Women's Health: PCOS, Hypertension, and Hyperlipidemia

TOPIC III: MEN'S AND WOMEN'S HEALTH
Introduction
Each medication prescribed during pregnancy and lactation should be scrutinized via drug information resources for adverse effects during pregnancy / lactation, with particular attention paid to the timing of the drug's administration (early, mid, or late pregnancy, or timing of doses in relation to expression of milk/infant feeding).Pre-pregnancy planning is strongly encouraged for patients with chronic conditions and on medications. There is a need to ascertain if there are safer alternative medications available as well as examining the overall necessity of continued therapy during pregnancy.
All practitioners should be familiar with drug that are absolutely contraindicated in pregnancy (drugs which have proven teratogenic effects - Category X drugs), such as statins, ACE inhibitors/ARBs, many anticonvulsants, isotretinoin, lithium, NSAIDS, and warfarin (see table 47-3 in PPP). Many of these drugs are quite common and women of childbearing age should be counseled on possible pregnancy consequences if they take these drugs.
Christina L. Wichman, DO, FACLP - ppt download
Medication use during pregnancy and lactation is challenging - patients with chronic conditions must be managed and acute issues requiring medication must be addressed as well. Patients must also be counseled with regard to over the counter medication use during pregnancy and lactation. Although many of these patients are also managed by specialists in obstetrics / gynecology, primary care practitioners should be familiar with the chronic and acute medications which pose risks in pregnancy and lactation.
There are many options available for medical contraception. Women may require a trial of several hormonal contraceptives before they find an option that is ideal for them. Clinicians may streamline medications by choosing OCs that are approved for additional indications (acne control, etc.). Choice of combined OC may be based on regimen that patient prefers (cyclic versus continuous).
Many drugs may interact with hormonal contraceptives and alter efficacy. Common interactions include antibiotics, steroids, and anticonvulsants. Hormonal contraceptives may also affect other medications as well. Patients should be counseled and interactions should be checked whenever a new medication is added to a patient on hormonal contraceptives (particularly oral formulations)
For older women, long term use of hormone replacement therapy for menopause is associated with more overall risk than benefit and should not be used. Short term hormonal therapy can be useful for patients with bothersome vasomotor symptoms, although should be prescribed at the lowest possible dose and for the shortest possible duration. Hormone replacement therapy should not be continued for any other purpose (eg. prevention of osteoporosis). Topical estrogen products (not transdermal systemic) with limited systemic absorption may be useful for women experiencing vulvovaginal atrophy.
Patients with erectile dysfunction (ED) should be carefully assessed for cardiac function and possible medication interactions (e.g. nitrates) prior to beginning medical therapy with PDE5 inhibitors (sildenafil, etc.). All PDE5 inhibitors appear to have similar efficacy for treatment of ED.
Men with ED should have their medication regimens examined for possible contribution to the condition, including antidepressants, antihypertensive drugs, and 5a-reductase inhibitors, among others (see Table 51-2).
Testosterone replacement has limited role in treatment of ED, and should not be offered routinely to older men in without other clinically significant symptoms and low testosterone levels.
For men, erectile dysfunction may be worsened by a variety of diseases and drugs. Treatment should always look to remove or modify potential contributing factors (including offending medications) before drugs are prescribed. First line treatment with PDE5 inhibitors is usually preferable for most patients due to ease of oral dosing and convenience. Second line therapies including injections and intraurethral pellets should probably be managed by a specialist.
BPH can be managed conservatively in the mild to moderate stages, and drug therapy can be started and escalated as the patient's symptoms worsen. Keep in mind that 5a reductase inhibitors will not provide immediate benefits for the patient. Patients on drug treatment for BPH should be monitored for adverse effects including hypotension and sexual dysfunction.
Medical management should be utilized for patients with moderate to severe BPH with bothersome symptoms, and should initially consist of alpha 1 blockers (alfuzosin 10 mg, doxazosin 2-8 mg, tamsulosin 0.4-0.8 mg, terazosin 2-10 mg, or silodosin 8 mg orally once daily). 5a-reductase inhibitors should be utilized for patients with larger prostate sizes and/or elevated PSA values. These two medication classes can be combined for patients with severe voiding issues.
