NR566 Final Exam Study Guide
Week 5
- Prevention of osteoporosis with hormone replacement therapy Tara (p.433)
Hormone therapy reduces postmenopausal bone loss and thereby decreases the risk for
osteoporosis and related fractures. Therapy is lifelong and the risk for harm is increased.
Hormone therapy should only be considered for women with significant risk for osteoporosis,
and only when that risk outweighs the risks of hormone therapy. Meds are: raloxifene (Evista),
bisphosphonates (e.g., alendronate {Fosamax}), calcitonin (Miacalin), and teriparatide (Forteo).
Encourage patients to prevent bone loss by ensuring adequate intake of calcium and Vit D,
performing regular weight-bearing exercises, and avoiding smoking and excessive alcohol use.
- When and when not to use progestin for hormone replacement therapy and why Tara
(p.430-432)
When: Menopausal hormone therapy
Why: The primary noncontraceptive use of progestins is to counteract the adverse
effects of estrogen on the endometrium in women undergoing menopausal HT.
When: Dysfunctional uterine bleeding
Why: Heavy irregular bleeding that occurs when progesterone levels are insufficient to
balance the stimulatory influence of estrogen on the endometrium. Treatment goals with
administration of progestins are to stop the bleeding and establish a regular monthly
cycle.
When: Amenorrhea
Why: Progestins can induce menstrual flow in selected women who are experiencing
amenorrhea.
When: Endometrial hyperplasia and carcinoma
Why: Progestins can provide palliation in women with metastatic endometrial carcinoma, but
they do not prolong life. Endometrial hyperplasia, a potentially precancerous condition,
can be suppressed with progestins. Benefits derive from counteracting the proliferative
effects of estrogen.
When: Other uses - Supports early pregnancies, prevention of preterm birth (Makena)
Why: Progestins can be used to support early pregnancy in women with corpus luteum
deficiency syndrome and in women undergoing in vitro fertilization (IVF). One progestin
(hydroxyprogesterone acetate (Makena) is approved for preventing preterm birth in
women with a singleton pregnancy and a history of preterm delivery.
When not to: Women with no uterus
Why: Do not prescribe progestins to women who have undergone a hysterectomy.
,- Local vs. systemic estrogen options and why one would be chosen over the other Tara
Intravaginal: Estrogens for intravaginal administration are available as inserts, creams, and
vaginal rings. The intravaginal inserts (Imvexxy, Vagifem, Yuvafem), creams (Estrace Vaginal,
Premarin Vaginal), and one of the two available vaginal rings (Estring) are used only for local
effects, primarily treatment of vulval and vaginal atrophy associated with menopause.
The other vaginal ring (Femring) is used for systemic effects (e.g., control of hot flashes and
night sweats) as well as local effects (e.g., treatment of vulval and vaginal atrophy).
Parenteral: Although estrogens are formulated for intravenous (IV) and intramuscular (IM)
administration, use of these routes is rare. IV administration is generally limited to acute,
emergency control of heavy uterine bleeding.
- Transdermal estrogen therapy has fewer adverse effects Tara
Compared with oral formulations, the transdermal formulations have four advantages:
• The total dose of estrogen is greatly reduced (because the liver is bypassed).
• There is less nausea and vomiting.
• Blood levels of estrogen fluctuate less.
• There is a lower risk for DVT, pulmonary embolism, and stroke.
- Management of oral contraceptives (OCs) Jennifer Jacques
o How to change patients from one combination of oral contraceptives to another.
When one combination OC is being substituted for another, the change is best made at the
beginning of a new cycle. Pg 440
o How to initiate treatment (when in the cycle is it best to start- may vary based on
type of contraceptive)
The 28-day regimens are subdivided into four groups: monophasic, biphasic, triphasic, and
quadriphasic (four-phasic) (see Table 51.5). In a monophasic regimen, the daily doses of
estrogen and progestin remain constant throughout the cycle of use. In the other regimens, the
estrogen, progestin, or both change as the cycle progresses. The biphasic, triphasic, and
quadriphasic schedules reflect efforts to more closely simulate ovarian production of estrogens
and progestins. However, these preparations appear to offer little or no advantage over
monophasic OCs.
