1.Dysmenorrhea ()

Primary dysmenorrhea

1-2 12 N/V

1.----2.-NSAIDs -Combination oral contraceptives 3-6 50-80 %

2.Sex Hormone Contraceptive

(Menstrual Cycle) 28 endometrium Gonadotropin releasing hormone (GnRH) Hypothalamus FSH LH follicle estrogen progesterone estrogen progesterone endometrium endometrium

Menstrual cycle Early Follicular phase ( 1-6) FSH LH FSH follicles estrogen Late Follicular phase ( 7-14) estrogen FSH negative feedback FSH estrogen endometrim LH Progesterone granulosa cell cell follicle Pre-Ovulation and Ovulation phase ( 13-14) 1 LH surge 24-36 follicle corpus luteum Progesteron progesterone 0.4-0.6 LH FSH negative feedback Early Luteal Phase ( 15-21) estrogen luteal phase corpus luteum estrogen progesterone progesterone endometrium Late Luteal phase ( 22-28) corpus luteum estrogen progesterone functionalis endometrium

(Combine pills) (Minipills) (Combine pills)1. Synthetic estrogen 2 Ethinyl estradiol (EE) Mestranol 1.1 Ethinyl estradiol (EE) mestranol 1.2- 2 N&V mestranol mestranol 1.2 Mestranol EE metabolism EE EE 20-50 mcg2. Progestin2.1 19-nortertosterone First generation : Norethindone Second generation : Levonorgestrel , dl-norgestrel , Third generation : Norgestimate , Desogestrel , Gestodene2.2 17-hydroxyprogesterone Cypoterone acetate 2.3 Spironolactone Drospirenone

3 generation2.1) first generation - Cyproterone acetate - Norethisterone - Lynestrenol2.2) Second generation - Norgestrel - Levonorgestrel androgen estrogen anabolic 2.3) Third generation - Desogestrel - Gestodene - Norgestimate - Drospirenone Progestin spironolactone analog edema androgen anabolic 2 Monophasic Triphasic Monophasic 21 28 21 7 Triphasic 3 monophasic estrogen COC Thromboembolism Cerebrovascular dz Coronary artery dz active 35 15 20 ( 160/100) aura phenytoid, phenobarbitone, rifampin 5 back up 1 ........... 6 .............. 3 ............................ 2-3 7 7 .............. 4 ................ 2 / 1 21 day packs.7 days break 28 day packs.no break 1 ......... back up 2 2 ......... 1 2 back up 1 2 3 ........ back up 1 COCs A-C- H- E- S-, , Progestin only pills (Minipills) Progestin 28 COCs estrogen 6 stroke IHD VTE 1 1 3 3 24 POPs IHD stroke COCs1) 2-3 2) 3) 3 ? ? ? ? : 4) Amenorrhea 1 2 5) anabolic () lifestyle 6) third generation cyproterone acetate7) third generation

8) Eye cornea edema contact lens Drug interaction hepatic enzyme inducer Carbamazepine, Phenytoid, Phenobarbitone, Primidone, Topiramate Griseofulvin HIV PIs, NNRTI Rifampin Herbal product St Johns wort

COC P only : Levonorgestrel E only IUD Anti-progestin : mifipristone DOC Levonorgestrel 750 mcg 85-88% 1 72 1 12 2 72 2 1 12 3 7 bleeding 2-3 2

Depo-medroxyprogesterone (DMPA) 3 5 2 3-18 2 1. progesterone Depot medroxyprogesterone acetate (DMPA) IM 3 Norethisterone enanthate (NET-EN) Noristerat IM 2 2. (estrogen + progesterone) DMPA1. 2. estrogen progesterone 3. 4. 5. DMPA DMPA 7 backup-method DMPA 7 backup-method 7 DMPA backup-method 7 6 6 DMPA back-up method DMPA DMPA 3 2 back-up method

1) Norplant capsule 6 LNG 36 mg 5 2) Norplant II capsule 3 LNG 75 mg 5 3) Etoplant capsule 1 etonogestrel 60 mg 3 5-7 3 7 Levonorgestrel Intrauterine system (LNG IUS) LNG 38-52 mg 20-65 mcg 5 7 4 ()

3.

Primalute-N northisterone 5 mg 3 1x2 1x3

4..Drugs used in pregnancy and lactation1. (Pregnancy Category) US FDA2. Teratogens Teratogens 3. /4.

