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Flashcards in Contraception Deck (86)
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1

What is the reproductive lifespan of a man?

10-12 years old until death as long as vas deferens intact and able to ejaculate

2

Emergency contraception: Highest probability at what time of the month?

Highest probability of conception is 1-2 days before ovulation

3

What are the drugs that are available for emergency contraception?
4

1. Plan B: levonorgestrel 0.75 mg two pills to be taken 12 hrs apart. Can be taken up to 24 hours apart

2. Plan B One Step or Next Choice One Dose and other branded generics: a single levonorgestrel 150 mg pill

3. Ella: ulipristal 30 mg: Single dose; prescription
-Formulated using a variety of combination oral contraceptives to achieve ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg, 2 doses in 12 hours (Yuzpe 1974)

4. Oral Hormonal EC (Levonorgestrel)

4

Levonorgestrel: SE?
3


Effective up to how long after the event but take as soon as possible?

1. N 24% & V 9% (higher with use of combined oral contraceptives or the Yuzpe method)

2. irregular bleeding the month after treatment

3. less common: dizziness, fatigue, HA, breast tenderness,

Effective up to 120 hours after the event but take as soon as possible*

5

Emergency contraception: Pregnancy should be excluded before administration of what?
2

1. ulipristal or
2. insertion of Cu IUD

6

EC Mechanism of Action
1. Oral methods?
2. Copper IUD? 2

3. Use of ORAL HORMONAL EC affects an already pregnant woman how? 2

1. Oral methods: Inhibiting or delaying ovulation
-Levonorgestrel is ineffective after ovulation has occurred

2. Copper IUD:
-Interfering with fertilization or tubal transport
-Preventing implantation by altering endometrial receptivity

3.
-does not interrupt a pregnancy and
-has no known adverse effects on pregnancy or fetus

7

EC counseling:

4

1. Obtain pregnancy test if no menses 3-4 weeks after EC

2. Discuss risk of pregnancy and STIs with unprotected sex

3. Encourage patient to start a regular contraceptive method or review correct use of current one

4. EC is a back-up,not a primary contraceptive method

8

Considerations for Choosing a Contraceptive Method
7

1. Efficacy (failure rate)

2. Safety (risks with consideration of health history)

3. Side effects (to include effect on menses)

4. Convenience ( correct use and access to care)

5. Cost

6. Personal lifestyle and pattern of sexual activity

7. Reversibility

9

What are the categories for contraception?
4

1. Hormonal
2. IUD (IUC)
3. Barrier
4. Permanent

10

Contraception Failure
is often due to?
3

1. Inappropriate use
2. Failure to use (influence of cost and access)
3. Failure of method (“correct use” failure rate)

11

What are the hormonal methods of contraception? 6

1. Oral pills
2. Transdermal patch
3. Injections
4. Intrauterine devices
5. Subdermal implants
6. Intravaginal

12

OCP: MOA?
The influence of estrogen (ethinyl estradiol):
2

1. SUPPRESSION of GnRH (Hypothalamus)


2.Stabilizes endometrium to minimize breakthrough bleeding

13

What does the suppression of GnRH in the hypothalamus lead to that works in contraception?
4

1. INHIBITS the midcycle surge of gonadotropin LH
2. PREVENTS ovulation
3. SUPPRESSES FSH secretion
4. PREVENTS ovarian folliculogenesis

14

1. What are considered low dose OCP doses?

2. High doses?

1. “Low dose” 20 or 30 or 35 mcg

2. “High dose” 50 mcg

15

OCP: Mechanism of Action
Influence of progestin (a 19-nortestosterone or drospirenone)?
4

1. Suppresses LH secretion and therefore, suppresses ovulation (less potent than estradiol)

2. Thickens cervical mucus which inhibits sperm migration

3. Creates an atrophic endometrium unfavorable to implantation

4. Impairs normal tubal motility/ peristalsis

16

Progestin Component
Several progestins (typical dose 0.15-1 mg):
1. Older more androgenic ones? 3
2. Advantage?

3. Newer progestestins (less androgenic effects)? 3
4. Advantage? 2
5. Possible increase of what?

Older more androgenic ones
1.
-Norethindrone,
-norethindrone acetate,
-levonorgestrel

2. Lower HDL cholesterol

Newer progestins—less androgenic effects

3.
-Norgestimate,
-desogestrel,
-drospirenone

4.
-Less effect on carbohydrate & lipid metabolism
-More effective at reducing acne & hirsutism

5. Possibly increased risk of thromboembolism

17

Examples of Progestins
1. First generation? 2

2. Second generation? 2

3. Third generation? 3

4. Unclassified? 1

1. First generation:
-Norethindrone (acetate),
-ethynodiol diacetate

2. Second generation:
-Levonorgestrel and
-dl-Norgestrel (higher androgenic but more effective than 3rd in countering thrombotic effects of estrogen)

