6.12 Women's Health, Men's Health, and Urologic Therapeutics
Key Takeaways
- Combined hormonal contraceptives are absolutely contraindicated in migraine with aura, uncontrolled hypertension, active thromboembolism, and smokers aged 35 or older.
- Levonorgestrel emergency contraception is less effective above a body mass index of about 26; ulipristal or a copper intrauterine device is preferred, and ulipristal must not be combined with hormonal contraception for five days.
- Menopausal hormone therapy requires a progestogen alongside estrogen in any person with an intact uterus to prevent endometrial hyperplasia.
- Alpha-1 blockers relieve benign prostatic hyperplasia symptoms within days, whereas 5-alpha-reductase inhibitors take three to six months and roughly halve the prostate-specific antigen value.
- Phosphodiesterase-5 inhibitors are absolutely contraindicated with any nitrate because the combination causes profound, potentially fatal hypotension.
6.12 Women's Health, Men's Health, and Urologic Therapeutics
Exam Focus: Contraception and prostate therapy are dense with absolute contraindications and time-dependent counselling. Examination items typically supply one comorbidity or one interacting drug and ask whether the therapy can proceed.
Contraception
Combined hormonal contraception
Combined products contain an estrogen (usually ethinyl estradiol) and a progestin, and are available as tablets, a transdermal patch, and a vaginal ring. They suppress ovulation, thicken cervical mucus, and thin the endometrium.
Absolute contraindications to combined hormonal contraception:
- Migraine with aura at any age (stroke risk)
- Smoking at age 35 or older
- History of venous thromboembolism, or known thrombophilia
- Uncontrolled hypertension
- Current or recent breast cancer
- Active liver disease
- Less than 21 days postpartum, or breastfeeding in the first six weeks
- Major surgery with prolonged immobilisation
Progestin-only options — the progestin-only pill, depot medroxyprogesterone acetate, the etonogestrel implant, and the levonorgestrel intrauterine system — are available when estrogen is contraindicated. Depot medroxyprogesterone acetate reduces bone mineral density, which is largely reversible after discontinuation, and delays return to fertility by up to a year.
Interactions causing contraceptive failure are a favourite item: enzyme inducers including carbamazepine, phenytoin, phenobarbital, primidone, topiramate at higher doses, rifampin, and St. John's wort all lower hormone concentrations. Advise an alternative or additional method. Broad-spectrum antibiotics other than rifamycins do not meaningfully reduce efficacy.
Teach the missed-dose rules and the warning acronym ACHES — abdominal pain, chest pain, headache, eye problems, severe leg pain — as signals to seek assessment.
Emergency contraception
| Option | Window | Notes |
|---|---|---|
| Levonorgestrel 1.5 mg | Up to 72 hours, sooner is better | Non-prescription; reduced efficacy above a body mass index of about 26 |
| Ulipristal acetate 30 mg | Up to 120 hours | More effective at higher body weight; delay restarting hormonal contraception for 5 days and use a barrier method |
| Copper intrauterine device | Up to 7 days | Most effective option and provides ongoing contraception |
Neither oral option terminates an established pregnancy, and neither is teratogenic.
Menstrual Disorders and Menopause
Dysmenorrhea responds best to an NSAID started at the onset of symptoms or just before, because prostaglandin synthesis inhibition is most effective before prostaglandins accumulate; hormonal contraception is an effective second option. Heavy menstrual bleeding is managed with tranexamic acid, NSAIDs, or a levonorgestrel intrauterine system. Polycystic ovary syndrome management targets the presenting problem: combined hormonal contraception for cycle regulation and hirsutism, metformin for metabolic features, and letrozole for ovulation induction.
