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Hello, everyone, thanks very much to everyone who has joined on time so far. If you don't mind standing this QR code that will take us to the slider where you'll be able to answer the questions from today's um, tutorial. And you also have the opportunity to ask any questions on the Q and A section. So if you understand that QR code for me last week for everyone else to join and we'll start in a few more minutes. Okay, let's crack on with today's session. Let's get the slides and everything loaded. So thanks to everyone for joining for today's tutorial, we're going to be covering the contraceptive pill and hormone replacement therapy side of the PAS. A prep course. My name is Doctor Check and one of the ones studying at Milton Keen's Hospital. Uh, for those of you who have joined a bit late, if you want to scan the QR code, that will take us over to the slide. Oh, and that's where you'll be able to answer any questions. So again, same disclaimers. Before we help, prepare the PS a course to provide as a supplement for your revision. Always remember to consult your university as well as the TNF or medicines complete for up to date information. So today we got a variety of learning objectives. We're going to quickly run through the different types of contraceptives, mainly focusing on the different oral contraceptions. Uh, specifically, we'll be looking at the types of pill regimes, what sort of advice to give when a patient has missed the pills and any other adult patient advice, which may come up in the later questions in the PS PSA exam, we'll also be doing a quick run through on hormone replacement therapy. Again, we'll give it a bit more focus on actually prescribing types of hormone replacement therapy as well as again, the patient advice side of things. I know that last week did rush the session a bit, so we'll try and take things a bit more slower this time. Hopefully, we should be able to get finish within the hour, and hopefully my audio doesn't cut off as much as last week. But please do let me know if there are any audio visual problems. So let's talk a bit about the oral contraceptive pill, having to look at both the combined and the progesterone only pill so quick run through what the pills actually are. The combined oral contraceptive pill abbreviated a C O. C. P contains both addressed estrogen, sorry and progesterone. And the usual regime for most women who take this pill will be a 21-7 regime. So what that means is they will be taking a pill for 21 days, and then they'll have a rest period for seven days, and this will be when they have their withdrawal bleeds. There are a few different schemes that you can give women. Um, sometimes they'll offer 21 4, so that will mean they'll have 21 days of the medication, and they have a four day break. Sometimes they can have longer scheme, so 63 would be for three months. They will continually take the pill, and they would have a seven day break. Sometimes they can have a continuous regime, which is where they were. Just constantly take it without having any rest periods. And there are a variety of contraindications for the combined oral contraceptive pill, which will go into later. And this is probably one of the most common, uh, C o. C. P pills that you'll see prescribed. This is a brand name known as Microalbumin, and we'll talk a bit about how we can find the specifics on the TNF in a bit. On the other side, we have the progesterone only pill, and I mean it's in the name. It only contains progesterone. There are three main preparations, which we supply in the UK, so it's good to get familiar with the names you have. Norethisterone you have levonorgestrel or you have desert gastral. These ones are essentially taken continuously, and they have the caveat that there are stricter missed pills rule. And there's a tighter schedule in terms of how regularly you have to take them. Um, just to let you know. And we'll have a look at the B N f later. Sometimes with especially with the C o. C P pills, they can have a slightly different prescription, which is known as an E D, which I think probably stand for extended duration. So rather than micro going on 30 it'll be micro going on 30 e. D. And this is essentially, uh, during that seven day break period, they'll be taking placebo pills so they're taking pills, which I don't do anything. They don't have any hormones in them. But it's more for the benefit of the patient, just so that they remember to take the pill every single day and just get it to get into that natural habit. But again, we'll explore all that on the TNF in a second, and this is again an example of one of the common progesterone only pills that you might see being prescribed. So enough about the background on the types of pills. Let's go straight into it with the first question. So I got a quite a pretty simple question here, but I made a bit more difficult. We've got an 18 year old female who's attending a GP practice for the first time. She's recently moved into town to start a university degree, and she'd like to prescribe her usual microalbumin 30 tablets, which she normally takes for contraception. She says that she normally takes the pill for 21 days and has a seven day break. So please write a prescription for her medication request, and if you guys can fill in this slider for me, that would be great. Sorry, Carey all right. I, uh, spoke incorrectly. Last week's session was canceled. What I meant was the last session with me, which was two weeks ago. So let's give it a few minutes for you guys to type up the prescription for a microadenoma first tablets, which you normally take for 21 days and a seven day break. Okay, so let's have a look at the answers and see what people are written down. So it seems like the majority. In fact, pretty much everybody has written down my question on 30 once a day oral. Um, I don't know why it's broken it down as a word cloud. I will get on top of my slider game. Um, but essentially, people have written down my question of 31 tablet orally once a day for 21 days. So let's go over to the question. So the reason why I said I made this question with a bit trickier is that in the actual PSA exam, when you get a question like this, you will actually get it written down like this. So usually they will type out the full drug name. So for microalbumin on, it's ethinyl estradiol. 30 micrograms with Boehner guests levonorgestrel 150 micrograms and then in brackets. They'll have the brand name, and we'll see that in some of the later examples as we go along. Um, so this is how it actually be written on the PS PSA exam. But I hit this bald out part to make it a bit harder to make you guys search it on the TNF. So on the TNF, when you search micro gin or when you search the brand, the drug name, this is what it comes up as on the TNF. So it says contraception with 21 day combined preparation by mouth, and you've kind of got all the information there. It tells you all the specifics about when they need to take it, how long they need to take your foot, etcetera, etcetera. But it's all a bit worthy, and secondly, it doesn't really give us the actual drug prescription recommendation. And what I mean by that is when you actually write the prescription out, what drug do you prescribe it as? Um so let's go over to the B n f. And I will show you how I would answer a question. Um, like this. So we'll use medicines complete first. Well, I'll try and go back and forth. So if I had a question like this, I would probably type something like oral contraceptive, and we can see here. We've got contraceptive hormonal, and we've got it down here as well. Make sure that you click the TNF version of the TNF for Children version. So if we have