Men's and Women's Health and Obstetrics

Estrogen and Progestin Combination Ethinyl estradiol and levonorgestrel Indications

• Contraception

• OL:

  • Abnormal uterine bleeding

  • Acne

  • Dysmenorrhea, endometriosis

  • Emergency contraception

  • Hirsutism

  • Hyper-lactation

  • Menstrual suppression

  • Polycystic ovary syndrome  

Estrogen and Progestin Combination Ethinyl estradiol and levonorgestrel Adverse Reactions

• Thrombosis

• MI

• CVA

Estrogen and Progestin Combination Ethinyl estradiol and levonorgestrel Safety/Monitoring

• Pregnancy

• Assess for contraindication

• BP

• Weight

Estrogen and Progestin Combination Ethinyl estradiol and levonorgestrel Pregnancy/Lactation

• D/c in pregnancy

• Avoid in breastfeeding

Estrogen and Progestin Combination Ethinyl estradiol and levonorgestrel MOA

• Combination hormonal contraceptives inhibit ovulation via a negative feedback mechanism on the hypothalamus → alters the normal pattern of gonadotropin secretion of a follicle-stimulating hormone (FSH) and luteinizing hormone by the anterior pituitary

• Changes in the cervical mucus and changes in the endometrium produce an unfavorable environment for nidation

Estrogen and Progestin Combination Ethinyl estradiol and levonorgestrel BLACK BOX

• Cigarette smoke/CVD > 35 y/o

• Obesity and DVT (patch)

Combined Oral Contraceptive Contraindications

Combined Oral Contraceptive Drug Interactions

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) Indications

• Contraception

• Abnormal uterine bleeding

• Endometriosis

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) Contraindications

• Progestin dependent malignant tumor

• Benign or malignant liver tumors

• Acute liver disease

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) Drug Interactions

• Rifampin

• Anti-convulsants

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) Adverse Reactions

• Menstrual bleeding irregularities

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) Safety/Monitoring

• Pregnancy

• Assess for abnormal bleeding

• Monitor glucose and lipids

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) Pregnancy/Lactation

• D/c in pregnancy

• Preferred in breastfeeding

Progestin Only Norethindrone (Camila), Drosperinone (Slynd) MOA

• Suppresses ovulation

• Thickens cervical mucus (which inhibits sperm penetration)

• Alters follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations

• Slows the movement of ovum through the fallopian tubes

• Alters the endometrium

Progestin Only

Progestin Only Depot Injection Medroxyprogesterone acetate Indications

• Contraception

• OL

  • Abnormal uterine bleeding

  • Endometrial hyperplasia

  • Menstrual suppression

Progestin Only Depot Injection Medroxyprogesterone acetate Contraindications

• Thromboembolic disorders (current or history of)

• Cerebral vascular disease

• Undiagnosed vaginal bleeding

• Breast cancer (known, suspected, or history of)

• Significant hepatic disease

Progestin Only Depot Injection Medroxyprogesterone acetate Drug Interactions

• Rifampin

• Anti-convulsants

• HIV antivirals

• St. John’s Wart

Progestin Only Depot Injection Medroxyprogesterone acetate Adverse Reactions

• Bone loss

• Menstrual irregularities

• Weight gain

Progestin Only Depot Injection Medroxyprogesterone acetate Safety/Monitoring

• Pregnancy

• Glucose

Progestin Only Depot Injection Medroxyprogesterone acetate Pregnancy/Lactation

• D/c during pregnancy but low risk

• Consider breastfeeding after 6 weeks

Progestin Only Depot Injection Medroxyprogesterone acetate MOA

• When used as an injection for contraception (doses of 150 mg IM or 104 mg SUBQ), medroxyprogesterone inhibits the secretion of pituitary gonadotropins, which prevents follicular maturation and ovulation and causes endometrial thinning. 

