Digital PharmD

Informatics in Pharmacy

Women's Health

Menopause

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Menopause is the cessation of menstrual periods for 1 year.  The average age for menopause is 52.

  • Estrogen:
    • Estrogen relieves genitourinary atrophy, vasomotor instability, reduces hip and vertebral fractures, relieves hot flashes which decreases insomnia and fatigue, stabilizes mood changes, improves sexual function.
    • Risks: cancer, especially when unopposed, CHD, bloating, headache, breast tenderness, increased blood clotting
    • Women with a uterus should not take unopposed estrogen.
  • Progesterone:
    • Decreases risks of estrogen-induced bleeding and carcinoma.
    • Risks: bloating, weight gain, irritability, and depression
  • Long-term use (from 1 to 5 years) of hormone therapy is not recommended.
    • Give the lowest dose for the shortest time.
    • Try topical for vasomotor symptoms first.  There isn’t much systemic absorption with topical.
  • SERMs: ospemifene: contraindications similar to estrogen (but only works for vaginal symptoms).  Add progestin if omen still has a uterus.
  • SSRIs: Good for vasomotor symptoms in high-risk patients
  • Conjugated estrogen and bazedoxifene: SERM plus estrogen, may be used with an intact uterus.
  • Clonidine, gabapentin, and pregabalin are sometimes used for symptomatic relief.

Osteoporosis

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All women over 65 and men over 70 should have bone mineral density (BMD) testing.  If fractures or risks, test sooner.

Initiate therapy if:

  • Hip or spine fracture and BMD T-score -2.5 or below at hip, spine or femoral neck
  • T-score is between -1.0 and -2.5 at femoral neck or spine and the 10-year probability of hip fracture (FRAX score) is 3% or greater
  • The 10-year probability of major fracture (FRAX score) is 20% or greater according to

Treatment:

  • Bisphosphonates: Standard.
    • Alendronate and risedronate are first line
    • Zoledronic acid, ibandronate and pamidronate are available in IV forms.
  • Calcium is recommended for all patients with osteoporosis. Give 1000-1200 mg/day
  • Vitamin D is recommended for all patients. Give 800-1000 IU daily
  • Raloxifene (SERM) reduces bone resorption
  • Conjugated estrogen and bazedoxifene is like a SERM.
  • Calcitonin is not first-line, but can be useful in bone pain.  Nasal route.
  • Teriparatide is reserved for high-risk patients.  Increases calcium concentration, but also increases digoxin toxicity
  • Denosumab inhibits bone resorption, alternate to first-line, can lead to cellulitis (subQ) and hypocalcemia

Contraception and Fertility

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Contraception:

Management of adverse effects:

  • Bleeding: if early in the cycle, you need higher estrogen component.  If late bleeding, you need more progesterone.
  • Nausea: Usually related to estrogen, take at night with food
  • Acne: Usually related to progestin

Severe effects:

  • Abdominal pain
  • Chest pain
  • Headaches: could be a stroke or blood clot
  • Eye problems, blurred vision, flashing lights, could be optic neuritis, stroke, clots
  • Severe leg pain could be DVT

Take a missed dose as soon as you realize you’ve missed it.  If 2 pills are missed in one week, use backup method for 7 days.

Progestin-only contraception is reserved for those who cannot tolerate combined contraception.  It can cause bone loss.

IUD:

Long term contraception.  No estrogen.  Copper can cause more monthly blood loss.  There are also progestin IUDs.

Adverse effects:

  • Periods late, abdominal spotting
  • Abdominal pain or pain with intercourse
  • Infection exposure, abnormal vaginal discharge
  • Not feeling well, fever, chills
  • String of IUD is missing or shorter or longer

Emergency Contraception:

  • Use within 72-120 hours of intercourse
  • High dose estrogen plus progestin (Yuzpe)
  • Progestin-only is preferred, but it is not as effective is BMI > 25 kg/m2.  Use ulipristal or copper IUD
  • Ulipristal binds to progesterone receptor.  It’s prescription only.  Use a backup method for 7 days.
  • Copper IUD – 5 days after sex, only course recommended for those >35 BMI
  • RU-486 0 May use within 5 days, but it is also abortifacient

Fertility Agents:

  • Clomiphene – take for five days, first line
  • Letrozole or anastrozole- less risk of multiple births
  • hmG – causes flu-like symptoms
  • FHS – follitropin or urofollitropin
  • hCG – given 36 hours before insemination
  • metformin can be given with clomiphene
  • Others: progesterone (maintains luteal phase), guaifenesin (thins cervical mucus), sildenafil (increases the thickness of uterus lining)