Most 28-day cycle products are taken in a repeating sequence consisting of 21 days of an active
pill followed by 7 days on which either (1) no pill is taken, (2) an inert pill is taken, or (3) an iron-
containing pill is taken. The sequence begins on either the first day of the menstrual cycle or the
first Sunday after the onset of menses. With the first option, protection is conferred
,immediately; hence no backup contraception is needed. With a Sunday start, which is done to
have menses occur on weekdays rather than the weekend, protection may not be immediate;
hence an alternate form of birth control should be used during the first 7 days of the pill pack.
With both options, each dose should be taken at the same time every day (e.g., with a meal or
at bedtime). Successive dosing cycles should commence every 28 days even if there is
breakthrough bleeding or spotting. Pg 441
o What teaching needs to be done
Educate patients on proper protocol for missed doses (depending on medication type and
cycle). Effectiveness of oral contraceptives can be reduced with some medications, including
certain common antibiotics. Pg 446
o What baseline data is needed?
Assess for history of hypertension, diabetes, thromboembolism, cerebrovascular or
cardiovascular disease, breast cancer. Urine pregnancy test. Pg 446
o Contraindications for OCs
Contraindications to use include current pregnancy, history of thromboembolus, breast cancer,
and women over 35 years of age who continue to smoke tobacco. Use with caution in women
with diabetes, hypertension, and cardiac disease. Pg 446
- How to achieve an extended cycle with oral contraceptives Jennifer Jacques
To achieve an extended schedule, the user would simply purchase four packets of a 28-day
product (each of which contains 21 active pills) and then take the active pills for 84 days
straight. Pg 442
- What behaviors would make one birth control method more effective over another? Akunna
Aguwa
o Be able to evaluate a patient scenario and suggest an appropriate birth control method
(type of prescribed contraception: OC, long-term methods, IUD, etc)
, Page 437-438: Among women of higher weight oral contraceptive’s efficacy is somewhat
reduced. Possible reasons include decreased blood levels of the hormones, sequestration in
adipose tissue, and altered metabolism. Combination oral should be avoided by women with
certain cardiovascular disorders as well as by women older than 35 years old who smoke. An
alternative method is preferred: diaphragm, progestin-only pill, or IUD.
- What effect does CYP450 inhibitors or inducers have on OCs? Akunna Aguwa
o Recall examples of CYP450 inhibitors and inducers from NR565 (Chapter 4 in textbook) o
How does this impact prescribing of OCs?
Page 441: CYP450 inducers like Phenytoin, carbamazepine, Rifampin, alcohol and sulfonylureas
can accelerate OC metabolism and thereby reduce OC effects. Women taking OC in combination
with any of these agents should be alert for indications of reduced OC blood levels, such as
breakthrough bleeding or spotting. It may be necessary to either:
1. Increase the estrogen dosage of the OC.
2. Combine the OC with a second form of birth control.
3. Switch to an alternative form of birth control.
OC’s can decrease the benefits of warfarin and hypoglycemic agents. When combined with OC
warfarin and hypoglycemic agents may require increased dosage.
OC’s can impair the hepatic metabolism of several agents, including theophylline, tricyclic
antidepressants, diazepam, and chlordiazepoxide. They may accumulate to toxic levels, with
signs of toxicity doses of these drugs should be reduced.
- Benefits and drawbacks of progestin-only contraception Krystal Paz Alvarez
Pg. 442
Benefits for progestin-only: do not cause thromboembolic disorders, headaches, nausea, or
most of the other adverse effects associated with combo OCs.
Drawbacks: Less effective and are more likely to cause irregular bleeding (breakthrough
bleeding, spotting, amenorrhea, inconsistent cycle length, variations in volume and duration of
monthly flow). Must take the pill at the same time very day for effectiveness. Even taking it a
few hours late can reduce their efficacy and a use of back up protection or emergency
contraception is recommended.