a look here, we can see you've got contraceptive hormonal. And this is another page I would highly recommend that you get familiar with. There's a lot of information all the way up here, but what I'm focused on, what I'm interested in is this or this set of tables here. I'll explain what the differences are later, but essentially, we are looking for this. Yeah, which is the microalbumin 30 again? A quick way to do it would be to do control F and search micro gain. Um, and here we go. We got the microalbumin 30 and it tells you here what the estrogen content is and what the progesterone content is. And on the actual ps PSA itself, this is technically how you should write out the prescription. So let's go over to the PPT. So, like I said, going to be NFL medicines complete, and you can search oral contraceptive. Or you can search micro going on in terms of the brand name itself. I would recommend going over to contraceptive hormonal, and then under the heading of preparation choice, you have this huge table which have cut up. But this is the one that we're looking for the CCP monophasic 21 day preparation. If you control f and search McKagan on or you're recovered on or whatever you're looking for, it will show up with the actual, um, drugs that are inside the pill the other way, which is a bit more convoluted. But some of you may prefer is again to head over there, search Michael gin on, and when you do search it, it can come up with the actual drug name itself. So I'll just quickly show you guys what I mean by that head over to the TNF this time you search micro going on, you can see here we've got the contraceptive hormonal treatment summary, or we've got the actual drug name itself under medicinal forms. Um, so there's two different pages to be familiar with. When you go into the BNFL medicine complete one is the drug monograph and one is the medicinal forms. So the drug monograph is what I showed you earlier. This is what you usually look at when you are prescribing something for the PS, PSA or in general, um, everyday practice. And this was the screen shot I showed you earlier. Um, it's the same for menstrual symptoms or for contraception, but it doesn't really give you the actual drug doses. So what you do is if you go down, if you click medicinal forms and then you can see the actual medicinal form here, it tells you how this drug is prepared and how it's readily available in the in the pharmacy, so you can see that you have tablets. Um, this will kind of go into later on. But what I'm interested in for the purpose of the question is to look at Michael J. And, um, and you can see here for the microalbumin 30 tablets, the active ingredients of ethinyl estradiol and levonogestrel at 30 and 150 micrograms. And there's that screen shot there. So the next question is okay. We've got all the information that we want. How do we actually prescribe it in terms of the PS PSA exam? So how does the PS PSA exam want us to format it? Do they want us to write my codeine? Um, do they want us to write out the full FNL estradiol, blah, blah, blah. So the answer is they want the full version. And, um, I'll say a time and time again when you're answering questions when you're practicing for the PSSA, always have one of the pas a mark papers open just so you can have the prescribing page ready, and you can type it in and test it out. When you go on to the PSSA, any of them on exams. The moment you search ethinyl estradiol, you'll get this huge drop down list, and you essentially be able to look through and find what prescription you're looking for. So the moment you type in FMLA straddle in the drop down list, you'll see that one of the options is ethanol estradiol, 30 micrograms slash levonorgestrel 150 micrograms monophasic 21 day tablets, and that is the full name of the medication that they want. Obviously you don't need to take it all out. You just click it on the drop down list. The dose itself, therefore is one tablet. Rather than writing out 30 microgram slash 250 micrograms, the root is going to be orally and the frequency is going to be once daily. So, um, it's in the name that it's a 21 day scheme, the actual frequency of them taking the tablet. The tablet themselves will be once daily. But of course, in real practice, you would explain to the patient that you're going to be taking this for 21 days and you have a seven day period in between where you don't take anything or four day period, etcetera, etcetera, depending on what the patient prefers. So when we looked at the tables earlier, in fact, I'll show you guys, if we go on to the TNF and we look at hormonal contraceptives, you can see down here. This is the C o C. P monophasic, which is the word. I want you to focus on the monophasic 21 day preparations. We've also got monophasic 28 day preparations so This is what I was talking about. Whether to take seven days of placebo pill. Um, but we can also see down here we have multiphasic 21 day and multiphasic 28 day preparations. This is where things get a bit more complicated. But I would reassure you guys, I'm saying you won't be asked to prescribed. You won't be asking the exam to prescribe a multiphasic tablet, but it's still useful to know in terms of, for example, your pace or your specialties exams or for real life practice what that actually means. So a monophasic tablet is essentially when every single tablet has the same dose of medication. So in your microalbumin on it will be your 30 micrograms and 150 micrograms. And so there's no confusion with taking the medication. You can essentially take any tablet randomly and you'll get the same dose. The benefits of the Monophasic tablet is that you will get less side effects from fluctuating hormones, and what I mean by that is, um, well, that's essentially what the multiphasic tablets are. You get a different group of tablets, which each have their own strength. So, um, in clinical practice they described as different phases of tablets, and you need to take the the pills, therefore in a specific order. So the reason why they have these multiphasic tablets is is because it mimics the body's normal menstrual cycle and the normal level of hormones that you would have during the different phases of the cycle. The benefits of this is that it's designed to reduce the total amount of hormone dosage that you get. And so for different people, they may react better to the monophasic tablets. Or they may react best to the multiphasic tablets in terms of side effects. So it's all about patient preference. The reason why I say that you won't get the multiphasic tablets in your PS PSA exam is because if you take this example the low guy, non coated tablets, it's very convoluted and complicated, So they would have to take six of the light brown tablets, which has 30 micrograms of ethinyl estradiol and 50 micrograms of levonorgestrel. After they finish the six. They would then have to take the five white tablets which you can see is a different dosage strength and then after that they have to take 10 of the local tablets, which is 30 micrograms and 125 micrograms. So already it's it's quite confusing in terms of you have to you have to write three prescriptions, Uh, which would be too much work or and it would be weird for them to ask if it would be weird for them to ask you guys to prescribe just one of these. I mean, theoretically, not impossible. But I think it would be really, really mean. Um, but let's familiarize ourselves with the TNF just to make sure, in case it does happen. So the low guy non coated tablets is produced by Bayer, and you can see here on the graphs here, we've got the 30 50 Bayer. We have the 40 75 Bayer, and we also have the 3200 and 25 Bayer. When you search ethinyl estradiol levonorgestrel. I guess