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What is osteoporosis?
: “A skeletal disorder characterized by loss of bone tissue
, deterioration of bone architecture
, and increased bone fragility
leading to increased risk of fractures
What are characteristics of osteoporosis?
Often a silent disorder
Women 4 times more likely to have
Hips and spine of most concern
Associated with morbidity (disease rate) and mortality (death rate)
Most important risk factors for fractures are low bone mineral density, advanced age, and a history of adult fracture
Reduced quality of life
What are possible complications of fractures?
Nursing Home placement
What is Primary osteoporosis?
Primary means there is no known cause.
What is Secondary osteoporosis?
- Disease related
- Medication induced
What three factors does osteoporosis vary by?
What are some risk factors for osteoporosis?
- White or Asian ethnicity
- Positive family history
- Female sex
- Advanced age
- Small body frame (<127 pounds)
- Inactivity or excessive exercise (need weight
- Excessive alcohol use
- Poor nutrition
- Low calcium and vitamin D intake
- Too much caffeine
What are some treatment or prevention mechanisms for osteoporosis?
- Consume a balanced diet
- Adequate calcium and vitamin D intake
- Avoid smoking
- Limit alcohol and caffeine intake
- Regular weight-bearing exercise
- Take measures to prevent falls
- Talk to your health care provider about bone health
- Have a bone density test and take medication when appropriate
How much calcium and vitamin D should someone get daily?
What are some calcium-rich foods?
- Skim milk
- Soy milk
- Sardines with bones
- Canned salmon
- Orange juice
What are the two calcium supplements called?
- calcium carbonate
- calcium citrate
What are some vitamin D-rich foods?
- Fortified dairy products
- Fatty fish/fish oils
What are the two vitamin D supplements called?
- Ergocalciferol (Vitamin D2)
- Cholecalciferol (Vitamin D3)
What are the treatment goals for osteoporosis?
Prevent fractures by improving bone strength and reducing risk of falling and injury
Relieve symptoms of fractures and skeletal deformity
Maximize physical function
What agents do we use to treat osteoporosis and in what order?
Bisphosphonates (first line)
SERM (selective estrogen receptor modulators) for POST menopausal women only!!
Monoclonal antibody (RANKL)
Prevention and treatment of osteoporosis
Inhibit osteoclast activity and reduce bone resorption and turnover
Long ½ life
Common side effects: Heartburn, indigestion, jaw bone pain
Do bisphosphonates have a long or short half life?
What are the common side effects of bisphosphonates?
- jaw bone pain
What is the proper administration technique for bisphosphonates?
MUST follow proper administration technique
Take first thing in the morning
Take with a full glass of water
Nothing other than water should be taken within 30 minutes
Remain sitting up right or in a standing position for at least 30 minutes
What does SERM stand for?
Selective Estrogen Receptor Modulator
What is Raloxifene?
Estrogen like activity on the bones
- Used for a variety of conditions:
- •Breast Cancer
- •Hormone Replacement Therapy
Common side effects: Hot flashes
, night sweats
, leg cramps
, blood clots
What is Calcitonin?
- Calcitonin (Miacalcin®)
- non-FDA approved drugs for osteoporosis
- treatment of osteoporosis
- does not prevent fractures
Nasal spray: report significant nasal irritation immediately
; possible anaphylactic shock because derived from salmon, an animal product
What is Denosumab?
Blocks osteoclast activation leading to decreased bone resorption
Used for treatment of osteoporosis in postmenopausal women
Twice yearly injection
Common side effects: Stomach upset, muscle pain, infection
What is menopause?
Permanent cessation of menses
due to the dysfunction of the ovaries
Occurs mainly between ages of 47-53
- Controversy on treatment: Studies differ
- •some show increased breast cancer risks , others show decreased breast cancer risks
What are symptoms of menopause?
- Hot flashes
- Night sweats
- Abnormal uterine bleeding
- Vaginal dryness
- Sleep disturbances
- Mood changes
- Sexual changes
- Problems with concentration
- Problems with Memory
What is the most effective therapy for moderate to severe vasomotor symptoms related to menopause?
, such as:
- *Premarin® (Conjugated Estrogens)
- - Pregnant Mare Urine
What are common side effects of estrogen derivatives?
