NR 566 Week 7 Study Guide
Chapter 48: Women as Patients
Pharmacokinetic gender differences between men and women
These three medications have shown differences that are clearly significant between men and women
Propranolol (Inderal): early drug that showed a clear gender difference in metabolism (clearance)
o PO doses: significantly higher (63%) rate of clearance in men than women
o IV doses do not do this: indicates hepatic first pass metabolism
o Women: show a significantly greater clinical response to PO doses
Verapamil (Isoptin, Calan): PO clears more quickly in men than women based on CYP3A4
o Higher absolute bioavailability in women causes greater pharmacodynamic effects on BP and HR in
women
Erythromycin: more effective in women
o More rapidly cleared in women than men r/t CYP 3A4
Pharmacokinetic
Parameter Sex-Based Difference
Absorption and • Gastric emptying time is slower in females, mainly related to the effects of
bioavailability estrogen. Drugs absorbed in the stomach will have longer exposure to
absorption sites.
• Gastric levels of alcohol dehydrogenase are lower in females. Plasma
concentrations are greater in females than males after ingestion of similar
amounts of alcohol.
• Gastric acid secretion, pH, osmolality, electrolyte concentrations, and levels
of bile acids and proteins do not vary significantly between sexes.
Distribution • Females have lower body weights and BMI than males.
• Females have a higher proportion of body fat. Lipophilic drugs are more
readily absorbed and have relatively greater volumes of distribution than
hydrophilic drugs.
• Plasma volume is lower in females. Drugs with high volumes of distribution
will be more concentrated in the plasma of females.
• Organ blood flow is lower in females.
• Estrogen is distributed attached to a serum-binding globulin. Exogenous
estrogens increase levels of many serum-binding globulins such as
corticosteroid-binding globulin and thyroxine-binding globulin resulting in
less free drug.
Metabolism • Studies have been inconsistent in showing differences in CYP450 substrates;
the general trend is toward high rates of metabolism for CYP450 3A4
substrates and lower rates for 1A2 and 2D6 substrates.
• Females have lower levels of p-glycoprotein and higher rates of drug
clearance for drugs that are substrates of p-glycoprotein.
Excretion • Gender differences in rates of renal excretion of most drugs are probably
more related to simple weight differences.
Renal clearance of drugs that are not actively secreted or reabsorbed is
dependent on the glomerular filtration rate, which is directly proportional to
weight and consequently higher (on average) in men.
, Pharmacokinetic
Parameter Sex-Based Difference
• Drugs that are actively secreted by the kidney may show gender differences,
but further study is required to demonstrate this difference.
Recommended Calcium and Vitamin D Intake for Adolescents and Adults
Adolescents
o 1,300 mg of calcium daily is recommended for females aged 9 through 18 years,
drinking three cups of low-fat or skim milk & consuming 8 ounces of low-fat yogurt.
If unable to meet the recommended daily amount of calcium through diet alone, calcium
carbonate (Tums, Caltrate, or Viactiv) with food to maximize absorption.
o vitamin D is required for optimal calcium absorption
a daily multivitamin that includes at least 400 IU vitamin D should also be taken
Adults
o 19-50 years old: 1,000 mg/day
o 51-70 y/o: 1,000 mg/day
o 71+: 1,200 mg/day
Non-Pharmaceutical Treatment of Symptoms Associated with Menopause
Many options for managing menopausal symptoms are available exercise, relaxation techniques, massage
therapy, acupuncture, herbs, or pharmaceuticals (such as HRT)
Some women unable or choose not to take HRT and have turned to phytoestrogenssubstances with
estrogen-like properties found in
o certain herbs: ginseng, black cohosh, dong quai, fenugreek, and licorice
o certain foods—especially carrots, yams, and soy products—varying efficacy
Nutritional supplements for a diet rich in calcium and vitamins E, D, and B complex.
