Episode 36: Birth Control and HTN.
Gonorrhea treatment update. Use of birth control in hypertension. Explanation of allodynia and hyperalgesia. Tips on contraceptives. Jokes.
HAPPY NEW YEARS EVERYONE! Welcome to our first episode of 2021. We are full of hope and optimism for this new year, even though this year is looking just the same so far.
Outdated treatment for gonorrhea: Ceftriaxone 250 mg IM and azithromycin 1 gram PO.
Updated treatment of gonorrhea: On December 18, 2020, the CDC recommended a new treatment of uncomplicated urogenital, rectal, or pharyngeal gonorrhea with a single IM dose of 500 mg of ceftriaxone (instead of 250 mg). For patients who weigh more than 150 kg (300 lbs), the single intramuscular dose is 1 gram. If chlamydial infection has not been excluded, doxycycline 100 mg orally twice a day for 7 days is recommended (instead of azithromycin). However, azithromycin, 1 g PO single dose, is still recommended in pregnancy.
Allergy to cephalosporins: In patients with cephalosporin allergy, a single 240 mg IM dose of gentamicin PLUS a single 2 GRAMS oral dose of azithromycin is an option.
Expedited Partner Therapy – EPT: When permitted by state law, the partner may be treated with a single 800 mg oral dose of cefixime, and ADD oral doxycycline 100 mg twice daily for 7 days if chlamydia infection has not been excluded.
Test of cure: A TOC is not needed for patients with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, a test-of-cure is recommended for pharyngeal gonorrhea, 7–14 days after initial treatment.
Retest: ALL persons treated for gonorrhea should be retested 3 months after treatment. If retesting at 3 months is not possible, we should retest within 12 months after initial treatment.
Summary: treat urogenital, rectal, and pharyngeal gonorrhea with single IM dose of 500 mg of Ceftriaxone PLUS doxycycline 100 mg BID for 7 days.
This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.
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Interview to Dr Tammela by Dr Arreaza (unscripted)
Highlights of the interview:
What measurement is essential before starting combined oral contraceptives? The answer is blood pressure measurement.
Dr Tammela is the chief of women’s health in Clinica Sierra Vista. She is a practicing OB/Gyn specialist.
Some topics discussed during the interview includes:
Why is blood pressure measurement essential before starting combined hormonal contraception?
Contraindications to combined hormonal contraception
Three scenarios and recommend what type of contraception should be used:
Patient younger than 35, healthy, well-controlled hypertension
Patient older than 35, well-controlled HTN, or patient of any age with BP 140-160/90-100 mm Hg
Patient of any age with blood pressure >160/100
Continued blood pressure monitoring after initiation of combined hormonal contraception
When to stop CHC
TIPS
by Valerie Civelli, MD and Patrick De Luna, MS3
Which OCP to choose?
Tip #1:
In general, higher estrogen in birth control pills (35mcg) means better cycle control but worse estrogen-related side effects: such as nausea or breast tenderness. Lower dose estrogen birth control, (typically 20 µg) are better for those experiencing estrogen related side effects and must be taken at the same time every day. Remember: the lower the dose of Estrogen means the higher risk of breakthrough ovulation and breakthrough bleeding. LoLo® is a great option!
Dr. Karen Tammela, OBGYN, when asked about her OCP preference for patients, she states, “I pretty much always use monophasic pills. They seem in general to provide improved cycle control. I think most OB/GYN‘s agree...”
Tip #2:
For patients who c/o bloating, weight gain, hirsutism and acne, think about Yaz®, and its higher dose sister Yasmin®: Drosperinone + Ethinyl Estradiol. Yaz or Yasmin have a special type of progesterone, Drospirinone, which makes it unique.
Tip #3:
Yaz and Yasmin: Let’s talk about insurance coverage (Family Pact and Kern Health) 12-month Supply may be provided twice in one year. For a 3rd dispense of 12-month supply, TAR is required for prior authorization. If you see this med was not covered, it’s likely the patient has been prescribed two-12/month supplies OCPs already. Submit a TAR in this case for coverage.
Tip #4:
Yaz or Yasmin are special because it is not just a low androgen option (which is what you look for in a pill for patients in need of acne control), but it is actually an ANTI-androgen, so it is THE BEST OPTION for acne. It also is the best option to reduce pill related weight gain, as the progesterone element (drospironone) acts as a diuretic. Did you know Drosperinone has antiandrogenic properties equivalent to 25mg of spironolactone?
Tip #5:
Menstrual headaches? Think Mircette®. Mircette® is good for patients with menstrual headaches, because it reduces the stark drop in estrogen that happens from the active pills to the placebo (and it is the drop that is believed to be the trigger for menstrual headaches) by having a smoother estrogen step-down effect and a shorter placebo pill length. In patients with migraines with aura, it is best to avoid Combined Hormonal Contraceptives, especially if older than 35.
Speaking Medical: Allodynia
by Xeng Xiong, MS4
Ouch my hair hurts! Are you serious? Yes. There is a condition where a person can experience pain from stimuli that isn't normally painful; the term is called allodynia. But wait, can that pain also be considered hyperalgesia? This is so confusing. Allodynia and hyperalgesia are both related to hypersensitivity to pain, so let’s break them down.
Allodynia is the feeling of pain caused by usually nonpainful stimuli, such as brushing your hair. Allodynia results from increased pain receptors. Some people with migraine may have allodynia and will often describe this experience by saying, “My hair hurts.”
Hyperalgesia, on the other hand, is an increased numbers of action potentials and spontaneous discharges in response to painful stimuli leading to a lower threshold. This means a patient will experience more pain with a stimulus that was previously less painful. In practice, patients on high dose opioid may experience hyperalgesia and stroking on their skin can cause pain. The treatment for this condition is to lower the opioids dose.
In the mist of all this medical jargons, allodynia and hyperalgesia are referred to as hypersensitivity to pain. However, their pathophysiology is different. Allodynia is related to stimuli that are generally non-painful which becomes painful upon stimulation, while hyperalgesia is related to stimuli that are generally painful but becomes significantly more painful when stimulated. By this time if you’re still confuse, Allodynia = non-painful stimuli; Hyperalgesia = painful stimuli. I hope listening to this was not so painful for you[3].
For your Sanity: Jokes
by Lisa Manzanares, MD
Finland has closed its borders, no one can cross the Finnish line.
Did you hear the rumor about butter? Well, I’m not going to spread it.
A cheese factory exploded in France. Da Brie is everywhere.
I have two dogs named Rolex and Timex. They are my watch dogs.
The difference between a numerator and a denominator is a short line. Only a fraction of people would understand this.
I know a lot of jokes about retired people, none of them work.
Now we conclude our episode number 36 “Birth Control and Hypertension”. Dr Tammela explained that whenever you have a patient with uncontrolled hypertension, be alert of the contraindications to hormonal birth control. Dr Civelli and Patrick gave us some interesting tips on birth control pills, and Xeng explained the difference between allodynia and hyperalgesia.
Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Lisa Manzanares, Steven Saito, Valerie Civelli, Patrick De Luna, Xeng Xiong, and Mohammad Suleman. Audio edition: Suraj Amrutia. See you next week!
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References:
St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1911–1916. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm?s_cid=mm6950a6_w#B1_down
Onusko, Edward, M.D., Diagnosing Secondary Hypertension, Am Fam Physician. 2003 Jan 1;67(1):67-74. https://www.aafp.org/afp/2003/0101/p67.html#afp20030101p67-t1.
Zeng, Thomas, MD, Comprehensive Handbook, Obstetrics & Gynecology, Second Edition, 2012 by Phoenix Medical Press LLC, pages 176-178.
