Men’s and Women’s Health Discussion 

Men’s and Women’s Health Discussion 

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Module 3: Men and Women’s Health

GD is, unfortunately, experiencing a side effect profile that is common with many alpha 1-adrenergic antagonists. While these medications are considered by many urologists to be superior in managing lower urinary tract symptoms (LUTS) through relaxing the bladder neck, prostatic urethra, and prostate small muscle (Gravas & Dimitropoulos, 2016), they can also cause hypotension, nasal congestion, and dizziness. GD is taking terazosin, which has a higher incidence of hypotension than other alpha 1-adrenergic antagonists (Guzmán et al., 2019). As GD is an elderly man who is still endorsing LUTS and the symptomatology of dizziness and hypotension, placing him at an increased risk for falls, a different pharmacological approach should be suggested (van der Worp et al., 2019).

As GD is experiencing LUTS and benign prostatic hypertrophy (BHT), he would benefit from a combination pharmacological therapy that targets both the prostate and the bladder, in addition to lifestyle modification including a bladder training program, not drinking 4 hours before bed, and double voiding. Female patients with overactive bladders are commonly prescribed antimuscarinics, but they are not used as often in men due to a concern that they will lead to acute urinary retention (Oelke et al., 2015). While antimuscarinics are a good choice, for GD, utilizing silodosin or tamsulosin in conjunction with mirabegron would provide relief from the symptoms that he is experiencing. Mirabegron is beta 3-adrenoreceptor agonist that attaches to beta 3 receptors in the bladder causing them to relax, resulting in decreased frequency, urgency, nocturia, and incontinence (Kakizaki et al., 2020). A possible side-effect of this medication that is beneficial to GD, is that it can raise blood pressure (Gravas & Dimitropoulos, 2016). Silodosin or tamsulosin have been shown to have a lower incidence of hypotension and resultant dizziness, so the concurrent use of one of these alpha 1-adrenergic antagonists, along with mirabegron should decrease the lower urinary tract symptoms that GD is experiencing and improve his quality of life.

Polycystic ovarian syndrome (PCOS) is an endocrine disorder which effects women of reproductive age at a rate of 5–15% of the population (Rosenfield & Ehrmann, 2016). These women often have difficulty getting pregnant as they generally do not have a regular menstrual cycle related to excessive androgen inhibiting ovulation. Additionally, PCOS is a multi-system metabolic disorder resulting in obesity, hypertension, dyslipidemia, and insulin resistance (Rosenfield & Ehrmann, 2016). Pregnant women with PCOS have a three times greater risk of pregnancy related hypertension, gestational diabetes, and preeclampsia

LW is currently taking medications that are contraindicated in pregnancy, which means a thorough medication reconciliation and resultant recommendation needs to be completed. The American College of Obstetricians and Gynecologists strongly recommend a reduction in weight in overweight or obese women before becoming pregnant, as pregnancy places an increased physiological demand on the body (&na;, 2013). As LW’s physical indicates obesity, this is the primary recommendation before she becomes pregnant. As she is already taking rosuvastatin, which is contraindicated in pregnancy, she needs to decrease her cholesterol as well, indicating the need for dietary education.

Previously metformin was listed as a category C medication, meaning one must evaluate the risk vs. the benefits. However, this labeling system is no longer in use, and each medication is evaluated differently. Current evidence-based research suggests that metformin can be safely used in pregnancy. One study even found evidence that supports metformin use in the first trimester of women with PCOS led to a decrease in early pregnancy loss (Zeng et al., 2016). While metformin is relatively safe, insulin is a better option during pregnancy and can be adjusted to maintain blood glucose levels. Finally, lisinopril has demonstrated teratogenic properties and should be avoided during pregnancy (Panchal et al., 2019). The first line recommended anti-hypertensive during pregnancy is methyldopa which should be given instead of lisinopril (Brown & Garovic, 2014).

While it is a primary care provider’s responsibility to be aware of contraindications in medication management for patients, as a PCP is the first line of contact for a patient, when a patient has medical complexity, they should be referred to a specialist. In the case of our previous patients, GD should be referred to a urologist, although rescheduled to see the primary provider in 2–4 weeks to follow up with the new medication regime. As LW is at risk for pregnancy complications, she should be referred to a high-risk obstetrician.

References

Gravas, S., & Dimitropoulos, K. (2015). Solifenacin/tamsulosin fixed-dose combination therapy to treat lower urinary tract symptoms in patients with benign prostatic hyperplasia. Drug Design, Development and Therapy, 1707. https://doi.org/10.2147/dddt.s53184

Gravas, S., & Dimitropoulos, K. (2016). New therapeutic strategies for the treatment of male lower urinary tract symptoms. Research and Reports in Urology, 51. https://doi.org/10.2147/rru.s63446