this is the more reassuring thing. When you look at the actual graph themselves, they are notated down in chronological order. So for if for some odd reason, the ps a exam asked you to prescribe the third phase of the Lodine on, you can just head over here and you can see it's the estradiol 30 and the Levonorgest 25 that should be fine. Um, same if we said if the exam said to prescribe the second phase of the sin phase tablet, you can just jump straight to the second tablet and prescribe as this, um, you need to figure out on the B N F. And it will be written down somewhere for how many days they need to take it, because it's different for each of the tablets. So it's very convoluted. It's quite complicated, and I think it's very, very unlikely they'll ask you to prescribe the multiphasic tablets. But it's nice to be aware that there is guidance on the B N F. And it's in the structured order, just in case it does come up. Just take a quick break here to see if anyone has asked any questions. Okay, using the PS, the market about the BP and Micro and 30 and the answer is to switch. Is Sarah set? Where do you find the information about prescribing in the contraceptive pill? There wasn't any informed patient info. It's a good question. I don't know the answer specifically off the top of my head, so we'll come back to that at the end of the session. Um, and it will be. It will be included in the recording if you can't stay after two. A couple of a good question, UH, which we'll have a look until later on. So the next part of the talk is the Missed Pills section. Now this is what it says on the B N F. It's got all the information there, but it's very worthy. It's very complicated. You're going to be stressed during your exam. You're not. You don't want to be reading for all this to find the specific information that you need in terms of advice when it comes to Ms pills, so to summarize, when it turns to the combined contraceptive pill. If they've missed one pill, they need to take the Ms Pill straight away and continue with the rest of the pack as normal, as simple as that. If they've missed two or more pills, then they need to take the most recently missed pills straight away. So, for example, if I had missed a pill on Friday, and if I had missed a pill today on Saturday. I only take Saturdays pill. I don't take Fridays and Saturdays. I would also need to make sure that I either abstain or the patient abstain from sex, or they use condoms for seven days. If they've had any recent intercourse in the previous seven days, especially in that period when they have not been on the pill, they also need to seek advice for emergency contraception. A quick side note is that if they have less than seven pills left in their pack after a mist pill, they are not to have that seven day break period. They're essentially to skip the seven day break and to start the next pack straight away. So, for example, if I was on the pill, if I had missed a pill yesterday and I only had two pills left, then I'll take one. Now I'll take my next pill at the normal time that I take it. I would skip my seven day break through withdrawal, withdrawal, bleeding, period, and I would start the next pack straight away if that will make sense. Okay, and there's there's further information on the notes of the slides, which I'll make sure you are handed out. When it comes to the progesterone only pill, it's a bit more stricter. So the important thing with the pop is that they have a three hour window in which they need to make sure they take it every day. So if I normally take the pop at 12 o'clock at noon, then the latest that I can take it is going to be by three o'clock every single day. So if they've missed a pill and it's not, it's been less than three hours. So let's say normally take the pill at 12 o'clock every day. But right now it's, um, once it's half past one, let's say I forgot to take my pill at 12 o'clock. It's okay for me to take the pill, and everything else will be fine. So up until 3 p.m. It will be fine for me to take the pill if I had forgotten to take it at 12 at noon Stone. Now, if they've forgotten a pill and it's been over three hours, then they need to take the most recent pill straight away, and they need to abstain from sex or they need to use condoms for at least two days, so the time it takes for the pop to kick in and provide adequate protection is two days. So if I hadn't taken it for the last five days, for example, I would take one. Now. I would make sure I would take it at 12 o'clock every day from tomorrow. And I'll have to use condoms or not have sex for the next two days to make sure. And of course, again, if they've had any recent intercourse during that missed period period, they need to seek advice for any emergency contraception. The reason why there's an asteroid asterisk next to the three hours is because that that's a bit more lenient if you're taking the desogestrel pop. So patients on the desogestrel well actually have a 12 hour limit. Whereas for the other two pops that we mentioned at the beginning, they only have a three hour window in which they need to make sure they take their, um, regular contraceptive in terms of patient information to provide again. This is all information that can be found on the B N F. But summarize if the patient has vomited within two hours of taking the pill. You need to assume that the patient hasn't had time to digest the pill and that they vomited out the contents. So all you advise them is to take another pill. If they vomited, let's say, three or four hours after taking the pill, you assume that they've absorbed everything the pills properties, and they should be fine. Conversely, if we're looking at diarrhea, if a patient has had severe diarrhea that has lasted at least 24 hours or longer, then you need to act as if they've missed the pill. So you need to assume that the pill hasn't probably been absorbed in the GI tract, and they just excreted out. And they need to keep acting like this until the diarrhea is no longer severe, essentially until the diarrhea has settled down in terms of the risks from the combined pill contraceptive pill, the main ones you need to be aware of is that there's an increased risk of V, T, e M I and stroke, and there's also an increased risk of breast and cervical cancer, whereas for the pop there's an increased risk of breast cancer only, and there's also a risk of them having, I think, benign ovarian cysts. But these are the major risks to be aware of in terms of the CCP and the P. O. P. And in terms of the absolute contraindications for the c. O. C. P again, all information that you can find on the TNF. But it's very, very worthy. So I've tried to break things down as summarized, uh, if the patient's pregnant, if they are an active smoker and they're older than 35 or if they are an ex smoker within the last one year and they are over 35 if there be MRI is greater than 35 if they have a past medical history of migraines with aura, if they are breast feeding up to the first six weeks, if they have any cardiovascular or V t risk factors or if they have any family history of breast cancer. This is when the CCP is contraindicated, the main ones that I would recommend if you have to. If you weren't able to learn, all this would be migraines with aura, any cardiovascular, VT risk factors or any family history of breast cancer. Those are the main ones, which you would typically see in the PSSA, but they could ask other things as well. And this is all found, um, under the contraindications section for any combined oral contraceptive pill on the TNF with the pump, it's a bit more or less contraindications to remember the main thing to remember. Is anything liver related, so severe liver cirrhosis? Or if