• Progestogens, such as medroxyprogesterone when used for endometriosis, lead to atrophy of the endometrial tissue

  • They may also suppress new growth and implantation

  • Pain associated with endometriosis is decreased

Progestin Only Depot Injection Medroxyprogesterone acetate BLACK BOX

• Long term use > 2 years → bone mineral density

Contraceptive Choice: Pharmacology Comparison

Emergency Contraception High dose Progestin Levonorgestrel Indications

• Emergency contraception

Emergency Contraception High dose Progestin Levonorgestrel Contraindications

• OTC labeling

• Do not use if already pregnant

• Do not use for regular birth control

Emergency Contraception High dose Progestin Levonorgestrel Adverse Reactions

• Irregular menses

• Abdominal pain

• Nausea

• HA

Emergency Contraception High dose Progestin Levonorgestrel Safety/Monitoring

• Evaluate for pregnancy

Emergency Contraception High dose Progestin Levonorgestrel Pregnancy/Lactation

• Avoid in pregnancy

• Safe in lactation

Emergency Contraception High dose Progestin Levonorgestrel MOA

• Pregnancy may be prevented through several mechanisms:

  • Thickening of cervical mucus, which inhibits sperm passage through the uterus and sperm survival

  • Inhibition of ovulation, from a negative feedback mechanism on the hypothalamus, leading to reduced secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH)

  • Altering the endometrium, which may affect implantation

• Levonorgestrel is not effective once the implantation process has begun.

Emergency Contraception Progestin Receptor Modulator Ulipristal Indications

• Emergency contraception

Emergency Contraception Progestin Receptor Modulator Ulipristal Contraindications

• OTC labeling

• Do not use if already pregnant

• Do not use for regular birth control

Emergency Contraception Progestin Receptor Modulator Ulipristal Adverse Reactions

• Irregular menses

• Abdominal pain

• Nausea

• HA

Emergency Contraception Progestin Receptor Modulator Ulipristal Safety/Monitoring

• Evaluate for pregnancy

Emergency Contraception Progestin Receptor Modulator Ulipristal Pregnancy/Lactation

• Avoid for pregnancy

• Safe in lactation

Emergency Contraception Progestin Receptor Modulator Ulipristal MOA

• Prevents progestin from binding to the progesterone receptor

• Postpones follicular rupture when administered prior to ovulation, thereby inhibiting or delaying ovulation

• May also alter the normal endometrium, impairing implantation

MOA Emergency Contraception

Cervical Ripening Prostaglandins Misoprostol and Dinoprostone Indications

• Cytotec: NSAID-induced gastric ulcers, pregnancy Termination

• (OL):

  • Cervical ripening

  • Postpartum hemorrhage

  • Pregnancy loss

• Cervidil: Cervical ripening

Cervical Ripening Prostaglandins Misoprostol and Dinoprostone Contraindications

• Abortifacient

Cervical Ripening Prostaglandins Misoprostol and Dinoprostone Adverse Reactions

• Uterine rupture

• Abdominal pain

• Diarrhea

Cervical Ripening Prostaglandins Misoprostol and Dinoprostone Safety/Monitoring

• Fetal HR

• Uterine activity

• Progression of cervical dilation and effacement

• Signs of amniotic fluid embolism

Cervical Ripening Prostaglandins Misoprostol and Dinoprostone MOA

• •Dinoprostone (prostaglandin E₂) is an endogenous hormone found in low concentrations in most tissues of the body → when administered for labor induction, it relaxes the smooth muscle of the cervix, allowing dilation and passage of the fetus through the birth canal

Cervical Ripening Prostaglandins Misoprostol and Dinoprostone BLACK BOX

• Abortifacient property

• Uterine rupture

Oxytocin Indications

• Refractory postpartum hemorrhage

• OL

  • Prion or augmentation

  • Pregnancy termination

Oxytocin Contraindications

• Significant cephalopelvic disproportion

• Unfavorable fetal presentation

• Cord presentation

• Total placenta previa

• Contraindicated vaginal delivery

Oxytocin Drug Interactions

• Prostaglandins (misoprostol, dinoprostone)

  • Uterine hyperstimulation

  • QT-prolongation

Oxytocin Safety/Monitoring

• Fluid intake and output during administration

• Uterine activity (tonus, amplitude, and frequency of contractions), maternal blood pressure

• Continuous electronic fetal heart rate monitoring in relation to uterine contractions

Oxytocin Pregnancy/Lactation

• Safe

Oxytocin MOA

• Oxytocin stimulates uterine contractions by acting on receptors that trigger the release of intracellular calcium and local prostaglandin production

