pharm exam 3 (GU/WH)

menopause

12 consecutive months of amenorrhea - diagnosed retrospectively - elevated FSH helps confirm

16, 18

2 strains of HPV cause 70% of all cervical cancers 90% of anal cancers & majority of oropharyngeal, vulvar/vaginal and penile cancer

6, 11

2 strains of HPV cause ~90% of anogenital warts

estrogen

HRT for menopause estrogen +/- progesterone if hysterectomy → ________ unpposed

estrogen, progesterone

HRT for menopause if uterus intact → ______ + _________ protects against endometrial cancer

10

HRT is safe for healthy, symptomatic women who are within _____ yrs of menopause or younger than 60 y/o who do not have contraindications to HRT/MHT WHI reported AE of HRT in women > 60

primary syphilis

STI 21 days after initial infection painless ulcer in mouth, genitals,rectum or skin chancre

secondary syphilis

STI 4-8 wks after primary infection ulcer appearance body rash, HA, fever, fatigue, lymphadenopathy

gonorrhea

STI all pregnant women should be screened @ first prenatal visit if at risk for ____ (< 25 y/o, hx STI, new/multiple partners, drug use, sex work) or living in high prevalence area

gonorrhea

STI sx may include vaginal discharge, postcoital bleeding, or dyspareunia but asymptomatic infection is most common annual screening for all sexually active women < 25 y/o recd

chlamydia

STI that accts for 1/3 of PID cases

episodic

_____ outbreak of HSV - fewer, less obvious lesions - may present w itching, vulvovaginal irritation or just vaginal fissures - same meds but for shorter amt of time

tinidazole

alternative med effective for metronidazole-resistant trichomoniasis

famciclovir

antiviral used in HSV 1 & 2 does not carry same concern for acute renal failure & crystal deposition in renal tubules but still use w caution in those w underlying renal impairment

valacyclovir

antiviral used in HSV 1 & 2 must hydrate well to prevent crystal deposition in renal tubules caution w renal failure

acyclovir

antiviral used in HSV 1 & 2 must hydrate well to prevent crystal deposition in renal tubules use caution w/ renal failure cheapest option but dosed most often

NAAT (nucleic acid amplification test)

chlamydia dx confirm w _____ on 1st catch urine or pt collects a vaginal swab can obtain endocervical specimen if speculum exam performed rectal & oropharyngeal swabs may also be performed

doxycycline

chlamydia treatment ________ 100mg orally 2 times/day for 7 days alternatives are azithromycin (1g single dose), levofloxacin (500mg QD for 7d)

azithromycin

chlamydia tx 1 gram dose PO may be given in office to be taken at time of presumptive diagnosis will cause GI upset (better taken w/ food, possible diarrhea)

doxycycline

chlamydia tx can cause gastric irritation, take w toast/crackers, may cause photosensitivity

expedited partner therapy

chlamydia tx, legal in VA can provide med/give rx for partner to take

jarisch herxheimer reaction

complication of syphilis acute, transient, systemic reaction to bacterial endotoxins and pyrogens that are released after initiation of antibiotic therapy flu like sx-fever, chills, HA, myalgia tachypnea, hypotension, tachycardia syphilitic exanthema may flare up self-limited w/i 12-24h

hormone replacement therapy

contraindications to this include: - undiagnosed vaginal bleeding - DVT/PE - CVA/TIA/MI: active or recent (w/in past yr) - active liver disease - estrogen dependent malignancy - breast cancer - endometrial cancer

PID

dx lower abdominal pain = cardinal presenting symptom usually bilateral and < 2 weeks duration

HSV type 2

dx? presentation- small, painful vesicles that are filled w fluid turning to shallow ulcerations on the genitalia dysuria, fever, tender local inguinal lymphadenopathy, HA local itching/tingling in prodromal phase; malaise, clear vag discharge may cause urinary retention

800

episodic outbreak therapy for HSV 1 & 2 - acyclovir _____ mg orally 2 times/day for 5 days or 3 times/day for 2 days