Guidelines for missed pill:
-if one pill is missed, must be taken as soon as remembered and backup contraception should
be used for at least 2 days. Pills should be resumed as scheduled on the next day
Week 5
- Prevention of osteoporosis with hormone replacement therapy Tara (p.433)
Hormone therapy reduces postmenopausal bone loss and thereby decreases the risk for
osteoporosis and related fractures. Therapy is lifelong and the risk for harm is increased.
Hormone therapy should only be considered for women with significant risk for osteoporosis,
and only when that risk outweighs the risks of hormone therapy. Meds are: raloxifene (Evista),
bisphosphonates (e.g., alendronate {Fosamax}), calcitonin (Miacalin), and teriparatide (Forteo).
Encourage patients to prevent bone loss by ensuring adequate intake of calcium and Vit D,
performing regular weight-bearing exercises, and avoiding smoking and excessive alcohol use.
- When and when not to use progestin for hormone replacement therapy and why Tara
(p.430-432)
When: Menopausal hormone therapy
Why: The primary noncontraceptive use of progestins is to counteract the adverse
effects of estrogen on the endometrium in women undergoing menopausal HT.
When: Dysfunctional uterine bleeding
Why: Heavy irregular bleeding that occurs when progesterone levels are insufficient to
balance the stimulatory influence of estrogen on the endometrium. Treatment goals with
administration of progestins are to stop the bleeding and establish a regular monthly
cycle.
When: Amenorrhea
Why: Progestins can induce menstrual flow in selected women who are experiencing
amenorrhea.
When: Endometrial hyperplasia and carcinoma
Why: Progestins can provide palliation in women with metastatic endometrial carcinoma, but
they do not prolong life. Endometrial hyperplasia, a potentially precancerous condition,
can be suppressed with progestins. Benefits derive from counteracting the proliferative
effects of estrogen.
When: Other uses - Supports early pregnancies, prevention of preterm birth (Makena)
Why: Progestins can be used to support early pregnancy in women with corpus luteum
deficiency syndrome and in women undergoing in vitro fertilization (IVF). One progestin
(hydroxyprogesterone acetate (Makena) is approved for preventing preterm birth in
women with a singleton pregnancy and a history of preterm delivery.
When not to: Women with no uterus
Why: Do not prescribe progestins to women who have undergone a hysterectomy.
,- Local vs. systemic estrogen options and why one would be chosen over the other Tara
Intravaginal: Estrogens for intravaginal administration are available as inserts, creams, and
vaginal rings. The intravaginal inserts (Imvexxy, Vagifem, Yuvafem), creams (Estrace Vaginal,
Premarin Vaginal), and one of the two available vaginal rings (Estring) are used only for local
effects, primarily treatment of vulval and vaginal atrophy associated with menopause.
The other vaginal ring (Femring) is used for systemic effects (e.g., control of hot flashes and
night sweats) as well as local effects (e.g., treatment of vulval and vaginal atrophy).
Parenteral: Although estrogens are formulated for intravenous (IV) and intramuscular (IM)
administration, use of these routes is rare. IV administration is generally limited to acute,
emergency control of heavy uterine bleeding.
- Transdermal estrogen therapy has fewer adverse effects Tara
Compared with oral formulations, the transdermal formulations have four advantages:
• The total dose of estrogen is greatly reduced (because the liver is bypassed).
• There is less nausea and vomiting.
• Blood levels of estrogen fluctuate less.
• There is a lower risk for DVT, pulmonary embolism, and stroke.
- Management of oral contraceptives (OCs) Jennifer Jacques
o How to change patients from one combination of oral contraceptives to another.
When one combination OC is being substituted for another, the change is best made at the
beginning of a new cycle. Pg 440
o How to initiate treatment (when in the cycle is it best to start- may vary based on
type of contraceptive)
The 28-day regimens are subdivided into four groups: monophasic, biphasic, triphasic, and
quadriphasic (four-phasic) (see Table 51.5). In a monophasic regimen, the daily doses of
estrogen and progestin remain constant throughout the cycle of use. In the other regimens, the
estrogen, progestin, or both change as the cycle progresses. The biphasic, triphasic, and
quadriphasic schedules reflect efforts to more closely simulate ovarian production of estrogens
and progestins. However, these preparations appear to offer little or no advantage over
monophasic OCs.