• Oxytocin specific receptors are not present in the uterus until ~13 weeks' gestation and increase as pregnancy progresses and reach maximum concentration at term → term pregnancies are more sensitive to lower oxytocin doses

Oxytocin BLACK BOX

• Elective induction of labor

Tranexamic Acid Indications

• Refractory postpartum hemorrhage

• Pregnancy termination

Tranexamic Acid Adverse Reactions

• HA

• Thromboembolic event

Tranexamic Acid Safety/Monitoring

• Hypersensitivity

• Seizures

Tranexamic Acid Pregnancy/Lactation

• Safe in pregnancy

• Avoid in lactation

Tranexamic Acid MOA

• Forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis

• It also inhibits the proteolytic activity of plasmin

Tranexamic Acid BLACK BOX

• IV only

Carboprost Tromethamine Indications

• Refractory postpartum hemorrhage

• Pregnancy termination

Carboprost Tromethamine Adverse Reactions

• Fever

• N/V

• HTN

Carboprost Tromethamine Safety/Monitoring

• BP

Carboprost Tromethamine Pregnancy/Lactation

• Not safe

Carboprost Tromethamine MOA

• Carboprost is an analog of naturally occurring prostaglandin F₂ alpha (dinoprost) → stimulates uterine contractility which usually results in expulsion of the products of conception and is used to induce abortion between 13-20 weeks of pregnancy

• When used postpartum, hemostasis at the placentation site is achieved through the myometrial contractions produced by carboprost

Carboprost Tromethamine BLACK BOX

• Appropriate use

• Experienced physician

Methylergometrine/Methylergonovine Indications

• Post-partum hemorrhage

Methylergometrine/Methylergonovine Contraindications

• CAD

Methylergometrine/Methylergonovine Drug Interactions

• Oxytocin

• Prostaglandins

Methylergometrine/Methylergonovine Adverse Reactions

• HTN

• hTN

Methylergometrine/Methylergonovine Safety/Monitoring

• BP

Methylergometrine/Methylergonovine MOA

• Increases the tone, rate and amplitude of contractions on the smooth muscles of the uterus, producing sustained contractions which shortens the third stage of labor and reduces blood loss

Magnesium Sulfate Indications

• Asthma

• COPD

• Constipation

• Eclampsia/preeclampsia

• Hypomagnesemia

• Torsades de pointes

Magnesium Sulfate Contraindications

• Heart block/myocardial damage within 2 hours of delivery

• Caution in renal impairment and neuromuscular disease

Magnesium Sulfate Drug Interactions

• Some antibiotics and antivirals

Magnesium Sulfate Adverse Reactions

• hTN

• Flushing

• Vasodilation

Magnesium Sulfate Safety/Monitoring

• ECG monitoring

• Vital signs

• Deep tendon reflexes

• Magnesium

Magnesium Sulfate Pregnancy/Lactation

• Safe

Magnesium Sulfate MOA

• Magnesium sulfate prevents and controls seizures in preeclampsia and eclampsia through three primary mechanisms

  • Blocking neuromuscular transmission

  • Blocking central nervous system depression

  • Blocking peripheral vasodilation

Magnesium Sulfate Toxicity

Early & Late Clinical Signs

• Early (most testable):

  • ↓ or absent deep tendon reflexes

  • Somnolence

  • Nausea, flushing

• Late (danger signs):

  • Respiratory depression

  • Hypoxia

  • Cardiac conduction abnormalities

• Risk Factors

  • Renal insufficiency (most common)

  • High infusion rates

  • Iatrogenic dosing errors

• Immediate Management

  • STOP magnesium infusion

  • Administer calcium gluconate (antidote)

  • 10 mL of 10% solution IV over 2–3 minutes

  • Support airway/ventilation if needed

  • Monitor urine output, reflexes, respiratory status

Sildenafil, Tadalafil, Varenafil, Avanafil Indications

• Erectile Dysfunction

• BPH (Cialis only)

• High Altitude pulmonary edema (HAPE)

• Pulmonary artery HTN (PAH)

Sildenafil, Tadalafil, Varenafil, Avanafil Contraindications

• CVD

• CAD

Sildenafil, Tadalafil, Varenafil, Avanafil Drug Interactions

• Nitrates

• BP lowering agents

• Protease inhibitors (HIV)