they have any liver tumors? And again we have if they've got a history of breast cancer or if they're pregnant, this is when the pop would be contra indicated, um, again, I'll come back to answer some of the questions, Um, later on. Just be wary of time. Let's head over to the next question. Uh, so we've got a 32 year old female with a past medical history of endometriosis. She's presented to your clinic for a routine review, and she says that she's been experiencing severe abdominal cramps, for which she takes algesia regularly. During these episodes, however, she would like some further additional medication to alleviate her symptoms. So she's on paracetamol and I repair from P R N, but she takes us regularly every time she has her cramping episodes and in terms of past medical history. She's got endometriosis, and she's got migraines with aura. So please write a prescription. Bear in mind that we've been talking about contraceptives for one drug that would be appropriate to manage her symptoms. So if you guys want to head back on the slide, though, and prescribe high medication for the scenario and just to answer your question Sorry, yes, hypertension, um, with a systolic greater than 1 60 or a diastolic greater than 100 would also be a contra indication. Uh, thank you very much. I didn't at that, um, which I will add on to the slides when it and when they handed out. Just having a look at the list of contraindications on the TNF. Now, which I'll show you guys, you can see there's quite an extensive list we've got Factor five Leiden mutations. I think sle was Yeah, they got you got you got S l A s l e. But with antiphospholipid antibodies. Um, it's quite an extensive list of Contra indication, which are all documented there, but it's a bit of a, um and this is quite worthy to monitor your way around, but I'll make sure to update the slides before they get sent out. Thank you very much for letting me know. Okay, so let's have a look at what people have. Um I talk for the slide down, so it seems like it's going to love you. There we go. So the majority of you have said norethisterone um, some of you think did also say I live on a gastro. Uh, yes, I think pretty much any of these answers any of these, um pops correct. So the important thing from the question was to identify that she has migraines with aura, which we just said is an absolute contraindications for anyone who you would consider taking the CCP. Um, so it's very good. Uh, we want to. The next question we have a 25 year old female who attends your GP practice for contraceptive advice at 11 a.m. she normally takes a northeastern pop for contraceptive for contraception at three PM every day. However, she's had a bout of diarrhea for the last 24 hours and asked if she needs to take any further precautions for contraception. So which of the following advice should be provided to her? A. B C D or e. Sorry, and I'll just move on to cruise. Do you have done this right? Here we go. Okay. So which of the following advice should be provided to her? And here's the question Stem. So she normally takes the pop at three. PM every day. She called her at 11 o'clock in the morning because she had a bout of diarrhea for the last 24 hours. So is it a She does not need to take any precautions and carry on taking the pill at three PM Is it be she needs to take a pill now at 11 a.m. and then carry on taking the pill at 11. Am every day, is it? See, she needs to take a pill now at 11 a.m. and then carry on taking the pill at three PM Is it d She needs to take a pill now carry take one at three pm and then obviously carry on at three pm and use contraception for at least two days. Or is it e she takes one now takes one at three. Pm every day and use contraception for at least seven days. Okay, so we've got a good mix of answers. It seems. How do I show the answers? Okay. Oh, gosh. Results. There. There we go. Okay, So the majority of you have gone for D, which is the correct answer. Some of your some of you have gone for E. So let's go back to the question and try and solve it together. So the important thing is we need to figure out whether or not she's still within, um, that three hour window for northeast their own. So she normally takes it at three PM every day. And we said earlier that if a patient has diarrhea lasting longer than 24 hours, we need to assume that they have had a missed pill. So she called her 11 o'clock and she said that she's had diarrhea for the past 24 hours. So, um, from 11 o'clock yesterday, which means that should have taken a pill at three PM yesterday. But we're assuming because she has this severe bout of diarrhea that she's essentially had a missed pill, and the advice for missed pills was that they need to take one straight away, and then they need to carry on taking it regularly, and if it's been greater than three hours, they need to also make sure that they use contraception for at least two days on top of that. So the answer to this question was D. And here is another question, which I have taken directly from the PS a mock paper and let me just set up slider so you guys can answer as well. But essentially, let's work through this one together, and I'll explain how I would answer a question like this so straightaway when it comes to a P s a question. I'd like to repeat the question itself first to see what they're asking for. So it says to select the most appropriate information about what should be provided. Okay, so we're looking for something in terms of information. We look at the case presentation and we can see okay, she wants to know whether she should continue with the pills, whether or not she needs to take additional contraception. So this is going to be a mist pill contraceptive question. Let's have a quick scan through. So she had a delayed return home from her honeymoon. Okay, so here's something important. She's missed her first pill of a cycle yesterday, and the second pill was also do five hours before the phone call. So she's had a two day history of missed pills, and on top of that, she's had sexual intercourse on each of the past three days. And, of course, it doesn't say anything about extra protection, any condoms or anything. So we need to assume that she has not used any contraceptive barriers. She's normally on the microphone on 30 and here we go. We can see on the exam they write up the full drug name, and then they put the brand name in brackets. So she's normally on the Microalbumin 30 on a 21 day schedule, so summer to summarize, We've got a lady on the market, and, um, she's not taking the pill for the past two days. And she's also had sexual intercourse over the past three days. So she's had sex, Um, during this pill free period, which is when she normally isn't on the pill. So out of these options we've got, she should discard taking the first two pills, resume taking the pill from day free and use contraceptives precautions. We got she she she should seek emergency contraception. You've got to take the first pill now and then resume the normal cycle from tomorrow, effectively extending her pill free brake to eight days. Uh, we've got the same well, essentially the same thing. But with you using additional contraceptive measures for the next seven days, um, we've got to take two pills now and then use contraception for the next seven days. So my concern for this patient would be that she's had sex during a pill free period when she would normally be on the pill. So I would advise her to seek emergency contraception straight away. And that's what you guys have put amazing. Perfect. Everyone has gone for beak. See if there's any urgent. Urgent questions. All right, so let's carry on, uh, with the talk. So now we're going to have a look a bit, um, into hormone