LPN INTENSIVE CLINICALS�� CHAPTER 7 – GENITO-URINARY SYSTEM ��� INTENSIVE GPHC Exam revision � programme FOR JUNE 2025

LONDON PHARMACIST NETWORK (LPN)

INTENSIVE REVISION FOR JUNE 2025

GPHC EXAM.

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TABLE OF CONTENT

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Oxytocin: risk of overdose during labour and childbirth [NPSA advice]

ENZYME INDUCERS = SCRAP- GPS

QUESTION

• Mrs. Dean is a 32-year-old woman who is seeking contraceptive advice. She is taking a course of carbamazepine for trigeminal neuralgia. She presents in your clinic today to enquire about contraception.
• Which of the following would be the most appropriate contraceptive recommendation?
• • A- Microgynon 30 tablets (ethinylestradiol 30mcg, levonorgestrel 150mcg)
• • B- Cerazette (75mcg desogestrel) tablets
• • C- Condoms
• • D- Norgeston 30 (levonogestrel 20 mcg) tablets
• • E - Mirena intrauterine device (levonorgestrel)

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NOCTURNAL ENURESIS IN CHILDREN

QUESTION

• Ben, a 7-year-old went swimming with his friends from school as part of physical Education activities . His teacher realizes that Ben’s records show that he takes Desmopressin regularly. Which of the following advice should the teacher give Ben. Choose most relevant option below.
• A. Ben should be warned he could vomit whilst swimming due to his current medication .
• B. Ben could feel thirsty as a result of the drug he is taking.
• C. Ben should not drink water from the pool whilst swimming.
• D. Ben should avoid swimming altogether.
• E. Ben should be isolated and asked to swim in a separate pool.

URINARY FREQUENCY, INCONTINENCE

• Antimuscarinics
• TCA - unlicensed
• Mirabegron – check BP . Contraception women of childbearing.
• 3 TYPES = stress , urge and mixed incontinence.
• Don’t give duloxetine in women with stress incontinence as first line.

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• URINARY RETENTION
• Causes
• Acute – catheterization
• Alpha blockers
• Finasteride

QUESTION

• Stella, a young lady , is a new dispenser who is about to make dossette boxes for the first time . She is instructed to wear gloves and use tweezers when handling certain drugs. Which of these drugs do NOT require Stella to use gloves or tweezers when handling?
• A. Dusteride
• B. Methotrexate
• C. Chlorpromazine
• D. Finasteride
• E. None of the above

HRT

• HRT IS THE REPLACEMENT OF HORMONES SUCH AS OESTROGEN AND PROGESTERONE THAT WOMEN LOSE DUE TO MENOPAUSE SYMPTOMS.
• HRT PRODUCTS ARE AVAILABLE AS PATCHES , TABLETS , GELS ETC

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• PATIENTS CAN CHOOSE WHICH FORM THEY PREFER.

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• SEEING PERIODS- GIVE CYCLICAL HRT (CONTAINS BOTH HORMONES)
• STOPPED PERIOD OVER A YEAR – GIVE CONTINOUS HRT
• HAVE A REVIEW EVERY YEAR.

CYCLICAL HRT VS CONTINOUS HRT

1. Cyclical hormone replacement therapy (HRT) involves taking estrogen and progestin separately. There are two main methods.

• Cyclic therapy (sequential therapy): You take estrogen every day and progesterone for 10 to 14 days each month.
• Monthly cyclical HRT: You take estrogen every day, but progestogen is added for 14 days of each 28-day treatment cycle, causing a regular bleed similar to a light period.

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2. CONTINUOUS HRT refers to taking both an oestrogen and a progestogen every day. This approach results in no bleeding.

HRT

• FOR PATIENTS WHO HAVE HAD A HYSTERECTOMY – DON’T NEED PROGESTERONE. GIVE OESTROGEN ONLY !!!

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• SIDE-EFFECTS – headaches, breast tenderness, mood changes, nausea, spotting.