Menopausal women should avoid foods such as caffeine, alcohol, and spicy foods that can trigger
vasomotor symptoms
Table 48-3: Alternative Therapies for Menopause Symptoms
o Hot flashes: pharmaceuticals
o Reduced libido: talk with the patient, sexual counseling/therapy, investigate sleep issues, screen for
depression, weight loss, suggest using alternative therapies for vaginal dryness or soreness
o Mood changes: Meditation, yoga, prayer, adequate sleep, stress management techniques
o Sleep disturbances: pharms, exercise, decreased intake of or avoid stimulants, avoid alcohol,
meditate, pray
o Stress incontinence: decrease intake of caffeine beverages and diuretics, Kegel exercises,
treat/reduce constipation, bladder training program
o Vaginal dryness or soreness: reduce or avoid use of medication such as antihistamines,
decongestants, anticholinergics, and diuretics, alternative therapies for hot flashes (increases
epithelial lining of vaginal tissues), water soluble lubricants
o Weight fluctuations: Exercise 30 to 60 minutes daily
Emphasis in the care of women in their 50s should be on health promotion and prevention of the diseases of
older age
o After menopause the lipid profile of women changes. The decline in endogenous estrogen
removes a protective physiological mechanism that supports higher levels of HDL and lowers LDL
Loss of estrogen places a woman at increased risk for CAD, HTN, and stroke
, o Primary prevention studies demonstrate that diets high in complex carbohydrates, fiber, and protein
and low in animal fat are best
thirty minutes of moderate physical activity for at least 6 days per week is recommended for best health
several years of gradual decline or erratic levels of endogenous estrogen precede cessation of ovarian
function.
All women experience changes in their secondary sexual characteristics. Some women barely notice
vasomotor instability, whereas hot flashes and insomnia incapacitate others
Treatment for Primary Dysmenorrhea
Pain shortly before or during menstruation, one of the most common gynecological complaints
more common in women under 20
Primary dysmenorrhea due to increased myometrial activity, with contractions induced by prostaglandins
in the second half of the menstrual cycle.
NSAIDS are the first line of drug treatment for women not desiring contraception (OTC doses may be
suboptimal)
o particularly effective if begun 2 to 3 days before menses or at the first sign of bleeding
o Preparations containing acetaminophen, which is not an NSAID, are ineffective because of the
absence of anti-prostaglandin properties.
For women who want contraception: PO contraceptives are a good therapeutic choice
Decreased prostaglandin synthesis results from an atrophic endometrium
Complementary and alternative medicines shown to improve symptoms of dysmenorrhea thiamine
(vitamin B1), magnesium, vitamin E, and omega-3 fatty acids
Comfort measures, heat (poultices or heating pads), massage/effleurage, guided imagery, progressive
relaxation, yoga, exercise, and meditation
Decreasing dietary intake of salt, sugar, and red meat in the luteal phase and increasing water intake may
reduce edema
If dysmenorrheal discomfort is NOT relieved by one of the NSAIDS, further investigation into the cause of
symptoms is required.
Secondary dysmenorrhea usually develops later in a woman’s life (after age 25) and often due to pelvic
pathology
o such as adenomyosis, endometriosis, pelvic inflammatory disease (PID), endometrial polyps, and
myomas (fibroids)
o Many of the relief measures for primary dysmenorrhea are also helpful for women with secondary
dysmenorrhea, but treatment is aimed at removal of the underlying pathology.
Patient Education for NSAID Administration to Treat Dysmenorrhea
Particularly effective if begun 2 to 3 days before menses or at the first sign of bleeding
Preparations containing acetaminophen, which is not an NSAID, are ineffective because of the absence of
anti-prostaglandin properties.
