and increased BMD 4. teriparatide (Forteo) 5. Calcitonin -Antiresorptive tx 6. PTH -stimualtes osteoblastic activity 7. MHT

initial workup for delayed or precocious puberty

1. Careful hx 2. PE 3. hormone assessment 4. bone age determination

Menstruation in more detail

1. During folluicular phase, endometrium in proliferative phase (growing in response to estrogen) 2. During luteal phase, endometrium in secretory phase (as it matures and is prepared to support implantation) 3. If ovum not fertilized, CL deg after approx 14 days, leading to fall in esrogen and progesterone levels 4. withdrawal of progesterone -causes endometrium to slough, initiating menstrual phase 5. At same time, FSH levels begin to slowl rise in absence of negative feedback, and the follicular phase starts again 6. Menstrual cycle <24 days or >34 days or a menses that lasts > 7 days merits further eval

Ovulation in more detail

1. Estrogen levels eventually surge to reach a critical level that triggers the anterior pituitary to release an LH spike 2. LH surge triggers the resumption of meiosis in the oocyte and induces production of progesterone and prostaglandins, which are repsonsible for rupture of ofllicular wall with release of mature ovum or ovulation 3. Ovum usually passes into adjoining fallopian tube and swept down to uterus by cilia -takes 3-4 days 4. fertilization of ovum must occur within 24 hrs of ovulation or it degenerates

Luteal phase in more detail

1. Granulosa and theca interna cells lining the wall of the follicle form the corpus luteum under stimulation by LH 2. The corpus luteum makes estrogen and significant quantities of progesterone, causes endometrium to become more glandular and secretory in prep for implant of fertilized ovum 3. If fertilization occurs, developing trophoblast synthesizes human chorionic gonadotropin (hCG) (glycoprotein v similar to LH, which maintains corpus luteum, so that it can continue production estorgen and progesterone to support the endometrium) 4. this continues untilt he placenta develops its own synthetic function at 8-10 wks of gestation 5. if fertilization, with its concomitant rise in hCG, does not occur, the CL degenerates 6. progesterone falls 7. endometrium not maintained -> menstruation

Effectiveness of IUDs

1. IUD effecicacy rivals permanent sterilization w/ prolonged use 2. Failure rate 0.8% for Paragard and 0.2% for Mirena within 1st year 3. 10 year failure rate for ParaGard ~1.9% 4. cumulative 5yr FR for Mirena ~0.7%

Physiology of perimenopause

1. Inhibin B secretion from granulosa cells falls b/c of diminished follicular numbers 2. FSH rises 3. progesterone levels low 4. estradiol levels fluctuate greatly, but in general preserved until late perimenopause when both estradiol and FSH ca fluctuate

Menopause Symptoms

1. Vasomotor symptoms (VMS) -night sweats -daytime hot flashes 2. mood swings -irritability -depression -anxiety 3. insomnia 4. sleep disturbances 80% of women experience them at some point during transition various physiolgoic changes due to decrease in estorgen 40-80% of women will begin having mild symptoms during perimenopause 50% will experience an increase in freq and intestnsity of symptoms during menopause transition

Diaphragm (MOA, Effectivness, Side Effects, Ads/Dis)

1. MOA -dome-shaped shallow cup made of a soft silicone or latex (rubber) sheet which is stretched over thin coiled rim -spermicidal gel, foam, or cream is placed on rim and on either side of diagpraghm -> placed into vagina and left in place after intercourse for minimum of 6 hrs (max of 30 hrs) -if further intercourse is to take place w/in 6-8 hrs after 1st episode, additional spermicie should be placed in vagina without removing 2. Effectiveness -theoretical effectiveness ~94% -actual effectiveness rate = 80-85% 3. Side Effects -bladder irritation-> UTIs -if in too long -> toxic shock syndrome (S. aureus colonization) -hypersensitivity to rubber, latex, or spermicide 4. Ads/Disad -safe, effective, convenient -must be fitted/prescribed -initial cost slightly higher than OCP contraception -should be placed every 2 yrs or when pt gains or loses more than 20% of body weight -fit should be checked after each pregnancy -if uncomfortable inserting and removing or cannot be properly fitted b/c pelvic relaxation defects AND women at high risk of HIV = poor candidates -used by less than 1%, few options on market

Periodic abstience (MOA, Effectiveness, Advantages/Disadvantages)

1. MOA -rhythm or calednar method -physiologic form of contraception, emphasizes fertility awareness and abstience (shortly before and after ovulation period) -requires instructions on determining ovulation -requires woman have regular, predictable menstrual cycles -kits include basal body temp measurements, menstrual tracking, cervical mucus evaluation, 2. Effectiveness -relatively low (55-80%) 3. Ad/Dis -no chemicals/mechanical barriers -need motivated couple willing to learn -relatively unreliable, may require longer periods of abstinence

Lactational amenorrhea (MOA, Effectiveness, Ads/Dis)

1. MOA -Continuation of breastfeeding -after delivery, restoration of ovulation delayed b/c breastfeeding-induced hypothalamic suppression of ovulation -prolactin-induced inhibition of pulsatile GnRH from hypothalamus (specifically) 2. Effectiveness -highly variable duration of ovulatory supression -50% of lactating mothers begin to ovulate between 6-12 mo post delivery, even when breastfeeding -return of ovulation occurs BEFORE return of mensturation (15%-55% using lactation for contraception become pregnant) -can be enhanced for short-term use by: a) using breast milk as only form of nutrition for infant B) only used as long as woman is experiencing amenorrhea, and even then only 6 mo after delivery 3. Ads/Dis -no effect on breastfeeding -safe, simple, free -increased body contact/bonding for baby, lower infection (maternal Abs) -limited to immediate 6 mo after delivery -can result in vaginal dryness -theortical failure rates reasonable, but actual practice are high and unacceptable

Cervical Cap (MOA, Effectivness, Ads/Dis) - most common cause of failure?