Common side effects
of estrogen derivatives
- Vaginal bleeding
- venous thromboembolism
In what specific population do estrogen derivatives increase the risk of endometrial cancer?
In women with a uterus, unopposed estrogen increases risk of endometrial cancer
In what population are estrogen derivatives contraindicated?
Estrogen derivatives are contraindicated in women with a history of breast cancer
What are three common indications of oral contraceptives?
- Prevent pregnancy
- Regulate menstrual cycles
- Treat acne
What are oral contraceptives?
Mostly considered safe (some debate)
- Combined form of progestins and estrogens
- Prevents Ovulation (98-99%)
- Alters endometrium lining
Do oral contreceptives protect from sexually transmitted diseases?
No. Does not protect from HIV or other sexually transmitted diseases.
What are some common side effects of oral contraceptives?
- Upset stomach
- Stomach cramps/bloating
- Diarrhea /constipation
- Gingivitis (swelling of the gum tissue)
- ↑ or ↓appetite
- Weight gain/weight loss
- Brown or black skin patches
- Unusual hair growth
- Intermittent bleeding/spotting
- Changes in menstrual flow
- Painful or missed periods
- Breast tenderness, enlargement, or discharge
- Swelling, redness, irritation, burning, or itching of the vagina
- White vaginal discharge
Which specialized population of women have an increased risk when taking oral contraceptives?
- Women with pre-existing cardiovascular
- disease or risk:
- DVT (deep vein thrombosis)
- Pulmonary embolism
- Myocardial Infarction (MI)
Which type of oral contraceptive may increase the risk of breast cancer?
Higher estrogen containing pills may increase the risk of breast cancer
*Recall that breast cancer is fueled by estrogen!
What are some benefits of taking oral contraceptives?
- PCOS (Polycystic ovarian syndrome) treatment
- Endometriosis treatment
- Dysmenorrhea treatment
- Decreased ovarian cancer risk by 40%
- Decreased endometrial cancer risk by 50%
- Increased breast size (in some patients)
What is PCOS?
- Hormone imbalance leading to overproduction of follicles each month by the ovaries without producing an egg
- Irregular or no periods
- Excessive weight gain
- Abnormal hair growth
- Often temporary
- Usually goes hand-in-hand with insulin resistance
- Body begins to make more androgens
What is endometriosis?
- Affects 5.5 million women in North America
- Endometrial tissue develops outside the uterus (commonly in the lining of pelvis, ovaries, or uterus)
- Tissue implants → proliferates → thickens → sheds with each menstrual cycle
- Tissue becomes trapped → scar tissue formation
What are the two symptoms of endometriosis?
What are the steps of the menstrual cycle?
When does Luteinising Hormone (LH) peak?
LH peaks before ovulation.
When does estrogen peak?
Estrogen peaks at ovulation.
Which oral contraceptive is an estrogenic compound?
Which oral contraceptives are progestational compounds?
Which oral contraceptives are on the drug list?
*TriNessa®, Ortho® Tri-Cyclen® (Lo)
- Yaz®, Yasmin® *Ocella® (Ethinyl Estradiol/Drosperinone)
- •Anti-mineralcorticoid activity
- •Avoid use in renal/adrenal insufficiency
*Loestrin 24 FE®, Necon 7/7/7®
- *NuvaRing® (Ethinyl Estradiol/ Etonogestrel)
- •Inserted every 3 wks on day 1 of cycle
- •Use back up if removed > 3hrs
(Ethinyl Estradiol/ Norethindrone
- Triphasil®, Alesse®, Aviane®, Levlen®, Trivora®, Lybrel® etc. (Ethinyl Estradiol/ Levonorgestrel)
- •Menstrual frequency varies, must discuss when menses will begin
- Ortho-Evra® (Ethinyl Estradiol/ Norelgestromin)
- •Contains 60% more estrogen
- •Replace patch weekly
- •Not recommended in pts >90 kg
What are some common complaints of too much estrogen?
- breast tenderness
- increased blood pressure
- melasma (dark skin discoloration on sun-exposed areas of face)
What are some common complaints of too little estrogen?