replacement therapy. So again, a quick run through as to what HRT actually is, um, it's hormonal treatment that we use to provide alleviate menopausal symptoms. And it's also got the additional benefits that it reduces the risk of osteoporosis, cardiovascular disease and stroke. Um, there are different modalities in terms of what sort of formulation of medication we can give to patients who request HRT. You can give it as tablets. You can give these patches. You can give it as gels. You can even give it as a marina implant. Uh, in terms of the symptoms that we're looking to target, we're going to be looking to target your classic symptoms such as hot flashes, any weakened bones, any vaginal dryness or any mood swings. And the important thing to know is that again, there are two different preparations. We've got the combined preparation, and this time we have the estrogen only preparation. So let's have a look at the combined HRT. Now this slide over, I've only really added. Just so you guys, uh, reminded as to what HRT is, what sort of preparations are available just to get become a bit more familiar with HRT options. So you've got the monthly option, which is where they will take daily estrogen, and on top of that, during the end of the cycle, they'll take progesterone in it as well as the estrogen for the last 10 to 14 days, and this can be given to those who are perimenopausal or post menopausal. We've got a very similar concept, but this time it's the three month um HRT, which is where they take daily estrogen every day without a break, and they would also take progesterone in for 14 days. But this time it's every 13 weeks, whereas for this one here you would take it at essentially every month and again, we offer this to Perry or post menopausal women yourself the continuous option, which is where they just continuously take estrogen and progesterone. And this morning we only offer to those who are post menopausal. Um, essentially. The reason why we add progesterone on top of the estrogen is because the progest a GYN, acts as a protective measure to those who have rooms because those with rooms if they take unopposed estrogen. There are an increased risk of endometrial hyperplasia, and they can also get endometrial cancer. And the other thing to take away from this slide is that the addition of progesterones will mimic the natural menstrual cycle and therefore patient's will typically have withdrawal bleed during their peri menopausal period when they take those progesterone cycles. In terms of the estrogen, only HRT. This one is a lot more simple. This unopposed estrogen therapy with no additional progestation this one we typically only give to those who do not have a uterus if they don't have a room inside their body, because there's no need for any endometrial protection, which is usually provided by the progesterones. Again, the key risk factors to be aware of for HRT is, um, similar with the c o c. P. Um, if they are an increased risk of having a venous thromboembolism, the risk is increased by 2 to 3 times and a side note. Um, if a patient is at an increased risk of V t E, then we typically give them a transdermal HRT, so HRT patch rather than oral HRT. The other risks to be aware of our an ischemic stroke, breast cancer and endometrial cancer. So again, the important ones, the ones that I always get mixed up about, is the different types of cancers that patients are at risk of when they're on HRT or when they're on C o C. P. So let's try and jump straight into a question again, it's It's a similar concept with all the previous questions we've done so far, but it's a bit harder. We've got 55 year old woman who presents to a GP for a review of her current hormone replacement therapy. She's requested for an alternative preparation that will not give her monthly withdrawal bleeds, and she would continue to use a transdermal preparation in terms of your past medical history. She's got menopause of flushes. She is normally on an estradiol transdermal patch and an estradiol norethisterone transdermal patch Combivent, which the drug name is known as the pharmaceutical name, is several Sequi. She's on this patch transdermally twice a week for two years on examination. Her weight 68 kg with no recent change, and her BP is stable. So prescribe write a prescription for one drug that is most appropriate to stop the withdrawal bleed. Let me just try and set up the so I do it again. So here's the question for you guys. I'll give you guys a bit more time with this question, because this is a question that I, um I struggle to answer myself. And this is a question again that I've taken directly from one of the pas amox just because I thought it was It was quite a good question when I first tried to answer it. Well, I had next to no clue what I was doing. Okay, I'm getting a few answers, so I need to come in now, so just give it a few more minutes, getting a good mixture of answers coming in so far. Okay, Um, let's have a look at the results. So we have a mixture of answers again. For some reason, it's all broken up here, but I can read out what people have typed. So someone has said Tranexamic acid 1 g o D. Q. D s. Someone has said, um levonorgestrel, 20 micrograms per 24 hours, intrauterine admission. And someone has said the viral county as the same patch twice weekly instead. So a lot of mixed answers all very good and reasonable answers. Let's head over to the question to see how I would interpret this So again, when you see a question, um, first thing I look at is to look at that green box at the bottom to see what they're asking for. Okay, it's a prescription to stop withdrawal bleeding. So what's the patient come in for Okay, so they're on HRT. They want an alternative preparation that will not give her monthly withdrawal bleeds. As I said earlier, any patient who takes the progest a gyn on top of the estrogen will have monthly withdrawal bleed. So it's the progesterone part of the prescription, which is inducing these withdrawal bleeds. The other thing is okay, so she would prefer to continue to use a transdermal preparation so she still wants the patches. Let's have a look. She's on the estradiol, and she's on the estradiol norethisterone patch combo, which she'll probably alternate back and forth. Um, not concerned with her weight, not concerned her BP so otherwise she's tolerating this well, it's purely the fact that she's having these withdrawal bleed from the North Testerone aspect of this prescription. So my answer for this would be as such. Um, now it's cut off here, but what this essentially says is it says estradiol. 50 micrograms, um, over 24. I've taken the wrong screen shot. Sorry. So it should just be estradiol. 50 micrograms over 24 hours, transdermal, twice weekly patch. You should ignore the second part of that. That was my mistake, but that's essentially what I would prescribe for this patient. The dose would be one patch. The route would be transdermal and the frequency would be twice weekly. So this question is that bit of a difficult question because you need to really break down the question, and you need to understand what she's asking for. What sort of patient preferences are being stated in the question. Um, essentially, all we're doing is we're removing the second patch here, the estradiol 50 micrograms, Northwestern getting rid of that. And we're just giving her the estradiol 50 micrograms over 24 hours, a transdermal patch. Okay, let's head over to the next question. Which again is one that I've taken straight from the PS a moderate to I think paper to has quite a lot of C o c p H r t ask questions. So this time we've got communicating information station. What would I look at first? I would jump straight to the question. It's like the most important information option that should be provided for the patient. Let me just sort this over. We got a question six. Okay, So information for something. Okay, I'm not too Sure what it is. Let's have a look at the case presentation. 