1. MOA -FemCap or Lea Shield -small, soft, silicone cap that fits directly over cervix -held in place by suction, barrier sperm -fitted by a clinician (proper fit essential to effectiveness) -must be used w/ sperm gel, foam, or cream -widely used in Britain and Europe, not widely available in US 2. Effectiveness -Actual effective rate= 68-84% (16-32% failure rate) -increased risk of failure in parous women -mcc of failure= dislodgment 3. Ads/Dis -small/immediately effective -does not interfere w/ endogenous hormones, can use while breastfeeding -can be inserted up to 6 hrs prior to intercourse, so it does not interrupt sex -can be left in place 1-2 days -foul discharge often develops after 1st day -must be refitted after preg or in event of large weight change -difficulty to place and remove -> continuation rate is low (30-50%)

Female Condoms (MOA, Effectieness, Ads/Dis)

1. MOA -female condom (FC2 Female COndom) aka internal condom = pouch made of synthetic nitrile (previously polyurethane) w/ flexible ring at each end -one ring=silicon and lubricated -inserted into depth of vagina near introitus -can also be inserted into anus 2. Effectiveness -TFR=5% -AFR=20-25% (somewhat higher than male condoms) 3. Ads/Dis -protect against STIs -stays in place even if male erection is lost -cost and overall bulkiness/decreased sensation -irrtation -acceptability rating is somewhat higher for male than female

Male Condoms (MOA, Effectiveness, Side Effects, Ads/Dis)

1. MOA -latex sheathes placed over erect penis before jeaculation 2. Effectiveness -actual efficacy rate in population is 85-90% -important to leave a well at tip to collect ejaculate and avoid leakage of semen as the penis is withdrawn -efficacy is also increased by use of spermicide-containing condoms or by using spermicide along w/ condoms 3. Side Effects -hypersensitivity to latex, lube, or spermicide in condoms 4. Ads/Dis -widely available -low cost -prevent STIs - only contraceptive protecting against HIV -dis: coital interruption, decreased sensation, hypersensitivity

Spermicides (MOA, Effectivness, Side Effects, Ads/Dis) - Contraindication?

1. MOA -most widely used = 1) nonoxynol-9, 2) octoxynol-9 -disrupt cell membranes of spermatozoa, also act as mechanical barrier to cervical canal -should be placed in vag at least 30 min before intercourse to allow for dispersion thruout vagina -may be used alone but more effectve in conjuction w/ other forms 2. Effectiveness -when properly and consistently used w/ condoms (95% effective rate) -actual use = 70-75% (reduced by failure to wait lone nough for spermicide to disperse in vag prior to intercourse) 3. Side Effects -irritation of vaginal mucosa and external male and female genitalia 4. Ads/Dis -various forms (creams, gels, films, suppositories, foams) -inexpensive -messy -do not protect against STIs -may make user more susceptible to STIs (including HIV by causing vaginal irritation) -do not use in women w/ HIV or at high risk of contracting HIV -general public: recommend consistent condom use to protect against STIs

Cotius interruptus (MOA, Effectiveness, Advantages/Disadvantages)

1. MOA -withdrawal of penis from vagina b/f ejaculation 2. Effectiveness -high failure rate (27%) -failure due to: 1) pre-ejaculate in vagina before orgasm 2) deposition of semen near introitus after intracrural intercourse 3. Ads/Dis -high failure rate -need for sufficient self-control

Recommendations for MHT Use

1. Moderate to Severe VMS or GSM and no contraindication to estrogen (MHT) 2. prevention of osteoporosis, but NOT treatment of osteoporosis (MHT) 3. only have symptoms relating to GSM, local, low-dose vaginal estrogens recommended 4. Doses = lowest effective dose -individualization -route of admin/types of estrogen/progest used or use of TSEC or SERM should be considered

pubertal sequence

1. accelerated growth 2. breast development (thelarche) 3. development of pubic and axillary hair (pubarche) 4. onset of mestruation (menarche) usually occur in order concerned pts can be reassured by knowing that on average the length of time from breast bud dev to menstruation is typically 2.5 years

Is antibiotic prophylaxis needed for IUD insertion in bacterial endocarditis pt? What should be done?

1. antibiotic prophylaxis not needed for IUD insertion, nor is it indicated 2. instead emphasis should be placed on appropriate pt selection

Medications approved for prevention OP

1. bisphosphonates -Fosamax -Actonel -Boniva 2. Zolendronic acid (Reclast) 3. Raloxifene (Evista) 4. MHT

Contraindications to MHT

1. chronic liver impairment 2. known estrogen-dependent neoplasm (breast, ovary, endometrium) 3. active thromboembolic disease 4. undiagnosed uterine bleeding

Ads/Disads of POPs

1. contain no estrogen 2. ideal for breastfeeding mothers 3. ideal for women for whom estrogens are contraindicated ->35 yrs who smoke -HTN -CAD -Collagen vascular disorder -lupus -migraines w/ aura -hx of thromboembolism 4. can be used to tx abnormal uterine bleeding in high-risk medical populations whose bleeding has been adequately evaulated -ie anovulatory bleeding/bengin endometrial hyperplasia in poor surgical candidates disads 1. irregular menses ranging from amenorrhea to irregular spotting 2. must be taken at same time each day 3. delay of >3 hrs akin to missed to pill

MHT benefits

1. excellent control of menopausal symptoms -reduction of VMS -imrpovement in mood/sleep dysfunction -prevention/tx of GSM -imrpovement in skin and muscle tone 2. Women who begin MHT before age 60 or within 10 yrs of FMP obtain largest benefit in control of vasomotor symptoms and prevention of bone loss 3. More remote a woman is from menopause (over 10 years from FMP and over 60 years of age) -less favorable outcomes -^ rates of stroke, DVT, CVD, and dementia

Ads/Dis of EC Copper T

1. extremely effective, more than oral forms 2. differs form ECPs in that it can be continued for long-term contraception (10 years) where as ECPs have only one-time-only use disads: 1. Must be placed by provider 2. Higher one-time cost than oral regimens 3. rare complications: infections/perforation 4. heavier menses 5. dysmennorhea

Advantages and DIsactanges of OCPs

1. extremely high efficacy rates 2. noncontraceptive health benefits including decreased menstural flow,a nemia, dysmenorrhea, and ovarian cysts 3. reduced incidence of ovarian cancer, endometrial cancer, ectopic preg, PID, and benign breast disease 4. by taking OCPs, nearly 50,000 women avoid hospitalization; of these, 10,000 avoid hospitalization for life-threatening illness 1. CV complications 2. increase GB disease 3. increased incidence of benign hepatic tumors 4. need for medication every day 5. nausea 6. headaches 7. breakthrough bleeding 8. weight gain mostly mild and transient

Risk factors of osteoporosis

1. fam hx 2. age 3. race/ethnicity -Caucasian and Asian at higher risk than Mexican American and AA women 4. prolonged use of medications -depot MPA, GnRH agonists, glucocorticoids (>/= 5 mg/day prednisone for >3 mo), and aromatase inhibitors

Etiology of Menopause - what is menopause generally heralded by?