Alpha 1-blockers are similar in efficacy within the medication class, as are 5a-reductase inhibitors. Older alpha blockers require titration to avoid orthostasis, an adverse event avoided with the use of uro-selective agents.
This image describes the management of benign prosthetic hyperplasia (BPH) based upon AUASI scores, if the symptoms are bothersome and if there are complications. Treatment may include
Objectives
At the completion of this module the student will be able to:
recognize common drugs that are absolutely contraindicated in pregnancy (category X).
state the appropriate course of action for checking the appropriateness of medications prior to prescribing medication to women who are pregnant or nursing.
recognize the drugs commonly causing interactions with hormonal contraception which may affect efficacy.
state the appropriate uses of hormonal replacement therapy and topical hormonal therapy for menopausal/post-menopausal women.
recognize medications which may contribute to ED.
suggest a first line treatment plan for ED and BPH
Other Resources
Dynamed - Oral Contraception https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T116852/
Dynamed - Hormone Replacement Therapy: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T113927
Dynamed - Hormone Replacement Therapy for Menopause and Perimenopause: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=https://www-dynamed-com(dot)wilkes(dot)idm(dot)oclc(dot)org/management/hormonal-replacement-therapy-hrt-for-menopause-and-perimenopause
Dynamed - Erectile Dysfunction: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T113875/
Dynamed - Benign Prostatic hyperplasia: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T116944/
Videos
Interactive tool looking at contraception failure: http://www(dot)nytimes(dot)com/interactive/2014/09/14/sunday-review/unplanned-pregnancies.html?_r=0
Impact of pregnancy on pharmacokinetics of medications: https://www(dot)youtube(dot)com/watch?v=nlTVW10XTE8
Transcript for Impact of Pregnancy on Pharmacokinetics of Medications video
Prescription Drugs and Pregnancy:
Note: You will have to create a "free account" to view
Estrogens and Antiestrogens :https://www(dot)osmosis(dot)org/learn/Estrogens_and_antiestrogens?from=/pa/foundational-sciences/pharmacology/reproductive-system/female-reproductive-system-medications
Progestins and Antiprogestins: https://www(dot)osmosis(dot)org/learn/Progestins_and_antiprogestins?from=/pa/foundational-sciences/pharmacology/reproductive-system/female-reproductive-system-medications
BPH drugs: https://www(dot)youtube(dot)com/watch?v=DU7VlOUFKYU
Transcript for BPH and Treatment video
Module III Discussions & Assignments
Discussion
Consider the following scenarios:
LW is a 32 year old female patient who comes to your medical clinic for primary care. She has been on hormonal contraceptives for years, although she's just been married and has stopped her pills in hopes of becoming pregnant. Her PMHx includes obesity, HTN (diagnosed 3 years ago), familial hypercholesterolemia, and PCOS. Her current medications are as follows: Metformin 2000 mg PO daily, Lisinopril 10 mg PO daily, rosuvastatin 5 mg PO daily, and a multivitamin.
GD is an 82-year-old patient is taking 2 mg of terazosin for BPH comes in complaining of dizziness and generalized muscle weakness and persistent LUTS. What would you recommend?
How should you advise these patients and manage her medications? What was the process you went through to assess her current medications and to recommend an updated regimen?
Module III: Men's and Women's Health Discussion
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
Special Guidance on APA formatting in Discussion Posts
APA formatting is required in discussion posts with the following two exceptions (due to limitations with the text editor in LIVE): double line space and indent 1/2 inch from the left margin. Discussion posts will NOT be evaluated on those two formatting requirements. All other APA formatting guidelines should be followed. For example, in-text citations must be formatted with the appropriate information and in the correct sequence (Author, year), reference list entries must include all appropriate information following guidelines for capitalization, italics, and be in the correct sequence. Refer to the APA Publication Manual 7th ed. for each source type's specific requirements. Please let your instructor know if you have any questions.