Take with at least 8 oz of water
GI ADRs: Risk for GI bleeding, gastric ulcers
Do not take more than prescribed
Rationale Drug Selection for PMDD
To meet diagnostic criteria, patients must exhibit five or more symptoms, including at least one “core”
symptom.
o core symptoms markedly depressed moods, heightened anxiety/tension/edginess/nervousness,
affective lability, persistent and marked anger and irritability
Chapter 48: Women as Patients
Pharmacokinetic gender differences between men and women
These three medications have shown differences that are clearly significant between men and women
Propranolol (Inderal): early drug that showed a clear gender difference in metabolism (clearance)
o PO doses: significantly higher (63%) rate of clearance in men than women
o IV doses do not do this: indicates hepatic first pass metabolism
o Women: show a significantly greater clinical response to PO doses
Verapamil (Isoptin, Calan): PO clears more quickly in men than women based on CYP3A4
o Higher absolute bioavailability in women causes greater pharmacodynamic effects on BP and HR in
women
Erythromycin: more effective in women
o More rapidly cleared in women than men r/t CYP 3A4
Pharmacokinetic
Parameter Sex-Based Difference
Absorption and • Gastric emptying time is slower in females, mainly related to the effects of
bioavailability estrogen. Drugs absorbed in the stomach will have longer exposure to
absorption sites.
• Gastric levels of alcohol dehydrogenase are lower in females. Plasma
concentrations are greater in females than males after ingestion of similar
amounts of alcohol.
• Gastric acid secretion, pH, osmolality, electrolyte concentrations, and levels
of bile acids and proteins do not vary significantly between sexes.
Distribution • Females have lower body weights and BMI than males.
• Females have a higher proportion of body fat. Lipophilic drugs are more
readily absorbed and have relatively greater volumes of distribution than
hydrophilic drugs.
• Plasma volume is lower in females. Drugs with high volumes of distribution
will be more concentrated in the plasma of females.
• Organ blood flow is lower in females.
• Estrogen is distributed attached to a serum-binding globulin. Exogenous
estrogens increase levels of many serum-binding globulins such as
corticosteroid-binding globulin and thyroxine-binding globulin resulting in
less free drug.
Metabolism • Studies have been inconsistent in showing differences in CYP450 substrates;
the general trend is toward high rates of metabolism for CYP450 3A4
substrates and lower rates for 1A2 and 2D6 substrates.
• Females have lower levels of p-glycoprotein and higher rates of drug
clearance for drugs that are substrates of p-glycoprotein.
Excretion • Gender differences in rates of renal excretion of most drugs are probably
more related to simple weight differences.
Renal clearance of drugs that are not actively secreted or reabsorbed is
dependent on the glomerular filtration rate, which is directly proportional to
weight and consequently higher (on average) in men.
, Pharmacokinetic
Parameter Sex-Based Difference
• Drugs that are actively secreted by the kidney may show gender differences,
but further study is required to demonstrate this difference.
Recommended Calcium and Vitamin D Intake for Adolescents and Adults
Adolescents
o 1,300 mg of calcium daily is recommended for females aged 9 through 18 years,
drinking three cups of low-fat or skim milk & consuming 8 ounces of low-fat yogurt.
If unable to meet the recommended daily amount of calcium through diet alone, calcium
carbonate (Tums, Caltrate, or Viactiv) with food to maximize absorption.
o vitamin D is required for optimal calcium absorption
a daily multivitamin that includes at least 400 IU vitamin D should also be taken
Adults
o 19-50 years old: 1,000 mg/day
o 51-70 y/o: 1,000 mg/day
o 71+: 1,200 mg/day
Non-Pharmaceutical Treatment of Symptoms Associated with Menopause
Many options for managing menopausal symptoms are available exercise, relaxation techniques, massage
therapy, acupuncture, herbs, or pharmaceuticals (such as HRT)
Some women unable or choose not to take HRT and have turned to phytoestrogenssubstances with
estrogen-like properties found in
o certain herbs: ginseng, black cohosh, dong quai, fenugreek, and licorice
o certain foods—especially carrots, yams, and soy products—varying efficacy
Nutritional supplements for a diet rich in calcium and vitamins E, D, and B complex.