1. generally heralded by menstural irregularity b/c the # of oocytes decreases 2. increasingly sporadic ovulation 3. commonly believed that, as part of nautral aging process, the onset of menopause is caused by disruption in function of HPO axis and gradual oocyte depletion (follicular atresia). 4. Causes decrease in estrogen production and increase in FSH and LH

In whom is menarche often delayed?

1. gymnasts 2. distance runners 3. ballet dancers theories: -insufficient % of body fat that may result in hypothalamic anovulation and amenorrhea -exercise and stress on body may inhibit ovulation thru + effects of NE and GnRH, thus interfering with menarche

ECP MOA

1. high doses of both estrogen and progestins or progesterone alone (Plan B One Step, Next Choice) 2. Sreveral dif regimens -higher doses of regularly prescribed OCPs 3. LNG methods are preferred over estrogen-progesterone regimens -LNG=more effective + fewer side effects (decrease N/V)

Advantages/Disadavantages of IUD

1. prescribed 2. inserted by dr 3. removed by dr 4. rapidly reversible 5. monthyl string check to ensure it hasn't been expelled (imrpoves coital spontaneity and decreases fear of pregnancy) 6. in US, ParaGard IUD has been approved for use for 10 yrs (but effective up to 12 yrs) 7. Mirena IUD approved for 5 years (but effective for at least 7 yrs) 8. Liletta and Sykle currently up to 3yrs 9. Kyleen (5-year LNG IUD) 10. one IUD can be removed and another inserted on same visit 11. may be inserted immediately after induced or spontaneous first trimester abortions w/o increased risk of infeciton/performation

Luteal Phase

1. remnants of follicle left behind in ovary develop into corpus luteum (secrtes progesterone), which maintains endometrial lining in prep to receive fertilized ovum

ads/disads for transdermal patch

1. safe 2. effective 3. convenient 4. bleeding generally lighter and shorter on hormonal contraceptives same 1* side effects and noncontraceptive health benefits of OCPs apply to patch 5. can cause skin irritation 6. added benefit of being self-administered only once a week

Emergency Contraception (EC)

1. safe effective means of prevention after unprotected intercourse or in case of contraceptive failure (condom break, patch/ring/diaphragm dislodgment, IUD expulsion, missed pill, and late Depo injection) 2. used only in women not already pregnant 3. use of ECPills (ECPs) not indicated in women w/ known or suspected pregnancy -however no known evidence of harm to pt, her pregnancy, or fetus if unintentionally taken during pregnancy 4. can be used safely in women in whom continual estrogen might otherwise be contraindicated, such as women w/ hx of DVT, PE, MI, stroke, or migraines w/ aura

Newer formulation OCPs

1. shortened placebo length 2. extended cycles 3. continous cycles

Who is sterilization ideal for? (2)

1. stable monogamous relationships where no (additionaL) children wanted 2. also in women for wom pregnancy would be life-threatening (ie major cardiac issues)

other causes for hot flashes

1. thyroid disease 2. autoimmune disorders 3. carcinoid tumors 4. pheochromocytoma tumors 5. SERMs (tamoxifen/raloxifene, ospemifene) use

Ads/Disads of SPRMs in EC (in who is ulipristal contraindicated)

1. ulipristal contraindicated in women who are breast feeding or currently pregnant, given its antiprogestin efffects and potential to terminate an exisiting pregnancy 2. pregnancy test required before amdin of ulipristal 3. advtanges of its use include: 1-time dosing and relatively mild side effects disad 1. prescription only 2. use is controversial b/c potential use as abortifacient (although not approved for this) -in contrast to progestin-only or combined estrogen/progestin ECPs, because they do not terminate an existing preg nor cause teratogenic effects -for these resaons ulitpristal not widely prescribed when compared with other ECPs

Effectiveness of ECPs

1. when taken w/in 72 hrs of intercourse, FR of 0.2-3% 2. sooner taken, the more effective 3. risk of pregnancy reduced by 75-90% in women who have had unprotected intercourse during 2nd or 3rd week of their menstural cycles, when they are most likely ovulating

Follicular phase in more detail

1. withdrawal of estrogen and progesterone during luteal phase of prior cycle causes a gradual increase in FSH 2. FSH stimulates growth of approx 5-15 primordial ovarian follicles (initiating follicular phase again) 3. one becomes dominant follicle and matures until ovulation 4. dominant follicle produces estrogen that enhances follicular maturation and increases the production FSH and LH receptors in autocrine fashion

In who is copper T not acceptable form of EC?

1. women who are not IUD candidates -active PID or STI cervicitis -hx of PID or STI cervicitis in past 3 mo -cervical or endometrial cancer 2. women who have confirmed pregnacny

Menopause

12 months of amenorrhea after the FMP in the absence of any other pathologic or physiologic causes at this point nearly all oocytes have undergone atresia although a few reamin and can be found on histologic exam characterized by complete, or near complete, ovarian follicular depletion and absence of ovarian estrogen secretion.