72

episodic outbreak therapy for HSV 1 & 2 ideally antivirals should be started asap after lesion appearance and within ______ hours however should still be offered if pts have ongoing development of new lesions and/or significant pain after this time frame acyclovir cheapest but is dosed more often

1

episodic outbreak therapy for HSV 1 & 2 valacyclovir ____ gm orally once daily for 5 days

500

episodic outbreak therapy for HSV 1 & 2 valacyclovir ______ mg orally 2 times/day for 3 days

estrogen

for HRT ______ replacement may help joint pains, body pain and reduced physical function (sx of menopause) also increases facial skin moisture & thickness, reduces seborrhea

transdermal

for HRT for women @ moderate risk of CVD they suggest ________ rather than oral estrogen for women w/ uterus - micronized progesterone (rather than MPA)

acyclovir

for HSV mothers may transmit virus to neonate during delivery C-section ______ 200-400 mg every 8 hours - 38 wks gestation til delivery minimize encephalitis risk

14

for PID after improvemenet on ceftriaxone, dozy and metro transition to oral doxy + metronidazole only to complete ______ days of therapy

ceftriaxone

for PID, if no hospitalization required or if its refused tx is _________ 500 mg IM in single dose PLUS doxy 100 mg orally BID for 14 days WITH metronidazole 500 mg orally 2 times/day for 14 days

1 cm

for condyloma acuminata (genital warts) tx patient applied topical therapy should be limited to 5 or less small warts and never for a wart > ______ ______

oral

for gonorrhea tx there are no acceptable ____ cephalosporins to treat it oral cefixime can be used but not preferred

NSAIDs

for jarisch herxheimer reaction (complication after initiation of antibiotics for syphilis) treatment for symptoms is what

vaginal

for menopause tx ______ preparations of estrogen achieve low dose concentrations - useful for atrophic vaginitis or CI to systemic estrogen - concomitant progesterone usually unnecessary (for intact uterus)

6-12

for pt admin therapy for genital warts if no response to initial therapy after ~3 weeks or complete clearance has not occurred by ______ wks, switch therapies

pregnancy

for pt counseling on topicals to tx genital warts - do thin layer, wash hands after use, avoid inside vagina, urethra or rectum - do not occlude (but underwear/gauze ok) - do not apply to open wounds - may weaken condoms or diaphragms not for use in what?

non-treponemal

for syphilis dx more common to order a treponemal assay first and use a _______ test as confirmation

gentamicin

gonorrhea alternative regimen if ceftriaxone not available _______ 240 mg IM single dose PLUS azithromycin 2g orally in single dose OR cefixime 800mg orally in single dose

ceftriaxone

gonorrhea treatment _________ 500mg IM in single dose if < 150 kg (1g if over that weight) (tx for chlamydia if not excluded - w/ doxy)

antivirals

group MOA inhibit replication of HSV 1 & HSV 2 also used for VZV, CMV all tolerated very well common SE: ha, NAUSEA

HRT

in 2002 (women's health initiative) this treatment showed to cause increase risk of: breast cancer, heart disease, stroke, blood clots and urinary incontinence - risk outweighed benefit

3-5

increased risk for breast cancer with combined HRT for > _____ years ET alone w/out a uterus for up to 7 years does not increase risk

7-10

initial outbreak of HSV is treated with _______ of antiviral therapy & condom use for 12 mos (w/ uninfected partner) advised after 1st outbreak

metronidazole (and tinidazole, ornidazole)

med for trichomonas MOA violation of DNA replication & protein synthesis in microbial cells, by inhibiting tissue respiration bactericidal covers anaerobes, bacteroides, clostridium, protozoa, h pylori

hormone replacement therapy (or menopausal hormone therapy)

most effective option for alleviating vasomotor and vaginal symptoms of menopause must be individualized (topical or systemic options) estrogen +/- progesterone

estrogen

part of hrt - decreases bone resorption - decr LDL, incr HDL, increase triglycerides - increases risk of gallstones - enhances coagulability (if oral)

estrogen

part of hrt metabolized by intestinal mucosa & liver (CYPA3A4), extensive 1st pass metabolism (can avoid that w/ patch or topical - having less effect on lipids and coagulation)

