Male & Female Health Part 1

Folic Acid Supplementation

• Regular Adult - 400 mcg per day

• Pregnancy - 600 mcg per day 

The Only Reversible Contraceptive that Delay in Return to Fertility

Medroxyprogesterone Injection

Combination Oral Contraceptives (COCs)

• contain Estrogen (Ethinyl Estradiol) & Progestin (Norethindrone, Levonorgestrel, Drospirenone)

  • Monophasic - same dose throughout

  • Biphasic, Triphasic, Quadriphasic - mimic menstrual cycle dose

• Indications besides Contraception

  • Dysmenorrhea, PMS, Acne, Anemia

  • 1st Line for PCOS, Endometriosis

• Drospirenone (special progestin)

  • also a Potassium-Sparing Diuretic

  • AVOID use with kidney, liver, or adrenal gland disease

Progestin Only Pills (POPs, mini-pills)

• Errin, Camila, Nora-BE

• Used in lactating (estrogen reduces milk production)

• Safe in women who have migraines with aura (Estrogen CAN’T use in this condition due to increased stroke risk)

• Must be taken daily within 3 hours of the scheduled time (NEED good adherence)

Contraceptive Patches

• Higher systemic estrogen exposure = higher thromboembolism risk 

• AVOID in high clotting risk PT (>35 YO + smoke, CVD, past blood clots, postpartum PT)

• AVOID in BMI >/= 30

• Xulane & Zafemy → less effective in > 90 kg

Injectable Contraceptives

• Depo-Provera

  • a depot medroxyprogesterone acetate (DMPA) [is a progestin]

  • IM or SC every 3 months

  • Can cause loss in bone mineral density - calcium & vitamin D supplement

Continuous Contraception

• Amethyst

  • Take hormonal pills only for 84 days

  • Less bleeding frequency (every 3 months)

  • Can have spotting (breakthrough bleeding) - resolve after 3-6 months

Severe & Rare ADE of Estrogen

ACHES

Abdominal Pain → mesentric or pelvic vein thrombosis

Chest Pain → heart attack, PE

Headaches → stroke

Eye problems → a blood clot in the eye

Swelling or sudden leg pain → DVT

AVOID Estrogen in These Conditions

• hx DVT/PE, stroke, CAD

• hx breast, ovarian, liver or endometrial cancer

• migraines with aura

Boxed Warnings for Contraceptives

ALL CHC (pills, patch, ring)

• AVOID > 35 YO who SMOKE

Estrogen + Progestin Patch

• AVOID BMI >/= 30

Depo-Provera

• Loss of bone mineral density with long-term use

Starting Birth Control Pills

COC

• Have back-up contraception for 7 days unless COC is started within 5 days after the start of a period

• If missed >1 pills → back-up for 7 days & omit hormone free week

Progestin Only Pills

• Start ANY TIME

• If missed pill > 3 hrs past schedule time → back-up for 48 hrs

Emergency Contraceptives (EC)

Copper IUD (Paragard)	Ulipristal Acetate (Ella)	Levonorgestrel (Plan B One-Step)
most effective indicated for EC and/or regular birth control	Take it ASAP or within 5 days Rx	Take it ASAP or within 3 days OTC Nausea

Infertility Treatment

Clomiphene	Aromatase Inhibitors	Gonadotropins
Selective estrogen receptor modulator (SERM) to increase LH/FSH	Suppress estrogen to increase FSH	Act as LH, FSH, or hCG

Calcium & Vitamin D Supplementation in Pregnancy

• Pregnant Women from 19-50 years old require

  • 1,000 mg/day of Calcium

  • 600 IU/day of Vitamin D

Teratogenic Drugs

Isotretinoin

Topical retinoids

Quinolones, Tetracyclines

Warfarin

Statins, ACEi, ARBs, Aliskiren, Entresto

Estrodiol, Progesterone, Raloxifene, Duavee, Testosterone, Contraceptives

Dihydroergotamine, Ergotamine

Hydroxyurea

Lithium

Methotrexate

Misoprostol

NSAIDs

Paroxetine

Ribavirin

Thalidomide

Topiramate

Weight Loss Drugs

Valproic Acid/Divalproex

Preeclampsia

• a complication of pregnancy that presents with eleevated BP & evidence of organ damage

Add daily low-dose Aspirin at the END of 1st trimester for PT at high risk (e.g., Diabetes)

Motion Sickness, Nausea, Vomiting in Pregnancy

• Lifestyle (First)

• Pyridoxine (Vit-B6) +/- Doxylamine [FIRST LINE]

• Ginger

GERD/Heartburn in Pregnancy

• Lifestyle (First)

• Fiber (psyllium, calcium polycarbophil)

Cough, Cold, Allergies in Pregnancy

• Cromolyn [FIRST LINE]

• 1st gen antihistamines (Chlorpheniramine)

• Budesonide (nasal)