Pregnancy rates after vasectomy reversal

18-60%

Tubal occlusion w/ bipolar electrocoagulation

2cm portion of isthmic tube dessicated w/ bipolar forceps

Osteoporosis epidemiology

5X more in woman than men -morbidity -mortality -quality of life issues 2X fracture rate in woman vs. men -80% of hip fractures occur among elderly women 15% of women >50 yrs will be diagnosed w/ OP and 50% w/ low bone density (formerly osteopenia) a woman can lose 20% of original bone density in first 5-7 years after menopause subsequently menopausal pts are at risk of hip and vertebral fractures, chronic pain, loss of heigh, immobility, and loss of funciton

when can all of the current IUDs be safely placed postpartum?

6 wks postpartum and are safe in breastfeeding women

Success rate of vasal reanastomosis

60%-70%

Vitamin D intake

600 IU/day for most women and 800 IU/day for women >70 yrs routine screening for vitamin D def should be limited to pts w/ medical conditions or medication use placing them at high risk of vit D deficiency Vit D levels of 30 ng/dL were assoc w/ decreased risk of bone fracture

Extended therapy

>3-5 years for EPT and >7 yrs for ET may be appropriate for woemn w/ persistent symptoms who understand risks

Ads/Disads of Tubal ligation/occlusion

Ads 1. permanent effective contraception w/o continual expense, effort, or motivation mortality rate=4/100,000 women major risks=those assoc w/ surgery including risk of infection, hemorrhage, conversion to laparotomy, viscus injury, vascular damgage, and anesthesia complications 1. results in very low risk of preg, however when does occur increased risk of ectopic preg (1/15,000) however nearly 1000 maternal lives are saved b/c of sterilization during the period from the time of sterilization to end of woman's reproductive life

Diagnosis of Osteoporosis

Bone mineral density (BMD) screening -should begin at age 65 yrs for all women -postmenopausal women under age of 65 yrs should be screened if they have significant risk factors including hx of fragility fracture, weight <127 lbs , parent with history of hip fx, current smoking, alcoholism, or RA

Emergency IUD Insertion MOA

Copper T IUD (ParaGard) can be inserted in the uterine cavity within 120 hours (or 5 days) of unprotected intercourse as a form of EC. IUD functions primarily by eliciting a sterile inflammatory response within the uterus, making the environment unsuitable for fertilization

Menstrual cycle phases

Divided in two 14-day phases (changes in ovary) 1. follicular 2. luteal (changes in endometrium) 1. proliferative 2. secretory

What is ParaGard also approved for?

EC (emergency contraception) when placed w/in 72 hrs of unprotected intercourse or contraceptive failure

IUD Side Effects

Extremely safe in general 1. pain 2. bleeding 3. intrauterine and ectopic pregnancy 4. expulsion 5. perforation 6. infection

FSH levels during perimenopause

FSH level may vary greatly and are not required to diagnose menopause absence of menses for 1 yr w/ consistently elevated FSH levels >40 IU/L is considered diagnostic of menopausa FSH levels above 40 IU/L do not, however, correlate with when a woman will have the FMP Lab analysis looking for reliable and predictive marker for the FMP is ongoing

Nonhormonal Tx of Menopausal Symptoms

For women who are unable or unwilling to take MHT or who have completed short term ET or EPT

When pregnancy is desired afte rtubal ligation, what offers a greater likelihood?

IVF however, when multiple future pregnancies are desired, tuboplasty may be more economical alternative than multiple IVF cycles

What can Mirena be used to treat? Newer forms of IUD?

LNG-contained IUD so can be used to tx: 1. menorrhagia 2. dysmenorrhea 3. postmenopausal women receing ET the newer forms of LNG IUDs (Skyla, Liletta, and Kyleena) do not have specific indications other than contraception at this time

in who is DMPA not contraindicated, but what should be done?

NOT contraindicated in obese women, but weight monitoring should be used in women w/ increased risk for weight gain women who gain >10 lbs after 6 mo of use should consider another contraceptive

Implantatable Progesterone-Only Contraception MOA

Nexplanon 1. subdermal progestin implant 2. provides 3 yrs of uninterrupted contraceptive coverage 3. progestin = etonogesterol (same as NuvaRing) 4. 4cm x 2 mm, contains 68 mg etonogestrel, provides slow release of hormone over 3 years 5. radiopaque, size of matchstick 6. applicator facilitates placement in subdermal skin of inner side owman's upper arm 7. when approriate timing of placement is utilized, Nexplanaon effective 24 hrs after placement and has quick return to fertility once removed 8. acts by supressing ovulation, altering endometrium, thickening cervical mcus

Vaginal Hormonal Contraception MOA

NuvaRing hormone-releasing vaginal ring with brand name NuvaRing releases daily dose of 15 mcg of EE and 120 mcg of etonogestrel (active form of desogestrel) ring is placed in the vagina for 3 weeks (it is likely effective for 4 weeks), and is removed for 1 week to allow for withdrawal bleed hormone free period can be skipped to allow for ocntinous dosing typically for 3 months

OCP MOA

Oral contraceptive pills are composed progesterone alone or a combo of progesterone and estrogen over 150 million women worldwide (1/3 of sexually active US women) use OCPs place body in "psuedopregnancy state" by interfereing with the pulsatile release FSH and LH from the AP -this suppresses ovulation and prevent pregnancy from occuring -estrogen components of OCPs inhibits FSH secretion thereby suppressing formation of the dominant follicle -progestin suppresses LH secretion, thus preventing the LH surge and ovulation, also induces thin decidualized endometrium that is not receptive to implantation, while also thickening the cervical mucus making it less permeable to sperm bleeding that takes place during homrone-free interval is actually bleed due to withdrawal of homrone rather than menstrual period induced by endogenous hormone fluctation

PEPI Trial

Postmenopausal Estrogen/Progestin Interventions Trial

Progestin-Only OCP MOA

Progestin-only pills (POPs, Micronor, Nor-QD) deliver a small daily dose of progestin (.35 mg norethidrone) w/o any estrogen POPs have lower progestin doses than combination pills, thus nickname= minipills alsodiffer from traditional pills in that they are taken every day of cycle w/ no hormone-free days POPs bleived to: 1. thicken cervical mucus making it less permeable to sperms -decreases after 22 hours, so minipil must taken at same time each day other MOA include: 1. endometrial atrophy 2. ovulation suppression (50% of cycles)