trichloroacetic acid (80-90%)

provider administered therapy for genital warts caustic acid that destroy the wart tissue via chemical coagulation safe in pregnancy repeat weekly for 4-6 wks 70% clearance rate (bichloracetic acid less commonly used)

surgical removal

provider administered therapy for genital warts laser ablation or excision for larger, thicker lesions

intralesional interferon

provider administered therapy for genital warts not commonly used unless in conjunction w surgery

cryotherapy with liquid nitrogen

provider administered therapy for genital warts repeated weekly until resolution painful, location irritation/inflammation after use local anesthesia for larger areas

5% cream

pt admin therapy for genital warts for imiquimod _____ ______: systemic SE of HA, muscle aches, fatigue, general malaise are possible

imiquimod 3.75% or 5% (Aldara)

pt admin therapy for genital warts, cream immune response modifier apply @ bedtime 3x/week for max of 16 wks wash area 6-10 hours after applying SE hypopig, redness, irritation

sinecatcehins 15% (Veregan)

pt admin therapy for genital warts, ointment green tea leaf substance-keratolytic apply 3x/day for max of 16 wks do NOT wash off SE: redness, irritation, burning or pain

sinecatechins (15% ointment)

pt administered therapy for genital warts this ointment is contraindicated in patients w/ HIV or HSV

vasomotor symptoms

relief of menopause ________ ________ non pharm therapies: - cognitive behavioral therapy - clinical hypnosis - mindfulness based stress reduction - wt loss - cooling technique - exercise (aerobic training 50 min 4x/wk) - yoga

gallbladder disease (incr risk of gallstones)

risk for estrogen HRT d/t increased cholesterol secretion in bile

thromboembolism

risk for estrogen HRT dose related? both combined HRT and ET alone increase risk particularly in first 1-2y of use patch, topical vaginal application LESS likely

cardiovascular disease

risk of estrogen HRT age and time since menopause are critical modifiers more favorable effects if 50-59 and w/in 10 years of menopause at treatment initiation

podofilox 0.5% (Condylox)

solution or gel, pt admin therapy for genital warts keratolytic, cheap apply 2x/day for 3 days, then 4 days off & repeat cycle max 4 times until warts resolve no more than 0.5 mL of this should be applied/day SE: mild to mod local pain or irritation

treponemal

syphilis diagnosis requires 2 tests one ______ test: - FTA-ABS - antibody assay - used as confirmatory test when non-treponemal test is positive more ocmplex and expensive

non-treponemal

syphilis diagnosis requires 2 tests one ________ test: - venereal disease laboratory (VDRL) - rapid plasma reagin (RPR) test

3

syphilis tx is 2.4 million units of benzathine penicillin G given IM once if neurosyphilis is diagnosed, give dose weekly _____ times

7

to minimize dz transmission ppl treated for chlamydia should abstain from intercourse for ____ days after single dose therapy or until completion of 7 day regimen and resolution of sx if present abstain til partners have been treated should also test for HIV, gonorrhea, syphilis

ceftriaxone, doxy, metronidazole

treatment for PID ________ 1g IV every 24 hours PLUS ______ 100mg orally or IV every 12 hours PLUS _______ 500 mg orally or IV every 12h

penicillin G

treatment for syphilis 2.4 million units of benzathine ______ _____ given IM once (benzathine is stabilizer, releases pcn slowly)

imiquimod

tx for genital warts 5% individual use packets cheapest 3.75% less likely to cure than 5% but is better tolerated w/ likely better compliance and shorter course

podofilox

tx for genital warts, generic is cheapest, gel (Condylox) more expensive gel vs solution equally effective

hormone replacement therapy

tx for menopause - relieves GU atrophy, relieves vasomotor instability - reduction in hip & vertebral fractures - lowers LDL, increases HDL - colon cancer reduction (w/ combined)

metronidazole

tx for trichomoniasis SE unpleasant metallic taste, darkened urine, disulfiram like rxn (rare: reversible neutropenia, urticaria, rash, flushing, dry mouth) no renal or hep adjustments

metronidazole

tx for trichomoniasis ________ 500 mg PO BID x 7 days or 2 gm PO once treat sexual partners too (expedited partner therapy)

metronidazole

tx for trichomoniasis caution in pregnancy possible increased cleft palate risk if given in first trimester, concern for carcinogenic properties, CDC still rec for pregnant women

