Flashcards in Contraception Deck (86)
What is the reproductive lifespan of a man?
10-12 years old until death as long as vas deferens intact and able to ejaculate
Emergency contraception: Highest probability at what time of the month?
Highest probability of conception is 1-2 days before ovulation
What are the drugs that are available for emergency contraception?
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)
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*
Emergency contraception: Pregnancy should be excluded before administration of what?
1. ulipristal or
2. insertion of Cu IUD
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
-does not interrupt a pregnancy and
-has no known adverse effects on pregnancy or fetus
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
Considerations for Choosing a Contraceptive Method
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)
6. Personal lifestyle and pattern of sexual activity
What are the categories for contraception?
2. IUD (IUC)
is often due to?
1. Inappropriate use
2. Failure to use (influence of cost and access)
3. Failure of method (“correct use” failure rate)
What are the hormonal methods of contraception? 6
1. Oral pills
2. Transdermal patch
4. Intrauterine devices
5. Subdermal implants
The influence of estrogen (ethinyl estradiol):
1. SUPPRESSION of GnRH (Hypothalamus)
2.Stabilizes endometrium to minimize breakthrough bleeding
What does the suppression of GnRH in the hypothalamus lead to that works in contraception?
1. INHIBITS the midcycle surge of gonadotropin LH
2. PREVENTS ovulation
3. SUPPRESSES FSH secretion
4. PREVENTS ovarian folliculogenesis
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
OCP: Mechanism of Action
Influence of progestin (a 19-nortestosterone or drospirenone)?
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
Several progestins (typical dose 0.15-1 mg):
1. Older more androgenic ones? 3
3. Newer progestestins (less androgenic effects)? 3
4. Advantage? 2
5. Possible increase of what?
Older more androgenic ones
2. Lower HDL cholesterol
Newer progestins—less androgenic effects
-Less effect on carbohydrate & lipid metabolism
-More effective at reducing acne & hirsutism
5. Possibly increased risk of thromboembolism
Examples of Progestins
1. First generation? 2
2. Second generation? 2
3. Third generation? 3
4. Unclassified? 1
1. First generation:
2. Second generation:
-dl-Norgestrel (higher androgenic but more effective than 3rd in countering thrombotic effects of estrogen)
3. Third generation:
-desogestrel (? Increased of VTE)
-drospirenone (in Yasmin and Yaz) less androgenic but risk of VTE up to 3x compared to levonorgestrel (FDA revised label in 2012)
Other Advantages of New Progestins
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
*OCP: Non-contraceptive Use *
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)
7. Decreased risk of ovarian cancer
8. Decreased risk of colon cancer
9. Decrease menstrual migraine (with continuous or extended cycle)
Higher Dose Estrogen Pills
1. Spotting or absence of withdrawal bleeding cannot be managed on what?
2. Treatment of other problems? 2
1. lower dose pill
-Dysfunctional uterine bleeding
-Reduce recurrent ovarian cysts
2. Multiphasic (biphasic or triphasic)
3. Extended cycle (withdrawal flow every 12 weeks)
4. Progestin-only pill (POP or “mini-pill”)
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
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.)
1. patients w/ endometriosis,
2. premenstrual dysphoric disorder and
3. women who prefer less frequent menses
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!
4. progesterone only pill
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
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?
progesterone only pill (POP)
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
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
*Absolute Contraindications for Estrogen Contraception*
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
Careful consideration before use of Estrogen
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
Hormonal Pills, Patch and Ring
1. Theoretical/Correct use?
2. Typical use?
1. less than 1%
HC Side Effects
2. Breast tenderness
3. Spotting/ break through bleeding (BTB): most common (10-30% in first three months)
4. Amenorrhea (about 5% after several years; more common with 20 mcg estradiol pill) (Goal with extended or continuous delivery.)