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• Consider changing doses or forms if patients complain of ongoing side-effects after 6 to 8 weeks.
• HRT PROTECTS BONES FROM OESTEOPOROSIS

RISKS OF HRT

• Risk of breast cancer
• Risk of endometrial cancer
• Risk of ovarian cancer
• Risk of venous thromboembolism
• Risk of stroke
• Risk of coronary heart disease

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Surgery

• Major surgery under general anaesthesia, including orthopaedic and vascular leg surgery, is a predisposing factor for venous thromboembolism and it may be prudent to stop HRT 4–6 weeks before surgery

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WHEN TO STOP HRT

• Hormone replacement therapy should be stopped (pending investigation and treatment), if any of the following occur:
• sudden severe chest pain (even if not radiating to left arm);
• sudden breathlessness (or cough with blood-stained sputum);
• unexplained swelling or severe pain in calf of one leg;
• severe stomach pain;
• serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body;
• hepatitis, jaundice, liver enlargement;
• blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
• prolonged immobility after surgery or leg injury;
• detection of a risk factor which contra-indicates treatment.

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QUESTION

• Ms. K , a 43-year-old woman presents after completing chemotherapy treatment for oestrogen-receptor-positive breast cancer, she is prescribed extended adjuvant endocrine therapy to reduce her risks of future recurrence of breast cancer. She is pre-menopausal and has not had previous adjuvant endocrine therapy.
• Which of the following medicines would be most appropriate for this woman?
• A. Anastrozole
• B. Letrozole
• C. Raloxifene
• D. Tamoxifen
• E. Tibolone

CANCER IN WOMEN

• Tamoxifen - ASCO guidelines published June 2014 recommend extended adjuvant endocrine therapy for women with early breast cancer either with tamoxifen alone or using sequential treatment with tamoxifen and aromatase inhibitors. All premenopausal women should receive at least 5 years of tamoxifen 20 mg once a day. Treatment beyond 5 years can be with either tamoxifen or an aromatase inhibitor dependent on menopausal status. Tamoxifen has 2 indications in women.
• •Letrozole – suitable for postmenopausal women only
• •Raloxifene – only used as chemoprevention in postmenopausal women at moderate to high risk, initiated under specialist supervision. Not licensed for this indication in the UK.
• •Anastrozole - suitable for postmenopausal women only
• •Tibolone – Licensed as HRT in postmenopausal women or for prevention of osteoporosis in postmenopausal women. Contraindicated in patients with a history of breast cancer. It would INCREASE the risk of breast cancer, as outlined in this Cochrane review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6458045/

PROSTRATE CANCER

• Prostate cancer is the most common form of cancer affecting men. It can also affect transgender women, as the prostate is usually conserved after gender‐confirming surgery. The main risk factors are age (most cases being diagnosed in men over 70 years of age), ethnicity (more common in black African-Caribbean men), obesity, and a familial component.
• Treatment decisions are guided by baseline prostate specific antigen (PSA) levels, tumor grade (Gleason score), the stage of the tumor, the patient's life expectancy (based on age and comorbid conditions), treatment morbidity, and patient preference.
• Localized or locally advanced prostate cancer- Active surveillance, radical prostatectomy or radiotherapy. docetaxel.
• Metastatic prostate cancer

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EVANA

• The tranexamic acid in Evana is an anti-fibrinolytic agent.

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• Evana should only be taken once heavy menstrual bleeding has started, for a maximum of 4 days.
• The recommended dosage is:
• • Two tablets to be taken 3 times a day (e.g., morning, afternoon, and evening), as long as needed
• • If menstrual bleeding isn’t reduced, an extra 2 tablets can be taken at night, – but no more than
• 8 tablets (4 g) should be taken per day
• • Evana can be used for as long as the woman’s periods remain regular and heavy6
• • However, if the patient has taken Evana as directed for three menstrual cycles and there has been no reduction in their HMB, then they should seek further advice from their doctor.6 Their doctor may recommend an alternative non-hormonal treatment, such as the off-licence use of an NSAID, or a hormonal option, with levonorgestrel intrauterine system (LNG-IUS) and combined hormonal contraceptives or cyclical oral progestogen

