CHAPTER 23 Women’s Health Issues
I. Osteoporosis
B. Pathophysiology
1. In normal bones, there is a regulated balance between the activity of cells that create bone and those that break it down, a process called bone remodeling. There are three main cell types that compose bone:
2. Healthy bone remains stable because osteoblasts and osteoclasts are working at a similar rate, allowing bone to continuously remodel and heal when damaged. If osteoclast activity outpaces osteoblast activity, bones become weakened. In other words, if resorption is greater than formation, bone loss occurs.
3. By the mid-30s, most men and women gradually begin to lose bone strength. When bones become less dense and structurally weaker, this condition is known as osteopenia. Osteopenia refers to mild bone loss that is not as severe as osteoporosis. Individuals with osteopenia are at increased risk of developing osteoporosis. As the condition progresses, bones lose calcium, phosphorus, boron, and other minerals and they become lighter, less dense, and more porous. If untreated, osteopenia can progress painlessly to osteoporosis, increasing likelihood of fracture. Although any bone is susceptible to fracture, the most common fractures due to osteoporosis occur at the spine, wrists, and hips. Spine and hip fractures in particular may lead to chronic pain, long-term disability, and even death.
4. Extracellular levels of calcium, vitamin D, and parathyroid hormone (PTH) are key regulators in maintaining bone remodeling. PTH enhances the release of calcium and stimulates bone resorption and formation. Estrogen is thought to have a direct effect on bone cells. It enhances bone formation by stimulating the estrogen receptors, which are located on the osteoblasts. There is a direct link between the estrogen loss after menopause and the development of osteoporosis. Low hormone levels that occur in early menopause can significantly increase the risk of osteoporosis. Using anti-inflammatory corticosteroids may also significantly affect bone health. Corticosteroids are commonly taken by women greater than 55 years of age for conditions such as arthritis but are known to directly lead to bone loss. It is estimated that 20% of all osteoporosis cases may be attributed to corticosteroid use.
F. Treatment
3. Adequate intake of vitamin D needed to help with absorption of calcium and maintain muscle strength
5. Medications
a. Therapies that increase BMD and prevent fractures
(1) Calcium
b. “Bone-building” treatments
| T-score | |
|---|---|
| Normal | > −1 |
| Osteopenia | −1 to −2.5 |
| Osteoporosis | < −2.5 |
(1) Bisphosphonates
(a) Mechanism of action: bisphosphonates adsorb to the bone, preventing osteoclasts from adhering to the same bone surfaces, thereby inhibiting osteoclast activity.
(c) Provide the greatest BMD increases, effect is dose-dependent, combination therapy with estrogen/hormone replacement therapy (HRT) results in greater increases in BMD
(e) Adverse effects: nausea, dyspepsia, abdominal pain, diarrhea; esophageal, gastric, or duodenal irritation, perforation, ulceration or bleeding, acid reflux; osteonecrosis of jaw
(f) Considerations, if patient is taking medication orally
(i) Take on an empty stomach, with plain water only, first thing in the morning before having anything to eat or drink.
(2) Hormone replacement therapy
(a) Estrogen alone or estrogen plus progestin
(i) Mechanism of action: The bone-protective effects of estrogen may involve suppression of inflammatory chemicals called cytokines, as discussed previously. There are estrogen receptors on osteoblasts and osteoclasts. Estrogens decrease osteoclast recruitment and activity, inhibit PTH peripherally, increase calcitriol concentrations and intestinal calcium absorption, and decrease renal calcium excretion. Estrogens also decrease cytokine levels.
(ii) Consideration: The progestin component is added only in women with an intact uterus to prevent endometrial overgrowth and endometrial cancer.
(iii) Caution: Use is contraindicated in active/suspected estrogen-dependent cancer, abnormal vaginal bleeding, severe liver disease, and active vascular thrombosis. Relative contraindications include migraines, thromboembolic disease, hypertriglyceridemia, uterine fibroids, endometriosis, gallbladder disease, family history of breast cancer, and chronic hepatic dysfunction.
c. Medications that increase BMD only
G. Prevention
6. Adequate calcium and vitamin D are essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis. Postmenopausal women are especially susceptible to fractures of the hip, wrist, and spine; therefore, it is recommended by healthcare professionals for postmenopausal women to have about 1200–1500 milligrams of calcium and 800 IU of vitamin D daily.
II. Vaginitis due to Yeast Infection
A. A yeast infection is a fungal infection called vulvovaginal candidiasis (VVC). It is rare before menarche. Incidence is likely after age 20, and 50% of women who have had a yeast infection before will have another yeast infection.