400

tx option for initial outbreak HSV 1 & 2 acyclovir ______ mg orally 3 times/day for 7-10 days

1

tx option for initial outbreak HSV 1 & 2 valacyclovir ____ gm orally 2 times/day for 7-10 days

estrogens

type of HRT common AE N, HA, bloating, breast tenderness, breakthrough uterine bleeding serious: coronary heart dz, stroke, VTE, breast cancer, gallbladder dz

estrogen

type of HRT increases risk of endometrial cancer (progestogen is protective) DO NOT give systemic_______ w/o a progestin when uterus is present low dose topical, vaginal application does not require a progesterone component tho

estrogens

type of HRT indicated in mod-severe VMS and vulvovaginal atrophy associated w/ menopause prevention of post-menopausal osteoporosis in women w significant risk (but therapies w/o this are preferable) oral, transderm, topical, intravaginal

estrogen

type of HRT usual dose is oral 1 mg/day or transdermal 0.05 mg/day - pre-menopausal women s/p bilateral oophorectomy: 2mg or 0.1 mg transdermal no real standard, start low and titrate up

type 2

type of HSV spreads typically through sexual contact and causes genital herpes

type 1

type of HSV typically spreads thru oral-oral contact and causes cold sores increasing prevalence of this type is causing genital herpes

suppressive therapy

type of HSV therapy used to prevent sexual transmission of HSV to an uninfected partner or for a pt w/ frequent and sever eoutbreaks reduces frequency of genital herpes recurrences acyclovir, valacyclovir, famciclovir

oral

type of estrogen HRT products - conjugated estrogens (Premarin) - esterified estrogens - estradiol - estropipate

topical

type of estrogen HRT products - conjugated estrogens (Premarin) - estradiol (estrace) - estradiol gel - estradiol spray (Evamist)

vaginal inserts

type of estrogen HRT products - estradiol (Estring) - estradiol acetate (Femring) - estradiol (Vagifem)

transdermal

type of estrogen HRT products - estradiol patch

topical

type of estrogen HRT products for moderate-severe VMS (+/- urogenital sx) - 17 b-estradiol emulsion, gel, or transdermal spray

transdermal patch

type of estrogen HRT products for moderate-severe VMS (+/- urogenital sx) - 17 b-estradiol patch

oral

type of estrogen HRT products for moderate-severe VMS (+/- urogenital sx) - conjugated equine estrogens - synthetic conjugated estrogens - esterified estrogens - estropipate - estradiol acetate - micronized 17 b-estradiol (Estrace)

vaginal

type of estrogen HRT products for moderate-severe VMS (+/- urogenital sx) estradiol acetate (ring)

NAAT

type of test for gonorrhea rec'd by CDC for deteching infection

non-hormonal

type of therapy for menopause that is suggested for symptomatic women @ high risk for CVD or moderate-high risk for breast cancer

gardasil 9 vaccine

vaccine that targets HPV type 6, 11, 16, 18, 31, 33, 45, 52, 58 routine vax rec'd at 11-12 years (M & F) - can be administered starting at 9 2 doses given, 2nd dose is 6-12 months after the first

gonorrhea

very common to see chlamydia co-infection with what other STI?

HSV type 2

virus 1st outbreak is usually the worst (2-4 wks to resolve) outbreaks can recur throughout life tx: decrease symptoms, shorten course of painful vesicles/ulcers, decrease viral shedding and prevent spread to an uninfected partner

HSV

virus no cure, no vaccine spread thru mucosal contact or open herpes lesion pts w/ asymptomatic or unrecognized genital _____ infections will still shed virus intermittently in the genital tract

5

women w menopausal sx (usually 40s-50s) - absolute risk of complications of taking MHT for _____ years is very low