51 year old flushing and vaginal dryness associated with the menopause. She asked if she should take HRT for these symptoms. No drug history. Mother died of breast cancer. A 56 and father developed angina age 60. Okay, so what information should we give us? Some of the options we have. A, uh, estrogen replacement therapy does not increase the risk of breast cancer. Got be estrogen replacement therapy provides an adequate contraception in the period before menopause is complete. Got See. Estrogen replacement therapy reduces the risk of angina or heart attacks. We've got deed. Estrogen replacement therapy will not affect the development of post menopausal osteoporosis. Now we've got e estrogen replacement therapy will be combined with progesterone to reduce the risk of causing cancer in the lining of the uterus. So I'll give you guys some time to answer the question. Okay, so it seems like some of you gone for A and D. But the majority of you have gone for E. Uh, which I would say is the correct answer. So Eastern therapy does slightly increase the risk of breast cancer. Um, in general, HRT is not adequate enough off the top of my head to provide adequate contraception. You would also always offer additional contraceptive measures for anyone who is on any Eastern replacement therapy. Um, it increases the risks of angina, heart attacks. It does affect the development of post menopausal osteoporosis by inhibiting or, um, yeah, inhibiting the development of osteoporosis. The most important thing, as we mentioned earlier as we highlighted, is that we provide them progesterones mainly to protect against the womb from any endometrial cancer which can occur again. We've got another question from the PS. A mock paper. This time, let's jump straight to the question. It's like the most appropriate monitoring option. Okay, so it's a drug monitoring question is going to be to assess the adverse effects of this treatment. Okay, so I'm going to be looking to see what treatment they have been started on. And, um, what the adverse effects are which are related to this so we can see straight away. They're on a cycle treatment of estradiol and estradiol slash norethisterone. So let's look at the whole case now. 51 year old Flushing night sweats. Uh, hypercholesterolemia. Irregular menses for six months. They're on a statin. Okay, so they had a diagnosis of asthma. Does vasomotor instability associated with the menopause? And she's taking this estrogen slash estrogen progesterone cycle, Um, as oral tablets known as the LS Stewart. Okay, So what are we going to monitor in terms of the adverse effects? Is it? Sorry. Let me just go to the next question. Is it a We're going to monitor the BP be? Are we going to monitor the LFTs? See, Is it the serum cholesterol D? Is it the serum? Creatinine or E? Is it their weight? This question I found particularly difficult to answer. Um, and I think it's quite a vague question. Still off the top of my head, I'm not 100% certain, um, what the answer would be. But I'm fairly certain in the answer that I've come up with and the reason backing reason I'm back in my, um, answer option. But it's it'll be interesting to see what you guys have said for this question. Okay, so let's go through this question together and let's see what you guys what we think So we have estradiol he hydrates the northeastern estate. Let's jump over two medicines complete, actually, Probably easier to step in the brand name unless you wet. Okay, So that's I think you can quit any of these. It jumped straight down to the medicinal form which are not interested in were interested in the adverse effect, because the question specifically is stating what's the most appropriate monitoring option to assess the adverse effects of this treatment? No, I don't think it's on here. Let me try. Be an f Look here. Yeah. So the interesting thing when I when I try to find some research to back my ads for this is that Well, it's not. It is here. Okay. So you can see that with estradiol with norethisterone, it doesn't actually have a section for any of the specific adverse affects contraindications, blah, blah, blah. But it splits it up. And there are links here as well to the estradiol component and the northeastern component. So we're joined. Probably the estradiol component when it loads. Here we go. Yeah, we've got a bigger drop down this compared to this section here, and we are looking for so mhm. I think side effects is what I was looking for here. Yeah. So the question here is asking what's the most appropriate monitoring option to assess the adverse effects of the side effects from this treatment? So my thought process when answering question like this is to look at the side effects and look for the most common side effects. We know that she's taking an oral preparation of this tablet, and if we go to side effects, we'll get specific side effects with all use which are common or very common from the list here. It actually says that weight changes is the most common side effect. Now, a lot of you guys for the question I have answered a which was BP, and I think b which was LFTs. Let me just check to make sure, yeah, most of you guys have said BP LFTs, but in terms of what's the most appropriate monitoring option to assess the adverse effects, I would have thought that based on what the TNF and what medicines complete tells me is that weight changes is actually one of the most common, um, adverse effects with regard to taking the estradiol. Um, if you go into Northeastern. I think there's not much in terms of side effects again. Specifically, we have dizziness, uh, so that I am mhm. Yeah. So? So with the the progesterone aspect of it, there's not really much that we can comment on, but in terms of the Eastern aspect, we can see that weight changes are very common side effect or an adverse effect from the medication. And so for this, that's why, for this question, specifically my answer, um, what I think is the correct answer would have been is e We are now at two o'clock. So thank you very much for everyone who has, um, stuck to the end of the session. But we will quickly run through just a few exercise that I've put together, and I'll have an attempt to answer any questions. If I aren't. If I'm not able to answer any questions, I'll make sure I answered them with the slides, Um, as they get sent out. So a few tips and tricks that I found particularly helpful, uh, feel free to take the brand name on B N f. And it will come up with the relevant prescription drug name equivalent. Uh, The other thing is you can score to the bottom of the drug monograph part to see other drugs in the same class. So, for example, estrogens combined with progesterones. If you're not too sure what you're looking for, if you can think of anything or if you can, if you can find any of them. For example, if you found a straddle FNL estradiol with levonorgestrel, scroll down to the very bottom and you've got the entire list of the other, uh, preparations. I've also added a few quick cheat sheets in terms of, um, some of the more niche or some of the weird prescriptions that you might see. So, for example, for the combined oral contraceptive patch the moment you type in levonorgestrel seven, you get the levonorgestrel seven microgram slash estrogel 50 micrograms over 24 hour transdermal weekly patch. And how you prescribed you prescribed it as that one application once a week. Um, you can see when you look at when you search this patch on the TNF, it just says one patch once