B. Yeast is part of the normal flora in the vagina. Usually, changes in the patient’s vaginal environment triggers the infection. Changes include hormonal changes, such as in pregnancy, or the use of antibiotics, which disrupt the normal flora in the vagina.
C. The major pathogen is Candida albicans. With increasing use of over-the-counter (OTC) products, short-course therapies, and the increased use of preventive or long-term maintenance therapy, there is an increased incidence of non-albicans candidiasis (e.g., Candida glabrata). A diagnosis for a yeast infection or VVC entails a positive vaginal culture for Candida.
D. Yeast infections can be sporadic or recurrent. They could also be defined as uncomplicated sporadic infections, which most likely, will be susceptible to all forms of antifungal therapy regardless of the duration of treatment. Complicated or recurrent VVC occurs in immunocompromised patients or those who have uncontrolled diabetes. Therapy in these populations requires longer duration (10–14 days), regardless of the route of administration.
F. Symptoms generally worsen during menstruation because the hormonal changes provide a better environment for fungal growth.
G. Treatment
2. Prescription antifungal suppositories/vaginal creams (Table 23-2)
3. Common OTC vaginal medications
III. Menopause
| Active Ingredient | Duration | |
|---|---|---|
| Terconazole (Terazol, Zazole) | 0.4% cream | 7 days |
| 0.8% cream or 80 mg suppository | 3 days | |
| Nystatin | 100,000 unit vaginal tablet | 14 days |
Table 23-3 OTC Medications for Vaginal Candidiasis
| Active Ingredient | Duration | |
|---|---|---|
| Butoconazole (Femstat) | 2% cream | 3 days |
| Clotrimazole (Gyne-Lotrimin, Mycelex, Canesten) | 1% cream or 100-mg tablet | 7 days |
| 2% cream or 200-mg tablet | 3 days | |
| 10% cream or 500-mg tablet | 1 day | |
| Miconazole (Monistat, Vagistat-3, Monistat-1 Ovule Pak) | 2% cream or 100-mg suppository | 7 days |
| 200-mg suppository | 3 days | |
| 1200-mg ovule | 1 day | |
| Tioconazole (Vagistat-1) | 6.5% ointment or 300-mg ovule | 1 day |
B. Signs and symptoms
D. Pharmacologic treatment
1. Hormone replacement therapy (HRT)
a. Can cause many short-term and long-term side effects; risks versus benefits should be weighed carefully and monitored closely by physician
b. Common minor side effects include bloating, breast tenderness, cramping, irritability, mood changes or depression, menstrual bleeding
c. More serious, long-term side effects
(1) Breast cancer and cardiovascular disease (stroke, heart attack), especially in women who have not had a hysterectomy
e. Estrogen therapy is the most popular treatment for hot flashes due to menopause
IV. Contraception
A. Oral contraceptives (Tables 23-4 to 23-9)
1. Consists of hormones, estrogen and progestin, in pill form to be taken daily. A 4-week cycle typically has 21 hormonally active pills followed by seven pills containing no hormones. Some packagings omit the inactive pills. Some regimens (e.g., Seasonique) allow for continuous dosing for 3 months.
2. There are three categories of oral contraceptives. Before prescribing, the physician considers age, medical history, lifestyle, cost, and potential side effect profile. If one category is tried, but the patient experiences too many adverse effects, the doctor may switch to another category. The doctor may also try another brand, within the same category, but with a different dose.
4. Advantages of oral contraceptive
c) Manipulating menstrual cycle to avoid a period during certain events, such as vacations or weekends, by extending the number of intake days of hormonally active pills or by skipping the nonactive pill week
6. More serious risks include blood clots, heart attack, stroke, or pulmonary embolism especially in women older than 35 years and women who smoke, have hypertension or hyperlipidemia, and are obese.
TABLE 23-4 Monophasic Oral Contraceptives
| Generic Components and Doses | Product Names |
|---|---|
| Desogen | |
| Ortho-Cept | |
| Reclipsen | |
| Solia | |
| Apri | |
| Yasmin | |
| Demulen 1/35 | |
| Zovia 1/35 | |
| Kelnor 1/35 | |
| Demulen 1/50 | |
| Zovia 1/50 | |
| Levlite | |
| Alesse | |
| Aviane | |
| Lutera | |
| Lessina | |
| Levlen | |
| Nordette | |
| Levora | |
| Portia | |
| Ovcon-35 | |
| Balziva | |
| Modicon | |
| Brevicon | |
| Necon 0.5/35 | |
| Nortrel 0.5/35 | |
| Ovcon-50 | |
| Loestrin 1-20 | |
| Microgestin 1-20 | |
| Junel 1/20 | |
| Ortho-Novum 1-50 | |
| Norinyl 1-50 | |
| Necon 1-50 | |
| Lo-Ovral | |
| Low-Ogestrel | |
| Cryselle | |
| Ovral | |
| Ogestrel | |
| Ortho-Cyclen | |
| Sprintec | |
| Mononessa | |
| Previfem | |
| Loestrin FE 1-20 | |
| Microgestin FE 1-20 | |
| Junel FE 1-20 | |
| Loestrin FE 1.5-30 | |
| Microgestin FE 1.5-30 | |
| Junel FE 1.5-30 |
Note: Bold indicates originator product brand names; italics indicate generic name.
