Urge/Overactive Bladder:
Antimuscarinic medications for treatment of women with urge incontinence or overactive bladder (OAB) with incontinence
General antimuscarinic issues:
All antimuscarinics are contraindicated in gastric retention, untreated narrow angle closure glaucoma, and supraventricular tachycardia.
Evidence suggests that cumulative exposure to potent antimuscarinics is associated with increased rates of dementia and Alzheimer disease [1].
All antimuscarinics exert peripheral anticholinergic effects (eg, dry mouth, constipation, tachycardia, palpitations).
All antimuscarinics may have additive side effects with other medications that have strong anticholinergic effects (eg, first-generation H1 antihistamines, muscle relaxants, tricyclic antidepressants, antipsychotics, inhaled anticholinergic bronchodilators).*
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Pelvic Pain:
NSAIDs:
- Indication:
- Dose:
- Contraindications:
- Side effects:
- MOA:
Gabapentin:
- Indication:
- Dose:
- Contraindications:
- Side effects:
- MOA:
Cyclobenzaprine:(Flexiril)
- Indication:
- Dose:
- Contraindications:
- Side effects:
- MOA:
Tri-cyclic Antidepressants:(Amitriptyline/Elavil or Nortriptyline)
- Indication: (Off-label) Chronic pain, fibromyalgia, interstitial cystitis.
- Dose: Oral: 10 to 25 mg daily titrated weekly over several weeks to a target dose of 75 to 100 mg as tolerated. For fibromyalgia, higher doses (50mg) may not be more effective than lower starting doses. For chronic pain, doses upt o 150mg have been used.
- Contraindications:
- Side effects:
- MOA: Increases the synaptic concentration of serotonin and/or norepinephrine in the central nervous system by inhibition of their reuptake by the presynaptic neuronal membrane pump --> Increased availability of norepinephrine and serotonin in the descending pain modulatory pathways appears to decrease pain sensitivity
SNRIs: (Duloxetine/Cymbalta)
- Indication: chronic musculoskeletal pain/fibromyalgia - chronic pelvic pain is off-label.
- Dose: Oral: Manufacturer's labeling: 30 mg once daily for 1 week, then increase to 60 mg once daily as tolerated; maximum dose: 60 mg once daily.
- Contraindications: Use of monoamine oxidase (MAO) inhibitors intended to treat psychiatric disorders (concurrently or within 14 days of discontinuing the MAO inhibitor); initiation of MAO inhibitor intended to treat psychiatric disorders within 5 days of discontinuing duloxetine; initiation of duloxetine in a patient receiving linezolid or intravenous methylene blue.
- Side effects: most common - nausea, headache, dry mouth, drowsiness/fatigue, abdominal pain,
- MOA: Duloxetine is a potent inhibitor of neuronal serotonin and norepinephrine reuptake and a weak inhibitor of dopamine reuptake.
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Atrophy:
- Intrarosa (Prasterone): steroid/DHEA
- Indication: moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy - only indicated in postmenopausal women.
- Dose: one vagina insert/suppository daily at bedtime.
- Contraindications: Undiagnosed AUB. Use with caution in women with breast cancer (estrogen is a metabolite of prasterone).
- Side effects: vaginal discharge. Possibly related abnormal pap smear.
- MOA: inactive endogenous steroid and is converted into active androgens and/or estrogens.
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