6. Headache: may occur in early cycles and generally improve with subsequent cycles
8. Decreased libido
1. Early/Acute SE of HC? 4
2. What is the most common SE of HC?
3. This is independant of what?
1. Early SE:
-breast tenderness, &
-mood changes (do not cause weight gain)
2. Breakthrough bleeding
-Most common side effect
3. Independent of progestin
-Can add extra estrogen or switch to more estrogenic progestin
How should we treat amenorrhea with HC?
try preparation w/ more estrogen
Risks with E-P Contraception
1. CVD? 3
2. HTN? 2
-Thrombotic, not atherosclerotic
- > 35YO who smoke or have HTN
-Women who have taken OCPs are not at increased risk for CVD later in life
-OCPs can cause mild elevation of BP
-Overt HTN can occur and is associated with increased risk of MI & stroke (Nurses' Health Study)
Risks with E-P contraception
2. Carbohydrate and Lipid Metabolism?
-Estrogen affects levels how? 3
-Progestin affects levels how? 2
-Ischemic: possible extremely low increased risk.
-Estrogen dose dependent. Other risk factors: smoking, older age, HTN, migraine with aura, obesity, prothrombotic mutations
--OCPs can cause mild insulin resistance; probable progestin effect
-Estrogen: serum triglycerides (Oral) and HDL increase;
-Progestin: decrease HDL; increase LDL cholesterol
Risks of E-P contraception
VTE Disease 4
GI risks? 1
1. Dose-dependent risk with estrogen
2. Risk varies with type of progestin
3. Older and obese women at greater risk
4. **Important to take careful personal & family hx of DVT or PE
1. Increased risk of cholithiasis
Risks with E-P Contraception
1. Breast cancer?
2. Cervical cancer? 3
(who can it affect and who does it usually not?)
1. Breast Cancer: (data is conflicting)
Large studies have not shown an association
-May increase breast cancer risk in carriers of BRCA1 mutations & possibly BRCA2
2. Cervical cancer:
-Low increased risk, increasing with duration of use
-Most indicate HPV negative OCP users do not have an increased risk
-In HPV positive women, a metabolite of estradiol can act as a cofactor with oncogenic HPV
Hormonal contraceptive-Drug Interactions
1. Metabolized where?
2. Drugs that ________ liver microsomal enzyme activity accelerate ___________ and may decrease efficacy?
3. _____________ can increase hormonal contraceptive metabolism by inducing the cytochrome P450 system?
2. increase, OCs metabolism
3. St. John's Wort
Hormonal Contraceptive Drug Interactions
1. _________ is the only proven antimicrobial shown to decrease the efficacy of OCs. (Similar effect expected with rifabutin.)
Hormonal contraceptive-Drug Interactions
1. What antifungal may decrease metabolism of estrogen resulting in a higher level than expected?
2. What food?
3. OCs reported to decrease plasma concentrations of the anticonvulsant __________ in one study?
4. Antiretroviral therapy, esp ritonavir-boosted protease inhibitors affect OC how? 2
1. Fluconazole and may decrease metabolism of estrogen resulting in a higher than expected serum EE level. (Significance unclear)
2. possibly grapefruit juice
-lower progestin levels with POP and implants ;
-some meds in this category increase and others decrease contraceptive steroids
OTHER PROGESTIN ONLY METHODS
1. Depo medroxyprogesteron acetate (DMPA or DepoProvera) injection
2. Progestin implant (Nexplanon; previously Implanon)
3. Progestin IUD (Mirena, Skyla)
Progestin Only Methods: Mechanism of Action
1. Inhibition of gonadotropin secretion
2. With resultant inhibition of follicular maturation and ovulation
3. Thickens cervical mucus
4. Creates thin, atrophic endometrium
5. Ovum transport may be slowed by reduced ciliary action in tubes
Progestin Only or Not Hormonal Contraception
When to use?
