Top 200: Osteoporosis, Menopause, Oral Contraceptives

  1. What is osteoporosis?
    Definition: “A skeletal disorder characterized by loss of bone tissue, deterioration of bone architecture, and increased bone fragility leading to increased risk of fractures.”

    "Porous bone"

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  2. 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
  3. What are possible complications of fractures?
    Chronic pain





    Nursing Home placement


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  4. What is Primary osteoporosis?
    Primary means there is no known cause.
  5. What is Secondary osteoporosis?
    • Disease related
    • Medication induced
  6. What three factors does osteoporosis vary by?
    • age
    • gender
    • ethinicity
  7. What are some risk factors for osteoporosis?
    • White or Asian ethnicity
    • Positive family history
    • Female sex
    • Advanced age
    • Small body frame (<127 pounds)
    • Smoking
    • Inactivity or excessive exercise (need weight
    • bearing)
    • Excessive alcohol use
    • Poor nutrition
    • Low calcium and vitamin D intake
    • Too much caffeine
  8. 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
  9. How much calcium and vitamin D should someone get daily?
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  10. What are some calcium-rich foods?
    • Skim milk
    • Soy milk
    • Yogurt
    • Cheeses
    • Broccoli
    • Almonds
    • Tofu
    • Sardines with bones
    • Canned salmon
    • Orange juice
  11. What are the two calcium supplements called?
    • calcium carbonate
    • calcium citrate
  12. What are some vitamin D-rich foods?
    • Fortified dairy products
    • Fatty fish/fish oils
    • Cereal

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  13. What are the two vitamin D supplements called?
    • Ergocalciferol (Vitamin D2)
    • Cholecalciferol (Vitamin D3)
  14. 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
  15. 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)
  16. Bisphosphonates
    Prevention and treatment of osteoporosis

    Inhibit osteoclast activity and reduce bone resorption and turnover

    Doses vary

    Long ½ life

    Common side effects: Heartburn, indigestion, jaw bone pain
  17. Do bisphosphonates have a long or short half life?
    long half-life
  18. What are the common side effects of bisphosphonates?
    • heartburn
    • indigestion
    • jaw bone pain
  19. 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
  20. Bisphosphonates
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  21. What does SERM stand for?
    Selective Estrogen Receptor Modulator
  22. What is Raloxifene?
    Raloxifene (Evista®)

    Estrogen like activity on the bones

    • Used for a variety of conditions:
    • Osteoporosis
    • Breast Cancer
    • Hormone Replacement Therapy

    Common side effects: Hot flashes, night sweats, leg cramps, blood clots
  23. What is Calcitonin?
    • Calcitonin (Miacalcin®)
    • non-FDA approved drugs for osteoporosis

    • Indications:
    • treatment of osteoporosis
    • does not prevent fractures

    Nasal spray: report significant nasal irritation immediately; possible anaphylactic shock because derived from salmon, an animal product
  24. What is Denosumab?
    Denosumab (Prolia®)

    Monoclonal antibody

    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
  25. 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
  26. What are symptoms of menopause?
    • Hot flashes
    • Night sweats
    • Abnormal uterine bleeding
    • Vaginal dryness
    • Incontinence
    • Sleep disturbances
    • Mood changes
    • Depression
    • Sexual changes
    • Problems with concentration
    • Problems with Memory
  27. What is the most effective therapy for moderate to severe vasomotor symptoms related to menopause?
    Estrogen derivatives, such as:

    • *Premarin® (Conjugated Estrogens)
    • - Pregnant Mare Urine

    Estrace ® (Estradiol)
  28. What are common side effects of estrogen derivatives?
    Common side effects of estrogen derivatives:

    • Vaginal bleeding
    • venous thromboembolism
    • stroke
  29. 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
  30. In what population are estrogen derivatives contraindicated?
    Estrogen derivatives are contraindicated in women with a history of breast cancer
  31. What are three common indications of oral contraceptives?
    • Prevent pregnancy
    • Regulate menstrual cycles
    • Treat acne
  32. What are oral contraceptives?
    • Combined form of progestins and estrogens
    • Prevents Ovulation (98-99%)
    • Alters endometrium lining

    Mostly considered safe (some debate)

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  33. Do oral contreceptives protect from sexually transmitted diseases?
    No. Does not protect from HIV or other sexually transmitted diseases.
  34. What are some common side effects of oral contraceptives?
    • Upset stomach
    • Vomiting
    • Stomach cramps/bloating
    • Diarrhea /constipation
    • Gingivitis (swelling of the gum tissue)
    • ↑ or ↓appetite
    • Weight gain/weight loss
    • Brown or black skin patches
    • Acne
    • 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
  35. 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
    • Stroke
    • Myocardial Infarction (MI)
  36. 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!
  37. 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)
  38. What is PCOS?
    • Hormone imbalance leading to overproduction of follicles each month by the ovaries without producing an egg
    • Irregular or no periods
    • Depression
    • Excessive weight gain
    • Acne
    • Abnormal hair growth
    • Infertility
    • Often temporary
    • Usually goes hand-in-hand with insulin resistance
    • Body begins to make more androgens

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  39. 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 implantsproliferatesthickenssheds with each menstrual cycle
    • Tissue becomes trappedscar tissue formation
  40. What are the two symptoms of endometriosis?
    • pelvic pain
    • infertility

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  41. What are the steps of the menstrual cycle?
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  42. When does Luteinising Hormone (LH) peak?
    LH peaks before ovulation.
  43. When does estrogen peak?
    Estrogen peaks at ovulation.
  44. Which oral contraceptive is an estrogenic compound?
    Ethinyl Estradiol
  45. Which oral contraceptives are progestational compounds?
    • Norgestimate
    • Drospirenone
    • Norelgestromin
    • Norethindrone
  46. Which oral contraceptives are on the drug list?
    • Yaz®, Yasmin® *Ocella® (Ethinyl Estradiol/Drosperinone)
    • •Anti-mineralcorticoid activity
    • •Avoid use in renal/adrenal insufficiency

    *TriNessa®, Ortho® Tri-Cyclen® (Lo) (Ethinyl Estradiol/Norgestimate)

    • *NuvaRing® (Ethinyl Estradiol/ Etonogestrel)
    • •Inserted every 3 wks on day 1 of cycle
    • •Use back up if removed > 3hrs

    *Loestrin 24 FE®, Necon 7/7/7® (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

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  47. What are some common complaints of too much estrogen?
    • Nausea
    • breast tenderness
    • increased blood pressure
    • headache
    • melasma (dark skin discoloration on sun-exposed areas of face)

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  48. What are some common complaints of too little estrogen?
    • Early or mid-cycle breakthrough bleeding
    • increased spotting
    • hypomenorrhea (scanty periods)

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  49. What are some common complaints of too little progestin?
    • breast tenderness
    • headache
    • fatigue
    • changes in mood

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  50. What are some common complaints of too much androgen?
    • increased appetite
    • weight gain
    • acne
    • oily skin
    • hirsutism
    • increased LDL
    • decreased HDL

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  51. 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.
  52. 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.
  53. 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
  54. 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
  55. 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.
  56. 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).
  57. Drug List
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Top 200: Osteoporosis, Menopause, Oral Contraceptives
Top 200: Spring 2011 Osteoporosis, Menopause, Oral Contraceptives