Side Effects of Vasectomy

Rare and usually invovle slight bleeding, skin infection, and reactions to sutures or local anesthesia 50% of pts form antisperm antibodies after procedure however, there are no long-term side effects of vasectomy

Osteoporosis diagnostic definition

T-score </= 2.5 Z-score is reserved for use in children, teens, premenopausal women, and younger men in rare instances when bone dnesity testing is indicated in them repeat BMD screenings are performed no more frequently than q 2 years unless pt response to med is being evaulated

Sample from Summary chart of US medical Eligibility criteria for contraceptive use

Table 24-7 (Page 391 or 853 on iPad)

2 other formulations

Triphasic (Trivora-28) and even quadriphasic (Natazia) these contain 3-4 different levels, respectively of estrogen and/or progestin w/in pack

WHIMS

WHI Memory Study

Can perimenopausal women ovulate?

Yes, and they are considered fertile until a full 12 months of amenorrhea contraceptive services and counseling should be provided to perimenopausal women who do not wish to become pregnant

HERS I and II

studies contributing to our knowledge of the safety and efficecy of HRT and ERT (Heart and Estrogen/Progestin Replacement Studies)

WHI

Women's Health Initative

Delayed puberty

absent or incomplete breast development by age of 12 years

growth spurt

acceleration in growth rate around age 9-10 yrs, leading to mean peak growth velokcity of about 9 cm/yr around age 12 yrs increased rate of growth is because of direct effect of sex steroids on epiphyseal growtha dn because of the increased pituitary GH secretion in response to sex steroids

What happens as a result of regeneration of the zona reticularis of the adrenal glands?

adrenal gland produces increased quantities of the androgens DHEAS, DHEA, and androstenedione production of these androgenic steroid hromones increases from age 6-8 yrs up until 13-15 yrs primary stimulus of adrenarche is unknonw

Ads/Disads of Depo-Provera

ads 1. highly effective 2. acts indepdent of intercourse 3. infrequent injections (every 3 months) 4. reduces risk of endometrial cancer and PID 5. reduces amount of mentural bleeding 6. can tx menorrhagic, dysmenorrhea, endometriosis, menstrual-related anemia, and endometrial hyperplasia 7. esp useful in women who desire effective contraception, but may have concomitant med conditions that prevent the use of estrogen-containing contraceptives such as w/ migrains w/ auras, seizure disorders, lupus, sickel cell, HTN, CAD, and smokers disads 1. irregular bleeding 2. weight gain 3. mood changes 4. use w/ caution in pts w/ hx of depression, mood disorders, PMS, and PMDD

levonorgestrel-releasing intrauterine system

an option for women with an intact uterus who desire contraception

what is usually prescribed w/ EC?

antiemetic to prevent nausea (more common in estrogen-containing regimens)

Mid cycle

approximately day 14 - LH spike in response to preceding estrogen surge, which stimulates ovulation (release of ovum from follcile)

menarche

average age at onset is between 12-13 yrs or 2.5 yrs after dev of breast buds as gonadal estrogen production increases during puberty, it increases sufficiently to stimulate endometrial proliferation, ultimately resutlign in start of meneses

Ectopic pregnancies and IUDs

b/c IUDs are so effective at preventing pregnancy, risk of ectopic is reduced in IUD user compared w/ that of non contraceptive users in rare event that a owman does become pregnant w/ IUD in place, however, the risk of ectopic pregnancy may be as high as 30-50% IUD is accetpable form of contraception for women w/ 1. prior hx of ectopic pregnancy 2. remote PID (none in past >3 mos) 3. hx of cervicitis 4. HIV

Who is DMPA a good option for?

b/c of possibility of amenorrhea - good option for women w/ bleeding disorders or HMB, women on anticoag, women in military, and women who are mentally or physically disabled)

What should be done after use of Essure?

b/c tubal blockage is accomplished over time, pts current method of BC should be continued until Essure Confirmation Test performed 3 mos after procedure modified hysterosalpingogram (HSG) can confirm coil location and compelte tubal occlusion, whereas specialized transvaginal U/S can verify correct micro-insert location w/o confirming occlusion -most pts reassurbed by thsi confirmatory test, whereas others burdened by additional step to acheiving permanent sterilization -prior to procedure pt should understand it is essnetially irreversible

In who are the results of MHT most favorable? Who should it not be used in?

before age 60 yrs and w/in 10 yrs of menopause tx must be considered carefully, however, particularly in older women Should not be used for prevention of other chronic disease such as CVD, CHD, or dementia

Risks of MHT

both ET and EPT use 1. increases DVTs 2. Pulmonary emboli 3. ischemic strokes appears by 1-2 years of use and decreases over time risk is rare in women ages 50-59 yrs, may be lower when a transdermal delivery method is used 4. increased risk of invasive breast cancer -w/ use of combined equine estrogen + medroxyprogesterone acetate (.625 mg CEE + 2.5 mg MPA) was seen in WHI after 3-5 years -risk decreases after therapy stopped 5. ET associated w/ fewer invasive breast cancers after 7 years 6. EPT (but NOT ET) assoc. w/ higher rates of death from NSC lung cancer, but neither assoc. w/ incidence of luing cancer 7. increased dementia in women ages 65-79

Essure

both OR and OP practices that involve non-incisional hysteroscopic approaches Essure= soft, flexible, 4cm radiopopaque microinserts introduced into proximal (uterine) portions of fallopian tubes -outer spring coil made of nickel-titanium alloy and molds to the shape of fallopian tube to anchor and microinsert across utero-tubal jxn -inner coil contain spolyethylene terephthalate (PET) fibers that incite natural in-growth of tissue -over about 12 wks, sterilization accomplished as in-growth of tissue around coils results in occlusion of fallopian tubes -tubal ligation achieved by both space-filling outer coil and tissue in-growth elicited by PET fibers of inner coil

How is diagnosis of menopause usually made?