1. Breast feeding (at least until breast milk well established)
2. Hepatic disease: acute viral hepatitis, hepatocellular adenoma, liver cancer, severe cirrhosis, symptomatic gallbladder disease, cholestasis related to COC
3. Postpartum- first 6 weeks
4. Age over 35 and smoker or HTN
5. Hx of DVT/PE/retinal artery occlusion
6. Anticipated major surgery
-Takes at least 6 weeks for procoagulant effects of estrogen to reverse
7. Migraine HA---with aura, any age; without aura > 35 or
Progestin Only Methods: Advantages
1. Compared to estrogen: fewer contraindications and fewer drug interactions
2. Injection, implant, and progestin IUD are all long acting
Noncontraceptive benefits: (also apply to estrogen)
3. Scanty or no menses (decreased anemia)
4. Decreased menstrual cramps
5. Decreased risk of endometrial cancer, PID
6. Decrease of endometriosis pain
7. Low risk of ectopic pregnancy
Progestin Only Methods: Disadvantages
1. Menstrual cycle disturbances? 2
2. Possible weight gain:
- How? 2
-Greatest with what?
3. Psych changes? 2
1. Menstrual cycle disturbances:
-Early on irregular bleeding and spotting
-Eventually most women become amenorrheic
2. Possible weight gain:
-Altered carbohydrate metabolism -anabolic effect with increased appetite
-Greatest with DMPA (Depo-medroxyprogesterone acetate)
-aggravation of depression
Progestin Only Methods
1. Bone density decrease? 3
2. Increased risk of type 2 diabetes in some high risk populations: Specifically who? 2
1. Bone density decrease:
-Black Box Warning to limit use to 2 years if possible, although no proven increased fracture risk.
-NO INDICATION for DXA
2. Increased risk of type 2 diabetes in some high risk populations
-Latino women on progestin only pill
-Navajo women on DMPA
Acetate (DMPA)(Depo Provera)
1. Two formulations: What are they?
2. Dosing schedule?
1. DMPA—two formulations
-150 mg/ 1mL for IM injections
-104 mg/0.65 mL for SQ injections: slower and more sustained absorption
2. Administer q 3 months (13 weeks with 1-2 week grace period)
First 7 days of menses: no need for pregnancy test or back-up
Quick start: day of visit with negative pregnancy test; use back-up for 7 days; consider EC if unprotected IC in prior 120 hour
1. Safe to use when?
2. After stopping DMPA return to fertility may be delayed up to___________ after the last injection
3. What is this delay related to ?
4. SE? 6
1. Safe to use immediately post delivery
2. 18 months
3. increased BMI, not duration of use
4. usually stop or decrease within several months:
-menstrual irregularities (unpredictable bleeding or amenorrhea (up to 75%))
Clinical Advantages of DMPA
1. Sickle cell anemia: decrease in painful crises
2. Has intrinsic anticonvulsant effect. May be a good choice for woman with seizures
2. Lasts how long?
3. Inserted where?
4. Primary reason of discontinuation?
Not marketed in the US
1. Single rod with slow release of 68mg etonogestrel
2. Lasts for 3 years
3. Inserted in the upper arm subdermally in the office
4. Irregular bleeding was the primary reason of discontinuation
2. May protect against what?
1. Mechanism of action: not precisely known but primary effect appears to be prevention of fertilization *
-Foreign body reaction creates sterile inflammatory changes toxic to sperm and ova and inhibits ovulation
2. Endometrial cancer
2. Lasts how long? 2
Local progestin effect:
3. creates _________ at 24 months in 50%;
4. _________ menstrual flow even with anticoagulant use;
5. may decrease risk of PID due to what?
6. SE? (main one) 4
2. LNG20 Mirena approved for 5 yrs, LNG14 Skyla approved for 3 yrs.
5. thickened cervical mucus
1. NON-hormonal IUC: What drug?
3. __________ monofilament string at end
4. Frame contains _______ for detection by x-ray
5. ___ okay
6. Approved to remain in place for ___ years
7. Advantages? 2
8. SE? 2
1. Tcu380A (copper) Paragard: T-shaped with 380 mm2 exposed surface w/ copper
2. releases copper continuously into the uterine cavity; this interferes with sperm transport and prevents fertilization of ova.