- Early or mid-cycle breakthrough bleeding
- increased spotting
- hypomenorrhea (scanty periods)
What are some common complaints of too little progestin?
- breast tenderness
- changes in mood
What are some common complaints of too much androgen?
- increased appetite
- weight gain
- oily skin
- increased LDL
- decreased HDL
How should I start and take my oral contraceptive?
Dosage is 1 tablet daily for 28 consecutive days.
Dose should be taken at the same time each day, either after the evening meal or at bedtime.
Dosing may be started on the first day of menstrual period (Day 1 starter) or on the first Sunday after the onset of the menstrual period (Sunday starter).
Day 1 starter: Dose starts on first day of menstrual cycle taking 1 tablet daily.
Sunday starter: Dose begins on first Sunday after onset of menstruation; if the menstrual period starts on Sunday, take first tablet that very same day. With a Sunday start, an additional method of contraception should be used until after the first 7 days of consecutive administration.
What should I do if I don't have a menstrual cycle (period)?
If all doses have been taken on schedule and one menstrual period is missed, continue dosing cycle.
If two consecutive menstrual periods are missed, pregnancy test is required before new dosing cycle is started.
If doses have been missed during the first 3 weeks (the non-sugar pills/non-period week) and the menstrual period is missed, pregnancy should be ruled out prior to continuing treatment.
What should I do if I miss a dose of my oral contraceptive?
Missed doses (monophasic formulations) (refer to package insert for complete information):
One dose missed:
Take as soon as remembered or take 2 tablets next day
Two consecutive doses missed in the first 2 weeks:
Take 2 tablets as soon as remembered or 2 tablets next 2 days.
An additional method of contraception should be used for 7 days after missed dose.
Two consecutive doses missed in week 3 or three consecutive doses missed at any time:
An additional method of contraception must be used for 7 days after a missed dose.
Day 1 starter: Current pack should be discarded, and a new pack should be started that same day.
Sunday starter: Continue dose of 1 tablet daily until Sunday, then discard the rest of the pack, and a new pack should be started that same day.
Any number of doses missed in week 4:
Continue taking one pill each day until pack is empty; no back-up method of contraception is needed
Is it okay to store my birth control pills in the bathroom?
- Keep away from moisture (thus, bathroom not the best place)
- Keep away from excessive heat or light
I am spotting between cycles. Is this normal?
Hormonal birth-control methods can cause spotting. Birth-control pill users can experience spotting if they miss a pill or if the hormone levels in their particular type of pill are not high enough.
Vaginal bleeding: Presentation of irregular, unresolving vaginal bleeding warrants further evaluation including endometrial sampling, if indicated, to rule out malignancy; evaluate hypothalamic-pituitary-function in women with persistent (≥6 months) amenorrhea (especially associated with breast secretion) following discontinuation of therapy.
Do I have to take the sugar pills on the last week?
You don't have to take the sugar pills, but they keep you in the habit of taking your medication every day.
You can also skip the sugar pills and go onto a new pack to completely skip your period. However, this should only be done under the direction of your physician because generally, it is healthy for your body to bleed at least three to four times a year.
One reason people don't skip the sugar pills and go through menstruation is as a confirmation that their birth control is indeed working. (ie, if you stop taking the pill, and you don't have your period, you may be pregnant) While this is not a foolproof way to confirm the efficacy of your birth control, it certainly is practical. (It's actually possible to have your period and still be pregnant, but this very rarely happens.)
It's important to know that you should only skip the inactive pills if you are taking monophasic birth control pills. (This just means that each of the pills that you're taking has an equal amount of the active ingredients in each of them. Some birth control pills work by increasing the estrogen week by week, so you shouldn't skip your period if you're on this type of pill.) Examples of monophasics include Alesse, Brevicon, Demulen, Desogen, Genora, Levlen, Levlite, Loestrin, Lo/Ovral, ModiCon, Necon, Nordette, Norethin, Norinyl, Ortho-Cyclen, Ortho-Novum, Ovcon, Ovral, Portia and Zovia.Check with your doctor to see how long you should/can skip inactive pills.
Some gynocologists recommend taking inactive pills once every 3-4 months (which means you'd have your "period" 3-4 times a year).