04-17 Clinical Contraception

Question 1

What are the absolute contraindications to estrogen-containing contraceptives?

Answer 1

1 thromboembolic disorders, 2 abnormal bleeding, 3 impaired liver fxn, 4 smokers >35 y/o, 5 known/suspected breast cancer

Question 2

All of the progesterones (except _________) are derivatives of __________.

Answer 2

All of the progesterones (except drosperindone) are derivatives of 19-nor-testosterone.

Question 3

How do OCPs/rings/patches work?

Answer 3

progestin: 1°ly inhibits LH -> no LH surge -> no ovulation
- -dominant anti-ovulatory MoA
estrogen: 1°ly inhibits FSH -> no follicular maturation
- -potentiates anti-ov effect of progestin: E ↑s # of P receptors
- -also stabilizes endometrium = fewer unscheduled bleeds

Question 4

Watershed dose of EE between “high” and “low” dose OCPs?

Answer 4

35mg of ethinyl estradiol

Question 5

Relative contraindications to E-containing contraceptives?

Answer 5

some examples: surgery, gall bladder dz, migraines, DM and HTN (See CDC Medical Eligibility guidelines)

Question 6

Is there any evidence that combination OCPs cause weight gain?

Answer 6

no, no statistically significant weight gain has ever been shown in research

Question 7

OCPs and Breast Cancer

Answer 7

• small increased RR; disappeared 10 years s/p d/c
• breast CA in current/recent users was less clinically advanced when detected
• no greater increase in that risk w/ + family hx

Question 8

Risk of thrombosis and dose of EE in and EE-containing contraceptives

Answer 8

clear increased risk when dose > 35ug; no difference shown between the various <35ug doses

Question 9

Thrombosis history and EE-containing contraceptives

Answer 9

ASK ABOUT FAMILY HX OF CLOTTING IN ♀ RELATIVES WHO WERE PREG OR TAKING HORMONES
—Pts w/ herid. predisposition to clotting (e.g. Factor V Leiden, Protein C and Protein S deficiencies) should NOT use estrogen-containing contraceptives.

Question 10

Medroxyprogesterone acetate depot problems

Answer 10

—need new shot q3 months
—weight gain (esp among obese ♀), erratic bleeding/amenorrhea,
—may last up to 1 year (mean time to fertility again 8 mos)

Question 11

Vaginal rings have increased failure rate if left out for more than _____________.

Answer 11

3 hours

Question 12

Contraceptive patch is less effective in which pt population?

Answer 12

pts > 90kg (200lbs)

Question 13

IUDs : Cu vs. Progestin
—Efficacy
—MoA
—Contraindications
—Menses
—How often must they be replaced?

Answer 13

Efficacy
—99% (typical and perfect use)
MoA
—paraguard: inflamm blocks fert
—progestin-containing: some prevention of ovulation + increased thickness/inhospitability of cervical mucus
Contraindications
—active cervicitis, though ACOG reading suggested ok as long as you screen and start tx for STIs at same time...
Menses
—paraguard: normal
—progestin-containing: variable
Replacement Schedule
—Pararguard (copper) replaced q10 yrs
—progestin-containing: Mirena q5 yrs, Skyla q3

Question 14

Implants
—drug
—efficacy

Answer 14

estrogen
—replacd q3
—highly effective (~= tubal ligation)

Question 15

Emergency Contraceptive
—When to consider EC?
—Med
—MoA

Answer 15

Plan B is appropriate when:
—no barrier/broken condom
—  >2 missed pills
—  >13 weeks late for Depo Provera shot
—  >2 days late w/ patch
—  >3 hrs with ring out
MED
—Plan B = levonogestrel
—there's a combo, but incr n/v;
—there's a new = ulipristal (equal efficacy w/in first 72 hrs; more efficacy 72-105 hrs

MoA
—most likely delays or stops follicular maturation (depending on how far along the follicles is)
—this means you CAN still ovulate that egg later!
—likely does not block fert, inhibit nidation thru endometrial ∆s
—DEFINITELY does not interrupt s/p implantation