TABLE 23-5 Biphasic Oral Contraceptives
| Generic Components and Doses | Product Names |
|---|---|
| Mircette | |
| Kariva | |
| Ortho Novum 10–11 | |
| Necon 10–11 |
Note: Bold indicates originator product brand names; italics indicate generic name.
TABLE 23-6 Triphasic Oral Contraceptives
| Generic Components and Doses | Product Names |
|---|---|
| Cyclessa | |
| Velivet | |
| Vesia | |
| Triphasil | |
| Tri-levlen | |
| Enpresse | |
| Trivora | |
| Ortho Novum 7-7-7 | |
| Necon 7/7/7 | |
| Nortrel 7/7/7 | |
| Tri-Norinyl | |
| Leena | |
| Aranelle | |
| Ortho Tri-Cyclen | |
| Tri-sprintec | |
| Trinessa | |
| Tri-previfem | |
| Ortho Tri-Cyclen Lo | |
| Estrostep/ Estrostep FE |
Note: Bold indicates originator product brand names; italics indicate generic name.
TABLE 23-7 Extended Cycle Oral Contraceptives
| Generic Components and Doses | Product Names |
|---|---|
| Ethinyl estradiol 20 mcg and drospirenone 3 mg | Yaz 24/4 |
| Ethinyl estradiol 20 mcg and norethindrone acetate 1mg + ferrous fumarate 75mg | |
| Ethinyl estradiol 30 mcg and levonorgestrel 0.15 mg | Seasonique |
Note: Bold indicates originator product brand names; italics indicate generic name.
TABLE 23-8 Progestin Only Oral Contraceptives
| Generic Components and Doses | Product Names |
|---|---|
| Norethindrone 0.35 mg | Ortho-Micronor |
| Nor-QD | |
| Camila | |
| Errin | |
| Jolivette |
Note: Bold indicates brand name; italics indicates generic brand name.
TABLE 23-9 Emergency Contraceptive
| Generic Component and Dose | Product Name |
|---|---|
| Levonorgestrel 0.75 mg | Plan B |
Note: Bold indicates brand name.
PATIENT PROFILE
PATIENT PROFILE QUESTIONS
1. Based on the evidence, which of the following statements is most true about the use of soy or black cohosh supplements in terms of efficacy?
a. The supplements may be tried as first option in patients with mild to moderate symptoms because there is little concern for safety or side effects in any woman and they have been proven efficacious at reducing hot flash episodes.
b. The North American Menopause Society (NAMS) 2007 guidelines state these may be reasonable first options in women with mild-moderate symptoms provided breast cancer risks and contraindications are not evident; however, trials of better evidence, such as the Herbal Alternatives for Menopause Trial (HALT study), do not support their efficacy.
2. RH tries a soy isoflavone supplement for several months with lifestyle changes. She returns to the pharmacy in 6 months stating symptoms are not really better and are “getting more pronounced and frequent.” She has discussed her options with her physician. She will try estrogen-progestin hormone replacement therapy (HRT) for a few months. What type of HRT regimen might be the best choice for RH?
b. Use traditional dosing of conjugated estrogens 0.625 mg PO per day with either a sequential or continuous oral progestin.
3. Several years later RH’s menstrual periods have ceased, with confirmatory FSH level of >40 ng/mL indicating menopause. RH is no longer interested in hormones due to the potential health risks, particularly with regard to breast cancer and heart disease. She is now on regular calcium and vitamin D supplements. She wonders what is the best way to discontinue hormone replacement. True or False: RH should quit estrogen regimen “cold turkey” because vasomotor symptoms should not occur now that she is in menopause.
REVIEW QUESTIONS
(Answers and Rationales on page 379.)
1. Which of the following underlying factors may be responsible for the development of osteoporosis in postmenopausal women?
6. Which of the following medications should be avoided in pregnant women due to ability to stimulate uterine contractions?
15. Which of the following is an appropriate indication for gonadotropin-releasing hormone analog therapy?