EVANA

• Evana can be recommended: For women aged 18–45 years with HMB who have regular menstrual cycles (21–35 days duration) where the length of their cycle does not vary by more than 3 days from month to month.
• The following patients cannot take Evana:
• • Under 18 years of age
• • With irregular menstrual bleeding – more than 3 days variability per 21–35 day cycle
• • Taking oral contraceptives, as this can increase the risk of thrombosis
• • Taking warfarin or other anticoagulants
• • Mild-to-moderate renal insufficiency or severe renal impairment
• • Active thromboembolic disease, or a previous thromboembolic event and a family history of thrombophilia
• • Blood in the urine (haematuria)
• • Fibrinolytic conditions following disseminated intravascular coagulation
• • History of convulsions
• • Hypersensitivity to tranexamic acid or any of the tablet excipients. These are - Calcium hydrogen phosphate, croscarmellose sodium, povidone, talc, and magnesium stearate
• • Pregnant women.

CONTRACEPTIVES

CHAPTER 7

QUESTION

• Miss. Zara ,A 23-year-old woman would like to discuss contraceptives options with her doctor. During the discussion, her doctor mentions that an IUD is less suitable for her. What is the most accurate reason for the doctor’s response?
• A. Increased risk of infertility
• B. Increased risk of Ovarian cancer
• C. Increased risk of P.I.D.
• D. Increased risk of multiple pregnancies
• E. Increased risk of breast cancer

CONTRACEPTIVES

• There are various types of contraceptives
• Barrier method
• I.U.D
• Patches
• Injections eg depo provera
• Vaginal rings
• Oral – COC or progesterone only . Examples?? Learn Brand names

COC

• Take for 21 days with 7-day break
• Not for women over 50 years
• Monophasic
• Phasic
• Everyday preparation
• Avoid if 2 or more Symptoms are present- Smoking, over 35yrs , BMI 30 or more, Family history, immobilization etc
• when should COC be stopped before major elective surgery???
• Long Journeys?? Advice
• COC reduces risk of endometrial and ovarian cancer.
• Breast feeding for all combined hormonal contraceptives = FSRH advises usually suitable for use from 6 weeks postpartum (benefits generally outweigh risks); safe for use 6 months or more postpartum.

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COC – REASONS TO STOP

• Stroke
• Breathlessness
• VTE
• High Blood pressure ......160/ 95
• Liver dysfunction
• Prolonged immobility after surgery or injury
• Detection of a risk factor eg smoking over 40 , BMI over 35 , diabetes

PROGESTERONE ONLY CONTRACEPTIVES

• Take one tablet at the same time every day
• If started after day 5 of cycle additional protection is needed.
• Increases risk of breast cancer.
• Used in Emergency contraception. Eg Levonell one-step
• If patient has BMI of ..26kg/M2 or more >70kg Give 2 tablets of levonorgestrel (unlicensed) or ELLA-ONE

SCENARIOS

• Pinky , An 18-year-old who have never taken contraceptives before . Starts a new pack of microgynon but missed a dose within the first 7 days and UPSI occurred during that same period. What advice would you give this patient.

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• Sharon , A 25-year-old woman who has been taking Rigevidon regularly for the past 6 months. Reports that she missed a tablet yesterday- within the first 7 days of a new pack and unprotected sexual intercourse occurred last night. What advice would you give this patient.

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• Mrs. Happy a 35-year-old woman takes Microgynon regularly, starts Micrigynon on day one of her cycle. She had unprotected sex yesterday(day 6 of cycle ) . She has not missed a pill but worries and would like to know what to do .

MISSED PILL

DESOGESTREL – BNF EXTRACT

EMERGENCY CONTRACEPTION

• levonelle- Within 72 hours
• ELLA ONE - Within 120 hours
• Copper IUD is the most effective
• PATIENT’S REP
• ADVANCE SUPPLY
• Age of patient
• Can affect menstrual cycle – LEVONELLE MORE LIKELY THAN ELLA-ONE
• Report signs of abuse- See safeguarding
• Take EHC as soon as possible.
• TRANSGENDER PATIENTS

DRUG INTERACTIONS

• Enzyme inducers examples- SCRAP- GPS
• Carbamazepine
• Phenytoin
• Rifampicin
• Phenorbabital
• St. John’s wort

Rx

• Regular contraceptive plus progesterone only injection or copper IUD.
• For how long ????

THE END