Sildenafil, Tadalafil, Varenafil, Avanafil Adverse Reactions

• •Flushing

• HA

• Hearing loss,

• hTN

• Priapism

• Visual disturbance  

Sildenafil, Tadalafil, Varenafil, Avanafil Safety/Monitoring

• HR

• BP

Sildenafil, Tadalafil, Varenafil, Avanafil Pregnancy/Lactation

• Avoid

Sildenafil, Tadalafil, Varenafil, Avanafil MOA

• Sildenafil enhances the effect of NO by inhibiting phosphodiesterase type 5 (PDE-5), which is responsible for degradation of cGMP in the corpus cavernosum → when sexual stimulation causes local release of NO, inhibition of PDE-5 by sildenafil causes increased levels of cGMP in the corpus cavernosum, resulting in smooth muscle relaxation and inflow of blood to the corpus cavernosum

• At recommended doses, it has no effect in the absence of sexual stimulation

PDE5 Inhibitors Contraindications and Patient Counseling

• Patient Counseling Points

  • Review all medications, especially nitrates and alpha-blockers

  • Assess cardiovascular status — is sexual activity safe?

  • Discuss timing — onset varies by agent:

    • Sildenafil/Vardenafil: ~30–60 min before

    • Avanafil: ~15 min before

    • Tadalafil: daily or as needed (longest duration)

• During Use

  • Avoid nitrates for 24–48 hours after PDE-5 use

  • Limit alcohol — may worsen hypotension

  • Report priapism (>4 hours) — medical emergency

  • Report sudden vision or hearing loss — rare but serious

• Lifestyle & Safety

  • Do not combine with recreational "poppers" (amyl nitrate)

  • Do not use with grapefruit juice (CYP3A4 interaction — mainly with sildenafil)

• Tadalafil also treats BPH — dual benefit

• Avanafil has the fastest onset, the lowest food interaction

• Sildenafil may cause blue-tinged vision (PDE-6 inhibition)

• Always ask about chest pain meds before prescribing

Hypogonadism Androgen Testosterone (AndroGel) Indications

• Hypogonadism

• Hormone replacement

Hypogonadism Androgen Testosterone (AndroGel) Contraindications

• Breast cancer

• Prostate cancer

• Pregnancy

Hypogonadism Androgen Testosterone (AndroGel) Adverse Reactions

• HTN

• Hepatotoxicity

• Polycythemia

• Venous thromboembolism (VTE)  

Hypogonadism Androgen Testosterone (AndroGel) Safety/Monitoring

• Confirm hypogonadism by measuring serum total testosterone on at least 2 separate mornings following overnight fasting

• LFTs

• Lipid panel

• Hemoglobin and hematocrit

• BP

• PSA

• Testosterone

Hypogonadism Androgen Testosterone (AndroGel) Pregnancy/Lactation

• Contraindicated

Hypogonadism Androgen Testosterone (AndroGel) MOA

• Principal endogenous androgen responsible for promoting the growth and development of the male sex organs and maintaining secondary sex characteristics in androgen-deficient males

Hypogonadism Androgen Testosterone (AndroGel) BLACK BOX

• HTN

• Secondary exposure

• Pulmonary oil embolism

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin Indications

• BPH

• OL

  • Chronic prostatitis

  • LUTS

  • Lower urinary tract symptoms

  • Ureteral stent and stones

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin Contraindications

• Sulfa allergy

• HF

• Floppy iris

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin Drug Interactions

• Numerous

• BP lowering agents

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin Adverse Reactions

• hTN

• Flushing

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin Safety/Monitoring

• UA

• BP,

• Prostate symptom score

• Prostate cancer screening

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin Pregnancy/Lactation

• Limited data

Alpa 1 Blockers Tamsulosin, Terazosin, Doxazosin, Alfuzosin MOA

• Tamsulosin is an antagonist of alpha_1A-adrenoreceptors in the prostate

• Smooth muscle tone in the prostate is mediated by alpha_1A-adrenoreceptors; blocking them leads to relaxation of smooth muscle in the bladder neck and prostate, causing an improvement of urine flow and decreased symptoms of BPH

5 alpha reductase inhibitors Finasteride, Dutasteride Indications

• Alopecia

• Alternative agent for BPH (indicated for high prostate volume)