weekly. But if you go down to the actual medicinal forms of the medicinal preparations, it will tell you the active ingredient is 50 micrograms per hour of estradiol and seven micrograms per 24 hours. Sorry of levonorgestrel. Um, easier concept with the vaginal rings, which are also used as a combined oral contraceptives. Um, so if you're looking for the combined oral contraceptive vaginal ring, the quickest way to find is just search vaginal ring, and I'll show you guys. Now jump over here a vaginal ring. And let's look at this one here F nostril with Etoh gastral. And you can see for menstrual symptoms or for contraception. Um, this one is given by vagina one unit blah, blah, blah. So there's all the information on there, but essentially, this is a quick summary of how I would prescribe it. So I prescribe it as one unit of the nonsteroidal with it on a gastro once a month, Uh, for seven days. So frequency duration. And the quickest way is just to search vaginal ring and just show you guys with the TNF as well. Research for general ring. Here we go. The better thing where the b n f I find is that it gives you a quick summary here when you search vaginal ring on medicines complete. You don't actually get that summary part, whereas on here, you can quite clearly see. Okay, the mention. A vaginal ring. Okay, we've got a combined oral contraceptive, so this must be, um, one of the right drugs, and then just call up to the top and you can find all the prescribing information. Um, What's this? So this is the progesterone. Only contraception in terms of a depo injection. So when you're giving a depo injection for the progesterone only contraceptive, when you search it all again, you can look under contraceptive Hormonal. You probably search depo injection or or progesterone injection. But the the best or the quickest way that I found was just go to the contraceptive hormonal summary page, and you can scroll down and you'll be able to find this information. You can either prescribe it as a deep im injection or subq injection. Uh, make sure you look specifically at the frequency is because they are slightly different again. Just to show you guys, it's up there. Hormonal. There's the treatment summary. Uh, let's go to progesterone. Only contraceptives. Got the oral stuff here. We've got the parental stuff here. Here. We have the information for the injection. So you can just click that, or you can click this. Um, we also information on the implant, which is Ito the gastro, which should be the last slide here. So again, it on a gastral. As an implant, I prescribe it as a one implant in terms of the dose, Uh, the route would be subdermal frequency would be once Only because you give it once and you leave it for three years. You could write the prescription is every three years, but I think it just makes more sense to do it once only And then in three years' time, you would review the patient to see if they needed replacing, um, or not. And again, quickest way, as I just showed you guys, is to go through the contraceptive summary part. Um, this is the last slide in terms of converting to different preparations. There is some information on the TNF, and this is all under the individual drugs. So this is a summary slide. I'll show you how I found it. Um, I found some of the Yeah. All right, well, let's just type it up. Okay, Now, let's go with, Let's say norethisterone tons of information you can see here We've got all the contraindications you've got all the cautions that you need to be worried about. So again, um, caution with regards to specific BMS cautions with diarrhea, vomiting, we've got information on the risk of V T e. You've got various risk factors for V t. E. So there is all the information that you will need for the TNF. It should all be on each of the pages. Um, risk of cardiovascular disease risk factors for cardiovascular disease, et cetera, et cetera. Um, side effects. I forgot what I was looking for. Now, here we go. Okay. So in terms of directions for administration, for starting the pill, you've got all the information you need here in terms of changing to a different preparation containing different progesterones. Um, again, you have all the information that you will need for the B N f. In terms of switching. It should all be stated here. So, for example, if you're stopping from the progesterone only to the combined pill, they say that if it's been used correctly, you can just stop it over straight away, and they recommend additional barriers for the first seven days or for nine days, specifically for Q error. Um, there's all this information that you can ever read about. Just a quick skin for is all I'd recommend, just, you know, whereabouts. It is where you can locate it. If, in case you do need to access this resource, um, during your actual exams. But that's the end of the session. Hopefully, that wasn't too much of an information overload for you guys, but thank you very much for sticking to the end. Uh, if you haven't done it already, please feel free to scan the QR code to provide feedback so I can deliver more, um, specific and better tutorials. Next week will be myself as well, but we'll be talking about diabetes management. Hyper hypoglycemia, adjusting, um, long acting and short acting insulin doses, blah blah, blah. It's just good look to see if there are any burning questions I can answer off the top of my head. Mhm. Does it matter which week they've missed the pills? I think it doesn't matter too much. Um, let's see here. So again, this is the old information on miss pills that the TNF provides. Um, I can't say anything. Specifically issues and expose. Remember normal taking up staying. Use condoms again. If there's if there is less than seven packs, seven pills in the pack, then they need to take the next pack straight away. Now, here we go. So emergency contraception is recommended if two or more tablets are missed from the first seven days in a package. Okay, so there's all the information with regard to information, um, specific to when they missed it, in terms of which week of the pack that they missed in. How can I find out each estradiol patch? Um, from medicines complete? That's a good question. Let's have a look, shall we? Mhm. I wonder if there's a HRP section. I don't ask for the same thing. Mhm. It's got a lot of information here. Good. I don't think we have any tables like the contraceptive ones, Um, specific to, um, the actual drugs, Uh, the drug prescriptions. So in that case, what I would do is let's just go back to the questions, too. Remind myself. So we're looking for estradiol. Patches? Yeah. Okay. So it's not like here estradiol. Cool. So we've got the estradiol. We've got a bunch of confusing crap here. Um, so what I would do is I think the first thing I would do is I'd look at a medicinal forms view all medicinal forms and pricing information. It's a bit of a convoluted way, but this is the way that I've learned to come and do it. Navigates section I don't want to pass through. You don't want no vaginal deliveries, a transdermal patch. Let's have a look here and then we have all these different patch types. If we look at the question itself, we know she's on the overall sick and she's taking 50 micrograms so far. In terms of the dosage, there's not actually anything we need to change because she's not complaining specifically with what's it called menopausal symptoms. She's just complaining of the withdrawal bleeding, so we can probably just carry it on the overall 50 patch, and you can see here the active ingredient itself is estradiol 50 micrograms per 24 hours again because you'll be doing this in the actual PSA exam. It's always good to have this opened up when you're answering these types of questions because we can go to any practice paper. Wow. And the moment I type, he's going to check? Yeah, for dial. You see, we got a huge drop down list. What are we looking for? Just to make sure we're looking for the right thing with the estradiol 50 micrograms for 24 hours. So let's go down to estradiol 50. Uh, here we go. Estrogen. 