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It can decrease pH and increase cell number in the vagina and thus decrease symptoms. Side Effects: hot flashes, vaginal discharge, muscles spasm, hyperhidrosis. Caution use ifhistory of DVT, PE, cardio/cerebrovascular event as possible pro-estrogenic effect. Contraindicated: pts with undiagnosed bleeding or estrogen-dependent neoplasm due to small increased risk of uterine cancer. Drug Availability: tablet Paroxetine (Brisdelle) – Inhibits the reuptake of serotonin into neurons with the mechanism in menopausal vasomotor symptoms unknown. FDA approved. Reduction in hot flashes by 1-2 episodes/day. Requires slow withdrawal to avoid dysphoric mood, irritability, and agitation. Side Effects: change in bowel habits, sleep habits, nausea, headache, dry mouth, fatigueBlack Box Warning: suicidality, Steven-Johnson’s, serotonin toxicity, risk of fracture, lower seizure threshold Drug Interaction: strong inhibitor for CYP2D6. Includes thioridazine, pimozide, tamoxifen, TCA, risperidone, Atomoxetine, Warfarin (due to protein binding), Digoxin, Theophylline Drug Availability: capsules, suspension, tabs Venlafaxine – an SSNRI that inhibits the reuptake of serotonin, norepi, dopamine into neurons. Not FDA approved. Requires slow withdrawal to avoid dysphoric mood, irritability, agitation, anxiety Side effects: headache, sweating, nausea, constipation, somnolence, dry mouth, dizziness,insomnia, astheniaBlack Box Warning: suicidality, sustained hypertension, serotonin toxicity Drug Interactions: be mindful of drugs that increase serotonin concentration. Contraindicated with MAOI’s. Drug availability: tabs and capsules Gabapentin – binding sites in the hypothalamus. Not FDA approved. Reduction in hot flashes 25%. Decrease dose for low CrCl. Side effects: somnolence, fatigue, dizziness, palpitation. Black Box Warning: Suicidality Drug interactions: absorption is decreased by antacids, most drugs used for epilepsy Drug availability: capsules, tabs, solution
29Erectile DysfunctionErectile dysfunction is the inability to achieve or sustain erection sufficient for intercourse. Erection involve the CNS, vascular system, hormones, peripheral nervous system, psychological component. Vascular risk factors for ED are similar to CV risk factors and include HTN, DM, hyperlipidemia. Must r/o medication induced, lifestyle, stress, and other causes. In the flaccid state, sympathetic and parasympathetic nerve impulses are balances (blood flow in equilibrium). During periods of stimulation the relaxation of the smooth muscle happens that increases in parasympathetic activity which results in a nitric oxide cascade. Phosphodiesterase 5 Inhibitors Inhibition of PDE5 causes increased levels of cGMP by inhibiting conversion to 5-GMP resulting in smooth muscle relaxation and inflow of blood to the corpus cavernosum. They are FDA approved.