-Advantage to women who cannot use hormonal methods;
-can be used for emergency contraception
IUC Ideal Candidates
1. Not planning a pregnancy for at least 1 year
2. Want to use a reversible form of contraception
3. Want or need to avoid estrogen
4. Want “minimal user effort” and/or privacy
1. IUC Complications
2. Sites of this complication? 3
1. Uterine perforation, embedding, cervical perforation
2. Perforation of 1 of 3 sites
-Body of uterus
IUCs Disadvantages & Cautions
1. PID: 1% incidence in first 3 weeks only
2. Menstrual problems
3. Expulsion: 2-10% in first year
4. Pregnancy complication if conception occurs
EXPULSION of IUD
Top reasons? 3
2. heavy menses,
3. severe dysmenorrhea are risk factors
Clues of Possible Expulsion of the IUC/IUD
1. Unusual vaginal discharge
2. Cramping or pain
3. Intermenstrual or postcoital spotting
4. Dyspareunia: for male or female
5. Absence or lengthening of the IUD string
6. Presence of the IUD at the cervical os or in the vagina
1. Severe uterine distortion
2. Acute pelvic infection
3. Known or suspected pregnancy
4. Wilson's disease or copper allergy
5. Unexplained abnormal uterine bleeding
6. Current breast cancer (Mirena or Skyla)
1. Good for who?
2. Indications? 2
1. Good choice for women who only need intermittent contraception
-Decreased cervical neoplasia risk
Barriers: Disadvantages & Cautions
1. Allergy to spermicide, rubber, latex or polyurethane
2. Abnormalities in vaginal anatomy
3. Inability to learn correct technique
4. History of toxic shock syndrome
5. Repeated UTIs (diaphragm)
Characteristics associated with higher risk of failure of barriers
1. Frequent intercourse (>3 x a week)
2. Age less than 30 years
3. Personal style or sexual patterns that make consistent use difficult
4. Previous contraceptive failure
5. Ambivalent feelings about pregnancy
Failure of Barrier Methods
How does it happen?
1. Lack of trained personnel to fit the device and/
2. or lack of clinical time to provide instruction in use
3. Full-term delivery within past 6 weeks,
4. recent SAB or EAB or vaginal bleeding from any cause including menstrual flow (cap, sponge)
1. What is it?
3. Must be left in the vagina for how long after intercourse?
1. A dome-shaped cup made of latex or silicone
2. Partially filled w/ spermicidal cream/jelly and then inserted deep into the vagina to cover the cervix
3. Must be left in the vagina for 6 to 8 hrs after intercourse, then needs to be removed.
Women who are not good candidates for the diaphragm?
1. Allergic to latex/silicone or spermicides
2. Significant organ prolapse
3. Frequent UTIs
4. HIV infection or at high risk
5. Difficulty with insertion
7. Contraindicated with hx of toxic shock syndrome
Advantages of the diaphragm
2. Inexpensive ($ 70 + $10.00 spermicide)
3. May offer some protection against GC and chlamydia (NOT HIV)
4. Immediately effective and reversible
5. No hormonal SE
6. Can be used by women who are breastfeeding
Disadvantages of diaphragms
1. Must be willing to insert before each episode of coitus and left in place for 6 hours after IC
2. Requires some skill to insert
3. Both the diaphragm & spermicide must be within reach within a few hours of coitus
4. May increase frequency of UTIs
5. Refitting recommended after childbirth
6. Not available at all pharmacies *
Fitting a Diaphragm
Sizing must be done when? 2
Sizing must be done>6 wks postpartum or 2 wks post abortion
1. What is it?
2. Whats the only one available in the US?
3. SE? 3
1. Reusable, deep rubber cup that fits over the cervix, must be used with a spermicide has to remain in for 6-8 hrs can be left in place for up to 48 hours