Most 28-day cycle products are taken in a repeating sequence consisting of 21 days of an active
pill followed by 7 days on which either (1) no pill is taken, (2) an inert pill is taken, or (3) an iron-
containing pill is taken. The sequence begins on either the first day of the menstrual cycle or the
first Sunday after the onset of menses. With the first option, protection is conferred
,immediately; hence no backup contraception is needed. With a Sunday start, which is done to
have menses occur on weekdays rather than the weekend, protection may not be immediate;
hence an alternate form of birth control should be used during the first 7 days of the pill pack.
With both options, each dose should be taken at the same time every day (e.g., with a meal or
at bedtime). Successive dosing cycles should commence every 28 days even if there is
breakthrough bleeding or spotting. Pg 441
o What teaching needs to be done
Educate patients on proper protocol for missed doses (depending on medication type and
cycle). Effectiveness of oral contraceptives can be reduced with some medications, including
certain common antibiotics. Pg 446
o What baseline data is needed?
Assess for history of hypertension, diabetes, thromboembolism, cerebrovascular or
cardiovascular disease, breast cancer. Urine pregnancy test. Pg 446
o Contraindications for OCs
Contraindications to use include current pregnancy, history of thromboembolus, breast cancer,
and women over 35 years of age who continue to smoke tobacco. Use with caution in women
with diabetes, hypertension, and cardiac disease. Pg 446
- How to achieve an extended cycle with oral contraceptives Jennifer Jacques
To achieve an extended schedule, the user would simply purchase four packets of a 28-day
product (each of which contains 21 active pills) and then take the active pills for 84 days
straight. Pg 442
- What behaviors would make one birth control method more effective over another? Akunna
Aguwa
o Be able to evaluate a patient scenario and suggest an appropriate birth control method
(type of prescribed contraception: OC, long-term methods, IUD, etc)
, Page 437-438: Among women of higher weight oral contraceptive’s efficacy is somewhat
reduced. Possible reasons include decreased blood levels of the hormones, sequestration in
adipose tissue, and altered metabolism. Combination oral should be avoided by women with
certain cardiovascular disorders as well as by women older than 35 years old who smoke. An
alternative method is preferred: diaphragm, progestin-only pill, or IUD.
- What effect does CYP450 inhibitors or inducers have on OCs? Akunna Aguwa
o Recall examples of CYP450 inhibitors and inducers from NR565 (Chapter 4 in textbook) o
How does this impact prescribing of OCs?
Page 441: CYP450 inducers like Phenytoin, carbamazepine, Rifampin, alcohol and sulfonylureas
can accelerate OC metabolism and thereby reduce OC effects. Women taking OC in combination
with any of these agents should be alert for indications of reduced OC blood levels, such as
breakthrough bleeding or spotting. It may be necessary to either:
1. Increase the estrogen dosage of the OC.
2. Combine the OC with a second form of birth control.
3. Switch to an alternative form of birth control.
OC’s can decrease the benefits of warfarin and hypoglycemic agents. When combined with OC
warfarin and hypoglycemic agents may require increased dosage.
OC’s can impair the hepatic metabolism of several agents, including theophylline, tricyclic
antidepressants, diazepam, and chlordiazepoxide. They may accumulate to toxic levels, with
signs of toxicity doses of these drugs should be reduced.
- Benefits and drawbacks of progestin-only contraception Krystal Paz Alvarez
Pg. 442
Benefits for progestin-only: do not cause thromboembolic disorders, headaches, nausea, or
most of the other adverse effects associated with combo OCs.
Drawbacks: Less effective and are more likely to cause irregular bleeding (breakthrough
bleeding, spotting, amenorrhea, inconsistent cycle length, variations in volume and duration of
monthly flow). Must take the pill at the same time very day for effectiveness. Even taking it a
few hours late can reduce their efficacy and a use of back up protection or emergency
contraception is recommended.
Guidelines for missed pill:
-if one pill is missed, must be taken as soon as remembered and backup contraception should
be used for at least 2 days. Pills should be resumed as scheduled on the next day