by hx and PE pts classicaly between 48-52 yrs (avg 51 yrs) complaining of irregular menses or amenorrhea and VMS, mood changes, depression or anxiety, insomnia, and vaginal dryness or dyspareunia (may be assoc w/ loss of desire for sex)

Clinical Diagnosis of Osteoporosis

can be made when pt suffers low-trauma (fragility) fracture as a result of normal activities like falling from a standing height or less

Placement of IUD in women w/ cervical infections

can lead to insertion-related pelvic infalamatory disease (PID) -believed to be due to contamination of endometrial cavity at time of insertion -otherwise, PID rarely seen beyond first 20 days after insert

What should be done before performing any sterilization procedure?

careful counseling and informed consent pt needs to understand: permanent and largely irreversible nature of procedure, operative risks, chance of failure, psosible side effects

Sucess rate of reanastomosis is highest when...

clips are used b/c they destroy a much smaller segment of tube

Best OCP dosing for endometriosis

continuous dosing- take active pills only 3 mos, then take 1 week of placebo to have withdrawal bleed

Most effective form of EC

copper IUD

If fertilization doesn't occur

corpus luteum degenerates and progesterone levels fall w/o progesterone endometrial lining is sloughed off (menstruation)

Risk of PID in women useing LNG IUDs, what does this implicate about their use?

decreased risk of PID owing to protection of progesterone-induced cervical mucus thickening given these findings, IUDs are being used more liberally in younger women, women who have not completed childbearing, and nulliparous women

MOA of ECPs

depends on point during cycle when pills are taken EC used to prevent preg by: 1. inhibitng ovulation 2. interfering w/ fertilization and tubal transport 3. preventing implantation 4. causing regression of corpus luteum

Theoretical efficacy rate

efficacy of contraception when used eact as instructed

actual efficacy rate

efficacy when used in real life, assuming variations in consistency of usage

Women >28 yrs?

electrocoag and falope ring equally effective unipolar sterilization no longer used due to safety concerns so Essure is best at this time

In US, EC does not require...

exam by provider, althoguh a pregnancy test should be performed befroe placing COpper IUD or giving uliprastal (Ella) the ECPs may be obtained over the counter without prescription by men and women 17+ yo

Ads/Disads of ECPs

extremely effective in preventing pregnancy are safe for the user major disads: 1. short window of time when cna be used (72-120hrs) 2. cannot be used as long-term contraception

Effectiveness of Vasectomy

failure rate in actual practice 0.15%

Estradiol levels

fluctuate greatly during late perimenopause and early postmenopause

FRAX

fracture risk assessment tool can help further predict person's risk of hip frature or major osteoporotic fracture in next 10 yrs based on factors such as: 1. age 2. BMI 3. Hx of fx 4. daily alcohol intake 5. smoker? 6. Rheumatoid arthritis 7. secondary causes of osteoporosis used most often in postmenopausal women w/ low bone density (osteopenia) than DXA to decide on tx initiation

High dose OCPs

generally refer to 55 mcg of EE

GSM

genital urinary syndrome of menopause includes symptoms of 1. vulvovaginal atrophy (VVA) -dryness w/ itching, discharge, dyspareunia -urinary system changes such as incontience and ysuria GSM seen in late peri- and postmenopausal women results from low-estrogen levels unlike VMS symptoms, the changes seen with GSM will, if untreated, become more severe over time over half of women with GSM do not report it to dr

Effectiveness of POPs

gneerally not as effective as combo homrone regimens, with failure rates estimated at greater than 8% this failure rate increases if punctual dosing is not achieved

Effectiveness of NuvaRing

highly effective (1%-2% Failure rate in acutal use)

What is the most commonly used reversible means of preventing pregnancy in the US?

hormonal contraceptives consist of combined (estrogen and progesterone) and progesterone-only methods combined forms: 1. oral 2. transdermal 3. vaginal forms progesterone-only forms: 1. oral 2. injectable 3. implantable 4. intrauterine forms

When can ParaGard be inserted?

immediately postpartum (w/in 10 min of placental delivery) with an increased risk of expulsion but no increased risk of infection or perforation

Risk of taking one pill every other day

increases risk of endometriosis flare and pregnancy

Selection of OCP brands

individual side effects, risk factors and goals for each pt

tubal occlusion w/ silicone band (Falope ring)

isthmic portion of tube retracted into applicator barrel using grasping tongs during this retraction process, ring is rolled forward to occlude portion of tube intervening "knuckle" of tube becomes ischemic and necroses

What if the device cannot be removed with gentle traction?

it should be left in situ during the pregnancy

What is most effective in women <28 yrs?

laparoscopic approach, Falope ring

Thermal and CO2 lasers

may be excellent option for vaginal rejuvenation for women with contraindications to ET, but need more research

MHT

menopausal hormone therapy -both ET + EPT (estrogen therapy and estrogen + progesterone therapy) -both successfully treat bothersome symptoms of menopause -oral, -topical (gels, patches, sprays) -vaginal rings and injections

Closely related drug to ulipristal

mifepristone (RU 486) similar MOA to ulipristal not avialable in US for prevention of preg - but trials show 99-100% efficacy (limited to preg termination in US)

Parkland method of postpartum tubal ligation

modified Pomeroy 2-3 cm segment of tube is doubly ligated, and intervening segment is removed typically performed immediately postpartum thru small subumbilical incision

IUDs and MRI

most are MRI compatible, but certain circumstances exist -recommended that product labeling be referenced

Side Effects of SPRMs in EC

most common side effects=similar to ECPs and include self-limited: 1. headache 2. bleeding 3. nausea 4. abdominal pain

% of unintentional pregnancies in US (% of these as live births, miscarriages, elective abortions)

nearly 50% of pregnancies -43% result in live births -13% in miscarriages -44% elective abortions

Emergency Progesterone Receptor Modulator MOA + dose

newsest form of ECP= Uliprastal (Ella, EllaOne)= derivative of 19-norprogesterone -acts as SPRM w/ agonist/antagonist effects at progesterone receptor sites primary MOA= 1. delay ovulation (follicular rupture) 2. inhibit implnatiaton into endometrial lining single dose of 30 mg within 120 hours (5 days)