50 micrograms. 24 hours, transdermal, twice weekly patch. So that's the prescription that you do for that specific question you can see down here. We also got the other combipatch. And this is how you would prescribe it if you're doing the alternative patches. But you just click that those would be one application. Was it topical or transferrable? Etcetera, Frequency, whatever. It was twice weekly, I think. I mean, that's how you feel that in, um, for the previous question, Does the patient have you Just how can we just prescribe estradiol alone? Uh, I think that's referring to the same question. So I guess in I think in terms of real clinical practice, what you would do is you wouldn't just willy nilly prescribe it and then send the patient way you'd have to have that discussion with regards to what? The progesterone? Er, um, which is actually doing why they're having it. So you need to clarify. That is for, um, protective factors in terms of preventing endometrial hyperplasia cancer. You'd have that informed discussion with the patient, and then it'll be the patient's choice as to whether or not they want to take those risks. I think, um and we're assuming in this case, that the patient has had this discussion and they're willing to have just the estradiol. I guess in terms of the question itself, all they're asking for is to give you the correct prescription to stop these withdrawal bleeds. And what that would entail would be to take off the northeastern part, um, of the HRT patch. If that makes sense for that question. Okay, so this was the other question. We recently had a pizza market's about BP and microalbumin 30 and the answer was to switch to Sarah set. I remember that the imperial marks were always a bit dubious and there was a ton of questions without any clear answers. So let me see if I can answer the question for you, but If not, I probably won't comment on it. Um, I don't switch to Hyzaar that Okay, so I'm assuming the question was about that was the machine. The the question state of the patient was a market going on, and they had high BP. And so they, because BP is a contraindications, A to stop taking it. And so you need to convert them on to a progesterone only pill in terms of which specific pop you would prescribe. I think it doesn't matter. I think you can prescribe all three of them. Um, usually I think it's the clinician's discretion. Just depends on which one they forgiving what they have in the pharmacy supply. Um, if there's anyone specifically what the patient wants to try, I guess there's no specific as to say Sara's. I think you can give the other, like the northeastern or the liver and the gastro, and it should still be fine. Um, hopefully that answers your question. Er, I think that's the majority of the questions. I'll just make sure I have not missed out anything over on. Okay, so we've got someone who asked a quick question about question three. Okay, Yeah, so? So someone has asked that Slightly confused about question for you. Why does the patient need to use contraception? So why is it DMI, is it not see because the only difference between the two of them is that they need to take the additional, um, contraception for two days. So let's go back to this part here. So the this is all we need to remember in terms of pop missed pills, the pop pill typically has a three hour window in which they need to take it. Um, so again, to use the 12 o'clock example, let's say I'm normally on the pop at 12 o'clock. I took my 12 o'clock pill yesterday today because I was preparing for this course. I forgot to take my pill, and I just remember now. Oh, crap. I need to take my pop pill. Um, it's to 19, which means I'm still within that three hour window. Normally, I would have taken at 12. I forgot today, but I'm still in that three hour window, which means it's absolutely fine, which means I'll take my pop and I'll carry on from tomorrow again from 12 o'clock. No, no changes happened. Nothing to be worried about because you have that three hour window in which you're still um protected gets protected is not the right word but protected against getting pregnant. If it's been greater than three hours, then I need to take my pill straight away because you still want to initiate or restart the protection of your body. But because it takes time for the pop to essentially build up and provide adequate protection, you need to abstain or use condoms for the next two days at least. Um, ignore the part about the 12 hour limit for desert gastro. It's more relaxed when you're on that pill for the questions. Specifically was about not desogestrel, but it was about Norethisterone. Uh, the other thing now we need to take away is that they had a bout of diarrhea for the last 24 hours. And as we said here in terms of providing patient information, if a patient has had severe diarrhea lasting greater than 24 hours, we need to act as if they have missed a pill. So let's break this question down again. I'm a 25 year old female, and I normally take my pop at three o'clock every day. So my protective window is from three till six PM I give the GP practice a ring at 11 o'clock this morning and I told them I've had a bout of diarrhea for the last 24 hours and I remember being told something about taking another pill if I've had diarrhea or something. So what does that? What information have I got from this question Stem? Essentially, if I called the GP practice at 11 AM today and I said that for the past 24 hours I've had diarrhea, then that means I had diarrhea from roughly 11 AM yesterday till today. So my diarrhea started at 11 o'clock yesterday and then at three pm I took my pill. But we need to assume because they've got this acute diarrhea, I haven't absorbed it properly. And I've just excreting it out, um, as fecal matter. And so because I've not absorbed any of the pill, we need to presume that I have had a missed pill. Now I'm calling at 11 a.m. which means I'm outside of that free our protective window which is normally from 3 to 6 PM it's taken me. What is that? 20 hours before I realized I called the GP. So because I've called 20 hours after I last took my pill because I'm outside of that three hour window. All I need to do based off of this information is take my, uh, recent recent miss pills straight away. But I also need to make sure I use condoms for at least two days until until the diarrhea settles down as well. So I understand it's a bit of a difficult question because a lot of wording and there's a lot of time calculations that you need to get through. The purpose of this question was essentially to assess you on two points to remember that diarrhea, uh, if someone has diarrhea for 24 hours longer, you need to presume that they've had a missed pill, and the second thing was to calculate times. If it's greater than three hours, then they'll need to take the pill and have to use condoms for for two days. It's within that three hour window. Then it should be absolutely fine. Hopefully that answers your question, and I think that brings us to the end of today's session. Unless anyone has any other questions, I'll make sure to update the slides bit more. Um, we've got especially the BP. Um, definitely should have added that on the slides, But other than that, that's the end of the session. And thank you very much for everyone who stay till the end. Yeah, I'll stick around for another five minutes in case anyone has any other questions to ask.