US FDA Pregnancy CategoryCategory A : 1st trimester fetusCategory B : fetus Category C : fetus Category D : fetus Category X : fetus Teratogens - (2 wks ) : All-or-none effect- 3 (1st trimester) : (organogenesis) - 4 : : Ex : alcohol Preimplantation : fetus Organogenesis : fetal alcohol syndromeLate pregnancy : mental retardation, functional incapacity Teratogens Alcohol (FAS)CyclophosphamideDiethylstylbestrol (Mulleriun duct, vagina)LithiumIsotretinoinIodine, Propylthiouracil (thyroid gland)Phenytoin (adrenal gland)Warfarin ()Tetracycline ()Thalidomide (Phocomelia)Valproic acid (Spina bifida)Vitamin A (high dose) 1. Antibiotics Anti-infective agentsPenicillins & derivatives Cephalosporins : Erythromycin : estolate form cholestatic hepatitisSulfonamides : - 1st trimester anti-folate activity fetus - 3rd trimester kernicterus billirubin albumin-binding site hyperbillirubinemia billirubin BBB billirubin encephalopathy (kernicterus)Tetracyclines : hepatotoxicity non-pregnant ( : Cat. D)Aminoglycosides : nephrototoxicity & ototoxicity ( : Cat.C)Quinolones (Norflox, Ciproflox) : ( : Cat D)Chloramphenicol : Gray syndrome Anti-TB (INH, PZA, RIF, ETB) : INH Pyridoxine (vitamin B6) fetal neural damageMetronidazole : (Category B) Tricomonas2. Analgesics & Anti-inflammatory drugsAcetaminophen : Drug of choice high dose long durationASA & NSAIDs : 3rd trimester Prostaglandins , , closure of ductus arteriosusIndomethacin : ductus arteriosus Meperidine : ( 6 hrs 60 min)Codeine & Opiates : 1st trimester malformation 2nd 3rd trimester 3. Antihistamines, Decongestants & AntitussiveAntihistamines : CPM, Diphenhydramine, Dimenhydrinate, TripolidineDecongestants : PseudoephedrineAntitussive : Dextromethorphan, Guaifenesin/1. Morning sickness : Pyridoxine, Doxylamine (Dendox), Dimenhydrinate, Meclizine, Metoclopramide2. Backache : Acetaminophen3. UTI : Asymptomatic - single dose therapy : Cephalexin 3 g/ Nitrofurantoin 200 mg- short course therapy (3-7 ) : Amoxycillin+Clavulanic acid, Cephalexin, CefuroximeSymptomatic - Acute cystitis : short course therapy 3-7 asymptomatic - Acute pyelonephritis : Piperacillin/Ticarcillin+Clavulanic acid, 3rd generation cephalosporin (Cefotaxime, Ceftriaxone, Ceftazidime), Aminoglycoside, Aztreonam 10-14 4. Constipation : Docusate sodium, Psyllium hydrophilic mucilloid ( non-absorption & non-irritate fiber) 2nd 3rd trimester Bisacodyl low dose MOMContraindication : Mineral oil, Castor oil, Saline cathartics high dose MOM, MgSO4, Mg citrate, Na2PO4 5. Legs cramp : CaCO3, Ca lactate6. Hemorrhoids : non-steroidal soothing ointment/suppo. (Anusol)7. Heart burn : , antacid (PPI, H2RA), NaHCO3, Sucralfate pH ~7.1 (6.35-7.65) ( > plasma) M:P ( M:P = drug conc. in milk / drug conc. in plasma ) M:P < 1 M:P > 1 M:P

5.Hormone Replacement Therapy (HRT)

(vasomotor symptom) topical product HRT 3 1) Estrogen onlyOral :Conjugated equine estrogen (CEE) Premarin Estradiol valerate ProgynovaMicronized estradiol17 beta estradiolTransdermal patch 1 1 2 3 1 hormone freeVagina cream ** 10**2) Progestin only 3) Estrogen+Progestin 2 Continuously 28

EP

EP

irregular bleeding amenorrhea

Cyclic 1-21 25 E 10-14 2

EE

PP

P HRT ......... E Premenstral-like syndrome ()........ P HRT 5 2-3 Venous thrombolism 2 MI 1-2 Other options for menopausal symptom relief Tibolone (Livial) 2.5mg/d vasomotor symptom bleeding TG HDL