12. Reproductive.pptx Study review for naplex

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1. Men’s and Women’s Health Presented by Lee Roy A Esposo

2. Topics Covered Contraception & Infertility Drug Use in Pregnancy and Lactation Osteoporosis, Menopause, & Testosterone Use Sexual Dysfunction Benign Prostatic Hyperplasia Urinary Tract Infection

3. Background Menstrual Cycle Follicular, Ovulatory, Luteal Preconception Folic Acid Smoking Vaccinations

4. Contraception

5. Contraception Prompt return to fertility once discontinued Only reversible contraceptive that has delay in return to fertility is injectable medroxyprogesterone Male options are limited Barrier Sterilization

6. Non-Pharm 100% way to prevent pregnancy and STDs Temperature/Cervical Mucus Methods Barrier Methods Diaphragm Condoms Spermicide Nonooxynol-9

7. Hormonal contraceptives How do they work? POP COC CHC

8. Combined Oral Contraceptives Most contain EE and a progestin Drospirenone Monophasic vs others Other Indications Can contain inactive pills

9. Other COC indications Dysmenorrhea PMS Acne Anemia Regulation of menses PCOS Endometriosis

10. Progestin Only No inactive pills Suppress ovulation Thicken cervical mucus Pregnancy and breastfeeding Need good adherence OK in migraine with aura

11. Non-Oral Hormonal Contraceptives Patch Ring Injectable IUD This Photo by Unknown Author is licensed under CC BY-NC-ND

12. Adverse Effects - COC Nausea, breast tenderness, bloating, weight gain, elevated blood pressure Thrombosis Heart attack Stroke DVT/PE Increase risk of severe adverse events Prolonged bed rest Overweight High Estrogen Exposure

13. Adverse Events - POP Breast tenderness, headache, fatigue, mood changes Break through bleeding Drospirenone Higher risk of clot Increased potassium DNU in kidney, liver or adrenal disease Monitor K Injectable medroxyprogesterone acetate Loss of BMD

14. Long Acting Reversible Intra Uterine Devices 3-5 years Progestin Copper-T IUD Can be used as EC The implant 3 years Progestin

15. Emergency Contraceptives Non-Hormonal Copper IUD Effective if inserted within 5 days Oral Levonorgestrel 89% effective if taken within 72 hours Delay ovulation/thicken cervical mucus Ulipristal acetate Delay ovulation Cousin to RU-486 bit different MOA

16. Infertility Defined as not being able to get pregnant after one year or longer of unprotected sex First line – clomiphene SERM Gonadotropins Includes hCG or GnRHA Trigger ovulation Given IM or SC Multiple eggs

17. Pregnancy and lactation

18. What do when Pregnant? Lifestyle management Behavioral interventions Tobacco cessation Vitamin and mineral supplementation Folate Vitamin D Calcium

19. What do? Part deux Immunizations Influenza TDAP Avoid teratogens See page 691 Brigg’s Pregnancy and Lactation Preeclampsia Usually presents after the first trimester Low dose ASA

20. Lactation Recommended for first 6 months of life if mutually desired May need additional Vit D and iron supplementation If HIV+ breastfeeding is not recommended Drugs that get excreted in breast milk Non-ionized, low molecular weight, lipophilic low Vd Pain APAP and IBU = ok No codeine or tramadol

21. Osteoporosis, Menopause, & Testosterone

22. OSTEOPOROSIS

23. Osteoporosis Porous Bones Common in postmenopausal women Vertebral fractures can be most common Can occur without fall Common over 74 years of age Wrist fracture common in younger people Earlier indicator of poor health

24. Risk Factors-page 696 Can be age related Ethnicity Low body weight Anorexia Menopause Hyperthyroidism RA and autoimmune diseases Gastro diseases Smoking Excessive alcohol intake Low calcium Low vitamin D Physical inactivity PPIs Anticonvulsants steroids

25. Diagnosis Bone Mineral Density – BMD Gold standard – DEXA Scan Measures BMD of hip and spine T-Score Calculated from DEXA scan Who should get one? Women 65 and older Men 70 and older FRAX 10 year risk This Photo by Unknown Author is licensed under CC BY-SA-NC

26. How do to stop bone loss? Fall Prevention Lifestyle Exercise Calcium and Vitamin D This Photo by Unknown Author is licensed under CC BY-NC-ND

27. Calcium and Vitamin D Adequate intake required Dietary preferred Vitamin D required for Calcium absorption Rickets and Osteomalacia Exogenous absorption is saturable Sunlight This Photo by Unknown Author is licensed under CC BY-SA-NC

28. Drug Treatment Prevention Bisphosphonates Estrogen-based therapies Raloxifene Treatment Bisphosphonates Denosumab Parathyroid hormone This Photo by Unknown Author is licensed under CC BY-SA

29. When to treat? Osteoporosis Presence of a fragility fracture OR Postmenopausal women or men age 50 or older T-score ≤ -2.5 Osteopenia if high risk Low bone density T-Score -1 to -2.5 AND FRAX score indicates ≥ 10% risk or osteoporosis related fracture or ≥ 3% hip fracture