Menopausal symptoms. Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms, and the benefit-risk balance is most favourable when started under age 60 or within 10 years of menopause. Any person with an intact uterus must receive a progestogen with systemic estrogen to prevent endometrial hyperplasia and carcinoma. Low-dose vaginal estrogen for genitourinary syndrome of menopause has minimal systemic absorption and does not require added progestogen. Non-hormonal options include selective serotonin and serotonin-norepinephrine reuptake inhibitors and gabapentin.
Pregnancy-Related Conditions in Pharmacy Practice
- Nausea and vomiting of pregnancy: doxylamine-pyridoxine is first-line in Canada; escalate to dimenhydrinate, metoclopramide, or ondansetron under medical direction.
- Preeclampsia: new hypertension after 20 weeks with proteinuria or end-organ involvement. Labetalol, nifedipine, and methyldopa are the accepted antihypertensives; ACE inhibitors and angiotensin receptor blockers are contraindicated throughout pregnancy.
- Folic acid: 0.4 to 1 mg daily before conception and through the first trimester, increased to 4 to 5 mg daily with a prior neural tube defect, diabetes, obesity, or antiepileptic therapy.
- Gestational diabetes: insulin is the preferred pharmacotherapy when nutrition therapy is inadequate.
Benign Prostatic Hyperplasia
Lower urinary tract symptoms in benign prostatic hyperplasia divide into storage symptoms (frequency, urgency, nocturia) and voiding symptoms (hesitancy, weak stream, incomplete emptying).
| Class | Examples | Onset | Key counselling |
|---|---|---|---|
| Alpha-1 blockers | Tamsulosin, silodosin, alfuzosin | Days | First-dose orthostatic hypotension; intraoperative floppy iris syndrome — tell the ophthalmologist before cataract surgery |
| 5-alpha-reductase inhibitors | Finasteride, dutasteride | 3 to 6 months | Reduces prostate volume; halves the prostate-specific antigen value, so double the measured result when screening; sexual adverse effects; pregnant persons must not handle crushed or broken tablets |
| Phosphodiesterase-5 inhibitor | Tadalafil 5 mg daily | Weeks | Useful when erectile dysfunction coexists |
| Anticholinergic or beta-3 agonist | Solifenacin, mirabegron | Weeks | Added for storage symptoms; caution with high post-void residual |
Anticholinergics, sympathomimetic decongestants, and opioids can precipitate acute urinary retention in men with significant obstruction — a routine but important non-prescription screening question.
Erectile Dysfunction and Urinary Incontinence
Phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) are first-line for erectile dysfunction. The absolute contraindication is concurrent nitrate use in any form, including nitroglycerin spray or patch, because the combination causes profound hypotension; separate riociguat is likewise contraindicated. Use caution with alpha-blockers. Sildenafil absorption is delayed by a high-fat meal, tadalafil has a long duration allowing daily dosing, and a persistent erection lasting more than four hours requires emergency care. Erectile dysfunction can be an early marker of cardiovascular disease and warrants risk assessment rather than a purely symptomatic response.
Urinary incontinence is classified before it is treated. Stress incontinence responds to pelvic floor training and, where appropriate, duloxetine. Urgency incontinence is managed with bladder training plus an antimuscarinic or mirabegron, which is preferred in older adults because it avoids anticholinergic burden and cognitive risk. Overflow incontinence points to obstruction or an atonic bladder and requires a review of anticholinergic and opioid therapy. Functional incontinence reflects mobility or cognition and is not primarily a drug problem.
A 34-year-old requests a combined oral contraceptive. She reports migraine headaches preceded by flashing zigzag lights lasting 20 minutes. What is the appropriate response?
A man taking finasteride for benign prostatic hyperplasia has a prostate-specific antigen result of 2.1 mcg/L after 12 months of therapy. How should this be interpreted?
A 58-year-old man asks for sildenafil. His medication list includes nitroglycerin spray used two or three times a week for angina. What is the correct action?
An 82-year-old woman with urgency incontinence and mild cognitive impairment needs pharmacotherapy after bladder training alone proved insufficient. Which agent is most appropriate?