Side Effects of Tubal Sterilization

no side effects some women report: 1. pain 2. menstural disturabnce this was once called post-tubal ligation syndrome (discounted by lit) in most of these women, symptoms are due to discontinuation of homrone-containg contraceptives -> as result pts may experience heavier baseline menses and dysmenorrhea in rare, circumstances, malplacement of Essure coils has constributed to signif pain requiring subseq surgical coil removal,salpingectomy, or rarely, hysterectomy

What are IUDs NOT assoicated w/?

not assoc. w/ any increased risk of congenital abnormalities

adrenarche

occurs before any perceived phenotypic change with regeneration of the zona reticularis in the adrenal cortex and production of androgens and ultimately stimulates the apperance of pubic hair between ages 6-8 yrs when the adrenal gland begins regeneration of the zona reticularis this inner layer of the adrenal cortex is responsible for secretion of sex steroid hormones

effectiveness of Nexplanon

one of most highly effective reversible methods, failure rate only .5%

Hot flashes and night sweats

only FDA approved nonhormonal medication to treat VMS in menopausal women is paroxetine sulfate (Brisdelle 7.5 mg) -other SSRIs and SNRIs, including citalopram and venlafaxine, have shown efficacy -low doses of gabapentin or clinidine have also shown beneficial effects Cognitive behavior therapy -effective for hot flashes -behavioral changes (avoiding triggers, using fans, cooling sleep pillow, sweat-wicking sleepwear AE of SSRIs and SNRIs: sexual side effects, drowsiness, or nausea making pt education a critical component to sucess

pubarche

onset of growth of pubic hair usually occurs around age 11, often accompanied by growth of axillary hair usually follows thelarche, but a normal variant may occur with pubarche preceding thelarche, particularly in African American girls. Growth of pubic and axillary hair is likely secondary to increase in circulating andorgens

Effectiveness of SPRMs in EC

pregancny rate when prescribed w/in 120 hr window ~2%

EC works by

preventing pregnancy, not by disrupting implanted pregnancy EC thought to account for 40% decline in therapeutic abortions in past 10 yrs, while also decreasing the number of teen pregnancies

Tubal Sterilization MOA

prevents pregnancy by surgically occluding both fallopian tubes to prevent the ovum and pserm from uniting can be performed in immediate postpartum period (postpartum sterilization PPS) or outside postpartum period via laprascopic approach (laparoscopic tubal ligation LTL) or via hyteroscopic tubal occlusion (Essure)

POI

primary ovarian insufficiency (formerly premature ovarian failure) onset of spontaneous menopause >40 yrs, requires fiurther testing usually 1. idiopathic or 2. autoimmune if it occurs before age 30, chromosomal studies can be ordered to rule out genetic basis (eg mosaicism) approx 6% of women with POI are found to have premutations of FMR1 gene, and another 3% will have autoimmune or adrenal abnormalities

tx of endometrial hyperplasia

progesterone, NOT COCs (estrogen causes uterine growth)

Which formulation of oral EC is most effective?

progesterone-only formulations (Plan B) =most effective and fewer side effects thus single dose of LNG 1.5 mg (Plan B One Step, My Way, Next Choice One Dose) should be used as a first choice when available, rather than combo method

most common prepacked Plan B

progestin only -canbe taken as single 1.5 mg of LNG (Plan B One Step) or as two 0.75 mg doses taken 12 hrs apart (next Choice) regardless of regimen, first dose must be taken w/in 72 hrs of unprotected vaginal intercourse some additional efficacy if initiated w/in 120 hrs although not as high as within first 72 hrs

multiphasic pills

provide a varying amount of estrogen and/or progestin over course of the cycle

Precocious puberty

pubarche or thelarche before 7 yrs of age in Caucasian girls and before 6 yrs of age in African American girls

What do the progestins in OCPs do to cholesterol?

raise LDL, while lowering HDL in pill users who smoke >1 ppd

neoplastic complications of OCPs

rare effect of long-term oral contraceptive use on breast cancer has been studied w/ no conclusive findings

Effectiveness of Emergency IUD

reduces risk of preg by 99.8% therefore, only 1/100 become pregnancy after emergecy IUD insertion making it the most effective form of EC

Follicular phase

release of FSH from pituiary gland results in dev of primary ovarian follicle -produces estrogen (causes uterine lining to perforate)

Effectiveness of OCPs

remarkably effective in preventing pregnancy TFR=<1% failure for actual real-life usage is closer to 8% nausea, breakthrough bleeding, and the necessity of taking the pill every day are often cited as reasons for discontinuing the pill

Advantages of Essure

requires no general anesthesia or surgical incisions -when hysteroscopic tubal sterilization/occlusion performed, very little recuperative time needed -safe, more effective, hormone-free method of permanent birth control most commonly performed in office setting making it preferable option to surgical steriliation for all women, including obese women, women w/ prior abdominal surgeries or those at risk from anesthesia use

Women using DMPA for more than 2 years may experience

reversible decrease in bone mineralization similar to that seen in lactating women, due to decreas ein ovarian estradiol production thus, vit D, Ca, weight-bearing/strength exercise, smoking cessation should be encouraged

Risk w/ Dalkon shield

risk of life-threatening spontaneous septic abortion seen only w/ Dalkon shield (which had a braided polyfilament tail that wicked bacteria into the uterus placing the user at risk for PID, sepsis, and infertility) -taken off market in 1975

With exception of Essure, vasecomty is .....

safer, simpler, and more effective than female sterilization when pregnancies occur after vasectomy, many are due to ahving intercourse too soon afte rvasectomy rather than from recanalization of vas deferns

Side Effects of Emergency IUD

same as discussed in IUD section

SERMs and TSEC

selective estrogen receptor modulators tissue-specific estrogen complex

new formulations of combo pill

shorten the placebo time and cycle length by giving 24 days of homrone (Rather than 21) followed by a 4-day hormone-free interval so-called "24/regimens" result in shorter 3-4 days menstrual cycle for most user

Rates of ectopic preg after Essure?

signficiantly decreased compared with that of LTL pts may also benefit from reduction in risk of ovarian cancer reason for this unclear, but it is speculated that tubal ligation may limit the migration of carcinogens from the lower genital tract into peritoneal cavity

Vasectomy MOA

simple and safe option for perm sterilization involving ligation of vas deferens may be performed in provider's office under local anesthesia thru small incision in upper outer aspect of each scrotum no-scalpel technique: -both vasa are ligated thru a single midline incision that reduces the laready low rate of complications assoc.