30. Counseling Points – All

31. Counseling Points Bisphosphonates Take in morning Must stay upright for at least 30 minutes Separate from multivitamins and mineral supplements Can cause dyspepsia Missed dose instructions Vary depending on daily, weekly, or monthly This Photo by Unknown Author is licensed under CC BY-SA

32. Counseling Points Raloxifene Can cause blood clots Discontinue at least 72 hours prior to and during prolonged immobilization This Photo by Unknown Author is licensed under CC BY

33. Counseling Points Parathyroid Hormones Teriparatide and Abaloparatide Dizziness Orthostasis This Photo by Unknown Author is licensed under CC BY-SA

34. Counseling Points Calcitonin

35. Menopause Last menstrual period was 1 year ago Usually occurs between 40– 50 years of age Can be earlier or later Vasomotor Symptoms (VMS) Hot flashes Night sweats Mood changes Vaginal dryness Painful intercourse This Photo by Unknown Author is licensed under CC BY-NC-ND

36. Hormonal treatments Most effective for VMS Estrogen Transdermal Local Preferred for vaginal symptoms Hormonal or lube Low-dose oral This Photo by Unknown Author is licensed under CC BY-NC-ND

37. Natural Products Black Cohosh Evening primrose oil Red clover Soy Flaxseed Dong quai St. John’s Wort Chastberry

38. Non-Hormonal Treatments Paroxetine – FDA approved for VMS symptoms Lower dose than depression CY2D6 SNRI, clonidine, gabapentinoids Not FDA approved Ospemifene Oral estrogen agonist/antagonist Not for mild symptoms

39. Hypogonadism in males Age related or secondary to medical cause Medications that lower testosterone Opioids Chemotherapy Cimetidine Spironolactone This Photo by Unknown Author is licensed under CC BY-SA

40. Testosterone Variety of uses Increased risk of clotting Increased hematocrit Can enlarge prostate Potential for abuse Formulations Injectable, topical, transdermal, buccal This Photo by Unknown Author is licensed under CC BY-SA

41. Sexual Dysfunction

42. Sexual dysfunction in women Inability to reach orgasm Painful intercourse Hypoactive sexual desire disorder Two FDA approved drugs Flibanserin Bremelanotide Premenopausal only

43. Sexual Dysfunction in women - Drugs Filbanserin Agonist – 5-HT1A Antagonist – 5-HT2A Contraindicated with alcohol or strong CYP3A4 REMS Bremelanotide Melanocortin agonist Contraindicated – uncontrolled HTN, known cardiovascular disease

44. Erectile Dysfunction Difficulty getting or sustaining an erection that is firm enough for sex Common cause – reduced blood flow to the penis Common with comorbidities Psychological issues Neurological illness Medications This Photo by Unknown Author is licensed under CC BY-ND

45. Medications that can cause ED

46. Non-Drug Treatment Lifestyle changes Weight loss Quitting tobacco Reduce alcohol Natural Products Yohimbe L-arginine Panax Treatment of underlying disease

47. Drug Treatment First line PDE-5 Sildenafil, vardenafil, tadalafil, avanafil Titrated to effect Can be used for other conditions Oral, injection, suppository

48. Benign Prostatic Hyperplasia

49. Benign Prostatic Hyperplasia (BPH) Overgrowth of prostate Can look like LUTS Bladder outlet obstruction Symptoms impact QOL but rarely causes serious symptoms Similar symptoms to prostate cancer

50. Treatment Treatment guided by symptom relief Mild – watchful waiting Moderate/Severe Medications Surgery Transurethral resection of the prostate TURP This Photo by Unknown Author is licensed under CC BY-SA

51. Drug Treatment Alpha blockers Used alone or in combo with 5 alpha-reductase inhibitors 5 alpha-reductase inhibitors Decrease size of prostate PDE-5 inhibitors With or without finasteride

52. Alpha Blocker First Line Relaxation of smooth muscle in prostate Reduces outlet obstruction and improves urinary flow Alpha-1 primarily in prostate Floppy iris syndrome Alpha-1 in the iris Pupils do not dilate well Delay alpha blocker until cataract surgery complete

53. 5 alpha-reductase inhibitors Blocks conversion of testosterone to dihydrotestosterone Improve symptoms Decrease risk of acute urinary retention Decrease need for surgery Contraindicated women of child-bearing age May require 6 months of treatment for maximal efficacy

54. PDE-5 Tadalafil only one with FDA approval for BPH How it works – not well known Should not used in combination with alpha-blocker Do not use with nitrates Impaired color vision Vision loss

55. Urinary Incontience

56. Overactive Bladder ~30% - 40% Affects more women than men Overactive bladder is not a disease Describes a group of urinary symptoms Urgency Incontinence Frequency Dry Vs. Wet

57. Overactive bladder

58. First Line Therapy “First line treatment” Change voiding habits Bladder training, delayed voiding, fluid restriction Bladder outlet Pelvic floor muscle training, exercise No one technique is considered superior to the other

59. Medication Therapy Antimuscarinic Target: M3 receptor Inhibits bladder contraction Inhibits relaxation of sphincter muscles Beta-3 agonists Target: Beta-3 receptor Inhibits bladder contraction OnaboulinumtoxinA 3 rd Line Stops release of ACh

60. Thank you Lee Roy A. Esposo Washington State University Class of 2021