3. Third generation:
-desogestrel (? Increased of VTE)
-norgestimate

4. Unclassified:
-drospirenone (in Yasmin and Yaz) less androgenic but risk of VTE up to 3x compared to levonorgestrel (FDA revised label in 2012)

18

Other Advantages of New Progestins
4

1. Higher HDL cholesterol/lower LDL cholesterol

2. Higher sex hormone binding globulin (SHBG) which results in decreased free testosterone levels and estrogen effects)

3. Greater affinity to progesterone binding sites

4. Reduced amenorrhea

19

*OCP: Non-contraceptive Use *
9

1. Endometriosis: reduce pelvic pain
2. Treatment for acne or hirsutism
3. Treatment for heavy, painful or irregular menstrual periods
4. Reduce occurrence of recurrent ovarian cysts
5. PCOS (acne, hirsutism, unopposed estrogen influence to endometrium)
6. PMS/PMDD
7. Decreased risk of ovarian cancer
8. Decreased risk of colon cancer
9. Decrease menstrual migraine (with continuous or extended cycle)

20

Higher Dose Estrogen Pills
50mcg

1. Spotting or absence of withdrawal bleeding cannot be managed on what?

2. Treatment of other problems? 2

1. lower dose pill

2.
-Dysfunctional uterine bleeding
-Reduce recurrent ovarian cysts

21

OCP Preparations
4

1. Monophasic
2. Multiphasic (biphasic or triphasic)
3. Extended cycle (withdrawal flow every 12 weeks)
4. Progestin-only pill (POP or “mini-pill”)

22

OCP cycles? 3

1. 21 days on, 7 days off (most formulations)

2. 24 days on, 4 days off (drospirenone containing forms)

3. 84 days on, 7 days off—extended cycle

23

Who uses the 84 days on, 7 days off—extended cycle specifically? 3

(Seasonale, Introvale, and Quasense (estradiol & levonorgestrel) 84 days of active pills and 7 days of placebo.)

Use:
1. patients w/ endometriosis,
2. premenstrual dysphoric disorder and
3. women who prefer less frequent menses

24

Choosing a Pill Formulation
1. Typically start with _______ in a younger or less compliant patient but generally it doesn't matter much

2. ____________ women are usually started on a lower estradiol pill

3. Androgenic influence of ___________ may be taken into consideration

4. Breastfeeding women?

If they have used a formulation in the past that's worked, be reluctant to mess with success!

1. monophasic

2. Perimenopausal

3. progestin

4. progesterone only pill

25

Three methods for starting for COC

1.Quick Start: start the day of RX regardless of day of cycle once pregnancy is ruled out

2.“Sunday” Start: start 1st Sunday after period begins

3. Start 1st day of menses

26

With Quick Start or Sunday Start, must use backup method for _________ after starting the pill

A what should be started in first 5 days of menses?

7 days

progesterone only pill (POP)

27

Contraceptive Patch
Ortho-Evra
1. Transdermal patch— changed how often?

2. Delivers constant level of 20 mcg ____________ and 150 mcg of ____________ daily

3. Resultant serum levels of ___ 66% higher than 35 mcg oral pill. In 2008, FDA revised labeling to state possible higher risk of thromboembolism.

1. every 7 days for 3 weeks and then1 week off for menses

2. ethinyl estradiol, norelgestromin

3. EE

28

Vaginal Ring
(NuvaRing)
1. Delivers 15 mcg _________ and 120 mcg _________ daily for 3 weeks intravaginally

2. Remove for ______ then insert new one

3. If it falls out or needs to be removed, rinse with cold or warm (not hot) water and reinsert when?

1. estradiol, estonogestrel

2. 1 week

3. within 3 hours

29

*Absolute Contraindications for Estrogen Contraception*
13

1. Hx of thromboembolic event or stroke or known thrombogenic mutation (Factor V Leiden)

2. Known CVD, cardiomyopathy,

3. BP 160/100 or greater,

4. complicated valvular heart disease

5. SLE with positive antiphospholipid antibodies

6. Women 35 or older who smoke

7. Migraines with aura

8. Women 35 or older with migraines

9. Hx of cholestatic jaundice with pill use

10. Hepatic carcinoma or benign adenoma; any active liver disease or severe cirrhosis

11. Breast cancer (current)

12. First 21 days postpartum (increased risk of clotting)

13. Undiagnosed abnormal uterine bleeding

30

Careful consideration before use of Estrogen

9

1. HTN (less than 35 yo, nonsmoker, evaluate cumulative risk factors for CAD/stroke)

2. Anticonvulsant therapy (see drug interactions)

3. Migraines without aura (less than 35 yo,evaluate cumulative risk factors for CAD/stroke)

4. Diabetes (evaluate cumulative risk factors for CAD/stroke)

5. Hx of bariatric surgery with malabsorptive procedure like

6. Roux en Y (possible decreased efficacy with oral pills)

7. Psychotic depression

8. Ulcerative colitis (may increase with years of use)

9. Obese, > 35 yo