Pain in Pregnancy

• Acetaminophen

• AVOID NSAIDs, including Aspirin

Asthma in Pregnancy

• Rescue → ICS-formoterol or Albuterol

• Maintenance → Budesonide

Hypertension in Pregnancy

• Labetalol, Methyldopa, Nifedipine Extended-release

• AVOID RAAS inhibitors

Diabetes in Pregnancy

• Insulin

Infection in Pregnancy

Vaginal Fungal Infections

• Topical antigungals x 7 days

UTI

• Cephalexin or Amoxicillin

• Alternative: Nitrofurantoin or Bactrim

  • last line in 1st trimester & NOT used in last 2 weeks of pregnancy

Venous Thromboembolism (VTE) in Pregnancy

• Treatment: LMWH preferred over UFH

• Prophylaxis: pneumatic compression devices ± LMWH

• AVOID Warfarin

Hypothyrodism in Pregnancy

• Levothyroxine INCREASE 30-50% dose

dIA

Diagnosis of Osteoporosis

A DEXA (DXA) Scan measures BMD so that a T score can be determined

• Women >/= 65 YO & Men >/= 70 YO & Young PT with high risk of frature

• Normal: >/= -1

• Osteopenia: -1 to -2.4

• Osteoporosis: </= -2.5

Calcium

• Adults → 1,000 - 1,200 mg elemental Calcium

• DO NOT exceed 500-600 mg per dose

Calcium Carbonate (e.g., Tums)

• 40% element Ca

• WITH meals

• AVOID PPIs

• + cholecalciferol (Caltrate)

• SE: constipation

Calcium Citrate (e.g., Cal-Citrate)

• 21% element Ca

• With or without meals

• + cholecalciferol (Citracal)

• SE: constipation

Vitamin D

• Required for Calcium absorption

• Deficiency:  serum vitamin D < 30 ng/mL

• Treat Deficiency

  • Cholecalciferol (D3): 125-175 mcg (5,000-7,000 IU) QD

  • Ergocalciferol (D2): 1,250 mcg (50,000 IU) QD

Criteria for Initiating Osteoporosis Treatment

• T score </= 2.5 in spine, femoral neck, total hip, or 1/3 radius

• Presence of a fragility fracture, regardless of BMD

• T score -1 - -2.4 AND FRAX score >/= 20% or a 10-yr hip fracture probability >/= 3%

Bisphosphonates

MOA: inhibits osteoclast activity & bone resorption

[FIRST LINE for treatment or prevention in most PT]

Oral Bisphosphonates

Alendronate (Fosamax)

Risedronate → [Treat only Males]

Ibandronate → [Treat only postmenopausal Females]

[Must stay upright for 30mins (Ibandronate 60mins) & drink 6-8oz of water]

[Osteonecrosis of the Jaw (ONJ) → Dental work before initiation]

[Esophagitis, Hypocalcemia, GI effects]

[Separate calcium, antacids, iron, & magnesium by at least 2 hrs]

Injectable Bisphosphonates

Ibandronate → [Treat only postmenopausal Females] - every 3 months

Zoledronic Acid (Reclast) - yearly

[Hypocalcemia]

[Preferred if esophagitis is present]

Estrogen Agonist/Antagonist-Containing Products

• SERMs that reduce bone resorption

[Alternatives to Bisphosphonates if High Risk of Vertebral Fractures]

Raloxifene (Evista)

• Prevention & Treatment of postmenopausal females

• Used if low VTE risk or high breast cancer risk

• Boxed - Increased VTE (DVT/PE) risk; increased risk of death due to stroke

• SE: hot flashes, peripheral edema, arthralgia, leg cramps

Duavee

• Prevention of postmenopausal females WITH a Uterus

• Boxed - Endometrial cancer; increased risk of DVT & stroke

• AVOID in breast cancer (any history), pregnancy, uterine bleeding, hx, or active VTE

Receptor Activator of Nuclear Factor kappa-B Ligand (RANKL) Inhibitor

• MOA: binds to RANKL and prevents osteoclast formation

Denosumab (Prolia)

• Treatment for males & females [Alternatives to Bisphosphonates]

• SC every 6 months

• Boxed - Hypocalcemia risk in PT with advanced kidney disease

• AVOID hypocalcemia & pregnancy

• ONJ, femur fractures

Calcitonin

MOA: inihibits bone resorption by osteoclasts

Calcitonin (Miocalcin)

• LAST LINE (less effective, increase risk of cancer when used long-term)

• Treatment for females > 5 years postmenopause

Parathyroid Hormone 1-34

• MOA: analogs of human parathyroid hormone, which stimulates osteoblast activity

Teriparatide (Forteo) → protect from light

Abaloparatide (Tymlos)

[SC daily]  [Osteosarcoma, Hypercalcemia, Restricted to 2yrs use]

[Recommended for very high risk PTs only e.g., hx of severe vertebral fractures]

Hormone Therapy in Menopause

Criteria for Use

• Health, symptomatic women with 10 years of menopause, </= 60YO

Estrogen

• Most effective treatment for vasomotor symptoms

• WITH a uterus → combo with a form of progesterone to reduce risk of endometrial cancer

• Boxed - Endometrial cancer, Dementia, increased risk of VTE & stroke, Breast cancer

Progestin

• Norethindrone, Levonorgestrel, Drospirenone (can be given with estrogen)

• Medroxyprogesterone (MPA) (commonly given separately)

• Cause mood disturbances, spotting

• Micronized progestin (Prometrium) is safer than synthetic progestin (MPA)

Other Drugs for Vasomotor Symptoms

Paroxetine (Brisdelle) → moderate-severe symptoms

Fezolinetant → moderate-severe symptoms

• Neurokinin B antagonists

Black cohosh

Evening primrose oil

Red Clover

Soy

Hypogonadism in Males

Testosterone gel (AndroGel)

• Boxed - secondary exposure in children

• increase appetite, acne, edema, hepatotoxicity, reduced sperm count

• Apply same time each morning