2. FemCap is only one available in the US
1. What is it?
2. Preparation for insertion?
3. Contraceptive benefit for up to how long?
4. Increased risk of what?
1. Today sponge is a 2 in. wide circular disk, ¾ in. thick that contains 1000 mg of nonoxynol-9 and has attached loop for removal
2. It is moistened w/ tap water before insertion
3. Contraceptive benefit for up to 24 hours regardless of number of episodes of IC. Must be left in place for 6 hours after intercourse
4. Increased risk of TSS
1. What is it?
2. Which one is available in the US?
3. Issues? 3
1. Lines the vagina and shields introitus providing physical barrier during intercourse
2. “Reality” female condom only one available in US
3. More problems with
Male Condoms Advantages
1. Accessible and portable
3. Male participation
4. Erection enhancement
6. Prevention of sperm allergy
7. Proof of protection
8. Decreased risk of STIs
Male Condoms: Disadvantages
1. Reduced sensitivity
2. Interference with erection
3. Interruption of coitus
4. Latex allergy
7. Failure rate: 18% typical use; 2% correct use
Spermicides: Advantages & Indications
1. Can be purchased OTC
2. Can be used without partner involvement
3. Immediate protection
4. Back-up option
5. Midcycle use to augment other methods
6. Emergency measure if condom breaks
7. Provides lubrication
Spermicides: Disadvantages & Cautions
3. Can irritate vaginal lining and enhance spread of viruses such as HIV if used 2 times or more a day
4. Failure rate:
typical use 28%
Correct use 18%
1. What is it called?
2. Failure occurs when? 2
3. Failure rates? 2
1. Coitus interruptus
Requires men to withdraw before ejaculation
2. Failure occurs if withdrawal is not timed correctly or preejaculatory fluid contains sperm
3. Failure rates:
correct use 4 %
Typical use 22 %
1. Why is lactation a form of BC?
2. Associated with subfertility, but can only be relied upon to prevent pregnancy when? 3
1. Breastfeeding delays ovulation
1. The woman is
Fertility Awareness-based Methods: Factors contributing to low utilization?
1. Readily available information is limited
2. Provider bias against or lack of education about these methods
3. Complicated, user dependent with cooperative partner
4. High failure rate
Not recommended when menses less predicatable such as?
Also not recommended for women with? 3
1. Recent menarche
2. Recent childbirth
3. Approaching menopause
4. Recent discontinuation of hormonal contraceptives
5. Currently breastfeeding
1. Women with cycles shorter then 26 days or longer than 32 days
2. Women who are unable to interpret their fertility signs correctly
3. Women with persistent vaginal infections that affect the signs of their fertility
1. Ovulation method: predicting fertile time based upon recent history of cycle length. If cycles 26-32 days, days 8-19 are most fertile.*
2. Symptothermal:basal body temperature and cervical mucus as well as other symptoms of ovulation
3. Cervical mucus: increases in amount and is thin and slippery in several days before and at ovulation
4. BBT alone: Basal body temperature increases 0.5-1 degree F at time of ovulation but 2-3 days before ovulation is most fertile time
Surgical Sterilization of Women
1. At time of C/sec?
2. Early postpartum?
3. Interval sterilization? 4
4. Hysteroscopic (also interval sterilization) as office procedure (Essure)
1. Pomeroy technique
2. minilaparotomy with general/regional/local anesthesia
-Laparoscopic (usually with general surgery)
-Bipolar electrocautery (highest ectopic rate)
-Mechanical devices (clips, bands)
4. HSG after 3 months to confirm occlusion
1. Laparoscopic tubal decreases risk of what?
2. If failure occurs, 33% of pregnancies are ______
Compared to 20% with IUD failure
1. ovarian cancer even in women with BRCA 1 and 2
Factors associated with regret afterwards?
1. Young age (30 or younger: 20% vs 5.9% over age 30)
2. Change in relationship
3. Low parity
4. Not aware of availability of long-acting reversible methods before having had tubal
Reversal usually not covered by insurance