What occurs after discontinuation of Depo-Provera

some women may experience significant delay in return of regular ovulation (range of 6-18 mo; avg of 10 mo) this is indepdent of # of injections but may be directly related to weight of pt within 18 mo however, fertility rates return to normal

Complementary and alternative therapies

soy, black cohosh, phytoestrogens, dong quai, evening primrose oil) have not been found to more effective than placebo in tx of VMS may have side effects and are not recommended

Current Indication for MHT

suitable option for women with bothersome symptoms of menopause, including vasomotor and GU symptoms (in absence of any contraindications)

What dosing method is reserved for heavy and prolonged bleeds?

tapering method - take four pills for 4 days, three pills for 3 days, and so on until pack is complete, then resume from beginning used for short time

Major limit of WHI trials is

that the particpants wer emuch older (avg age of 63 yrs) and had higher BMIs (avg BMI of 34), and the sample had a higher percentage of smokers than subjects in most studies -makes more difficultt o generalize

gonadarche

the activation of the hypothalamic-pituitary-gonadal axis, which involves pulsatile GnRH secretion stimulating the AP to produce LH and FSH, which in turn, trigger the ovary to produce estorgens indepdnent of adrenarche and begins around age 8 years, when pulsatile GnRH secretion from the hypothalamus is increased there is also a changing sensitivity of the neuroendocrine system to negative feedback by gonadal hormones. This leads to pulsatile secretion of LH and FSH from the AP initially these increases occur mostly during sleep and fail to lead to any phenotypic changes as a girl enters early puberty, the LH and FSH pulsatility lasts thruout the day, eventualyl leading to stimulation of the ovary and subsequent estrogen release this in turn, triggers the characteristic breast bud development associated w/ puberty positive feedback of estradiol also results in initiation of LH surge and ability to ovulate

Tubal occlusion w/ Filshie clip

the clip is applied to the mid-isthmic poriton of the tube about 2 cm from the cornua lower jaw of clip should be vissible thru mesosalpinx to ensure inclusion of entire circumference of tube

Contraindications for ECPs

the contraindication for use of oral contraceptives in women w/ hx of smoke, MI, DVT, and PE, these contraindications do not apply to women using EC however, repeated use of ECP is not recommended in this high-risk group

How can tubal ligation be immediately postpartum (PPS)?

thorugh small subumbilical incision using epidural or spinal anesthesia most commonly used method = modified Pomeroy tubal ligation (aka Parkland) laprascopically, there are # of methods for tubal occlusion, including: 1. bipolar fulguration 2. silastic banding w/ Falope rings 3. clipping w/ Hulka clips or Filshie clips

Risk of taking 2 OCPs/day

thromboembolic events used for short periods such as for EC and abnormal uterine bleeding

What has the Mirena IUD been found to do? Other LNG IUDs?

to decrease menorrhagia (90% less blood loss) and dysmenorrhea also as equally or more effective than oral progestins in treating: 1. endometriosis 2. benign endometrial hyperplasia 3. endometrial cancer protects from PID w/ lower rate of PID than found in women w/o -decreases # of surgeries (D&Cs, endometrial ablations, hysterectomies) needed for pelvic paina nd bleeding ~60% of women will experience amenorrhea while using MIrena IUD at 5 years -other LNG IUDs also reduce bleeding and dysmenorrhea in some capacity

persistent VMS

up to 25% of women will have persistent VMS, however, and other physiologic etiologies need to be ruled out highest reported incidence of VMS in AA, Causcasian, then Asian

Adolescent menstural cycle

usually irregular for first 1-2 yrs after menarche, reflecting anovulatory cycles on avg takes about 2 yrs after menarche before regular ovulartory cycles acheived (failure to achieve may = reproductive disorder)

success of reversal

varies from 41-84$ dependign on method used

How does vasectomy differ from female tubal ligations?

vasectomy is not immediately effective (unlike female tubal ligations) b/c sperm can remain viable in proximal collecting system after vasectomy, pts should use another form of contraception until azoospermia is confirmed by semed analysis (6-8 wks)

Pregnancy Rate w/ IUD use + what to do if intrauterine preg occurs?

very low, however, when pregnancy does occur, spontaneous abortion rate increased to 40-50% for women who become pregnant with an IUD in place given this, if intrauterine preg occurs while iud is in place, the device should be removed by gentle traction on the string

vaginal and urogenital atrophy tx

vuvlovaginal lubricants and moisturizers low-dose vaginal estrogen can have excellent local effects on vaginal and urethral atrophy with only minimal systemic absorption when used at low vaginal dosing, these estrogen sources do not require opposing progestin use in women with an intact uterus

When do menopause symptoms generally begin dissipate?

when estrogen and FSH levels stabilize about 2 years after the FMP

in who are OCPs contraindicated? What can be used for them?

women >35 yo who smoke 15 or more cigs/day these women often benefit from progesterone-only contraception (depo-provera, Nexplanon), hormonal and inert IUDs or permanent female or male sterilization

What should be done prior to performance of sterilzation?

women should be thoroughly counseled on the risk of regret, as well as alternatives such as vasectomy and LARCs

Who is ET reserved for?

women without intact uterus -use of unopposed estrogen is contraindicated in women with a uterus and requires addition of a suitable progestin to prevent increased incidence of EIN, endometrial hyperplasia, and endometrial cancer

Of women who undergo permanent sterilization, regret is highest in women who were....

younger than 30 yrs when procedure was performed however, estimated <2$ of women seek reversal

What % of reproductive-age couples in US and Great Britian choose female sterilization for contraception?

~30%