Menopausal women should avoid foods such as caffeine, alcohol, and spicy foods that can trigger
vasomotor symptoms
Table 48-3: Alternative Therapies for Menopause Symptoms
o Hot flashes: pharmaceuticals
o Reduced libido: talk with the patient, sexual counseling/therapy, investigate sleep issues, screen for
depression, weight loss, suggest using alternative therapies for vaginal dryness or soreness
o Mood changes: Meditation, yoga, prayer, adequate sleep, stress management techniques
o Sleep disturbances: pharms, exercise, decreased intake of or avoid stimulants, avoid alcohol,
meditate, pray
o Stress incontinence: decrease intake of caffeine beverages and diuretics, Kegel exercises,
treat/reduce constipation, bladder training program
o Vaginal dryness or soreness: reduce or avoid use of medication such as antihistamines,
decongestants, anticholinergics, and diuretics, alternative therapies for hot flashes (increases
epithelial lining of vaginal tissues), water soluble lubricants
o Weight fluctuations: Exercise 30 to 60 minutes daily
Emphasis in the care of women in their 50s should be on health promotion and prevention of the diseases of
older age
o After menopause the lipid profile of women changes. The decline in endogenous estrogen
removes a protective physiological mechanism that supports higher levels of HDL and lowers LDL
Loss of estrogen places a woman at increased risk for CAD, HTN, and stroke
, o Primary prevention studies demonstrate that diets high in complex carbohydrates, fiber, and protein
and low in animal fat are best
thirty minutes of moderate physical activity for at least 6 days per week is recommended for best health
several years of gradual decline or erratic levels of endogenous estrogen precede cessation of ovarian
function.
All women experience changes in their secondary sexual characteristics. Some women barely notice
vasomotor instability, whereas hot flashes and insomnia incapacitate others
Treatment for Primary Dysmenorrhea
Pain shortly before or during menstruation, one of the most common gynecological complaints
more common in women under 20
Primary dysmenorrhea due to increased myometrial activity, with contractions induced by prostaglandins
in the second half of the menstrual cycle.
NSAIDS are the first line of drug treatment for women not desiring contraception (OTC doses may be
suboptimal)
o particularly effective if begun 2 to 3 days before menses or at the first sign of bleeding
o Preparations containing acetaminophen, which is not an NSAID, are ineffective because of the
absence of anti-prostaglandin properties.
For women who want contraception: PO contraceptives are a good therapeutic choice
Decreased prostaglandin synthesis results from an atrophic endometrium
Complementary and alternative medicines shown to improve symptoms of dysmenorrhea thiamine
(vitamin B1), magnesium, vitamin E, and omega-3 fatty acids
Comfort measures, heat (poultices or heating pads), massage/effleurage, guided imagery, progressive
relaxation, yoga, exercise, and meditation
Decreasing dietary intake of salt, sugar, and red meat in the luteal phase and increasing water intake may
reduce edema
If dysmenorrheal discomfort is NOT relieved by one of the NSAIDS, further investigation into the cause of
symptoms is required.
Secondary dysmenorrhea usually develops later in a woman’s life (after age 25) and often due to pelvic
pathology
o such as adenomyosis, endometriosis, pelvic inflammatory disease (PID), endometrial polyps, and
myomas (fibroids)
o Many of the relief measures for primary dysmenorrhea are also helpful for women with secondary
dysmenorrhea, but treatment is aimed at removal of the underlying pathology.
Patient Education for NSAID Administration to Treat Dysmenorrhea
Particularly effective if begun 2 to 3 days before menses or at the first sign of bleeding
Preparations containing acetaminophen, which is not an NSAID, are ineffective because of the absence of
anti-prostaglandin properties.
Take with at least 8 oz of water
GI ADRs: Risk for GI bleeding, gastric ulcers
Do not take more than prescribed
Rationale Drug Selection for PMDD
To meet diagnostic criteria, patients must exhibit five or more symptoms, including at least one “core”
symptom.
o core symptoms markedly depressed moods, heightened anxiety/tension/edginess/nervousness,
affective lability, persistent and marked anger and irritability
