30 Control of Fertility: Contraception Besinque Flashcards
What are some Combination Estrogen and Progestin contraceptives?
Oral. Patch. Vaginal Ring. Injection (+/- Lunelle)
What are some Progestin only contraceptives?
Injection (DepoProvera). Implants. Pills. IUD/IUS (Mirena)
What are the three top contraception uses?
Sterilization > OC > Male condom
What are considered “Tier 1” contraceptives?
Long acting reversible contraceptives (LARCs: implants, IUDs). Female sterilization. Vasectomy
What are considered “Tier 2” contraceptives?
Injectables. LAM (lactation). Pills. Patch. Vaginal ring
What are considered “Tier 3” contraceptives?
Male condoms. Diaphragm. Female condom. Fertility awareness methods
What are considered “Tier 4” contraceptives?
Withdrawal. Spermicides
What are considered “Tier 5” contraceptives?
Morning after pills
Which Tiers are the most effective?
Tier 1 > Tier 2 > Tier 3 > Tier 4 > Tier 5
What is considered “perfect use” for contraceptives?
The probability of pregnancy during the first year of perfect use of the method; i.e., among those who use the method consistently and according to instructions
What is considered “typical use” for contraception?
The probability of pregnancy during the first year of typical use; i.e. effectiveness for the average person who does not always use the method correctly or consistently
What is the discontinuation rate for women using hormonal contraception?
28% discontinue by 6 months. 33-50% discontinue use by 1 year
What are the menstrual-related health benefits of combined hormonal contraception?
Decreased dysmenorrhea. Decreased menstrual blood loss and anemia. May reduce PMS symptoms
What is there a decreased risk of with combined hormonal contraception?
Ectopic pregnancies. Endometrial and ovarian cancer. Benign breast conditions. PID
What are the Progestin-Related side effects of hormonal contraception?
Bloating. Anxiety. Irritability. Depression. Menstrual irregularities. Reduced libido
What are the Estrogen-Related side effects of hormonal contraception?
Breast tenderness. Nausea. Vomiting. HA. Elevated blood pressure (rare)
What are the contraindications for combined hormonal contraception?
Clotting disorders. History of DVT or pulmonary embolism. Migraine with aura or focal neurological deficit. Uncontrolled hypertension
What are the ADRs from combined oral contraceptives that should cause the patient to stop using the product and contact provider?
ACHES. Abdominal pain. Chest pain. Headaches. Eye problems. Severe leg pain
What is the relationship between blood clots and hormonal contraception?
COCs are CONTRAINDICATED in women who have a personal for family history of idiopathic venous thromboembolism. Smoking is an independent risk factor. Pregnancy and Post-Partum period have a higher risk of blood clots than hormonal contraception (2-5 times the risk)
What are the risk factors for VTE?
Increasing age. Increasing weight (obesity). Family or personal history of VTE. Genetic mutations affecting coagulation. Immobilization or surgery. Long-haul travel. Estrogen containing contraceptives and HRT
In the study, what were the combined hormonal contraceptives (CHCs) and the risks of cardiovascular disease endpoints?
Positive finding to the increasing body of evidence linking drospirenone to increased risk of VTE relative to standard low-dose CHCs
What is the relationship between breast cancer and oral contraception?
There may be an increased risk of breast cancer associated with long-term oral contraceptive pill use in women under the age of 35. However, because the incidence of breast cancer is so low in this population, the attributable risk of breast cancer from birth control pill use is small
When should CHCs be used for women during the postpartum period?
< 21 days is not recommended. 21-42 days, benefits seem to outweigh risks for women without other risk factors for VTE. > 42 days is fine to use
What are the three different ways to start hormonal contraception?
Sunday start. First day of bleeding start. “Any time” start (Quick Start)
What is the “Sunday Start” for hormonal contraception?
Protection after 7 days of active pills/patch/ring. Cycle begins on Sunday always
What is the “First Day of Bleeding Start” for hormonal contraception?
Protection immediate (no back up required). Cycle begins on same day each month (i.e. Wednesday)
What is the “Any Time Start (Quick Start)” for hormonal contraception?
Start pills today (or tomorrow if EC used today). Protection requires 7 days of active pills/patch/ring
What are the 4 classes of hormonal contraceptives used?
Estrogens. Progestins. Drospirenone (17-alpha spironolactone). Ulipristal
What are the three sub-classes of Progestins?
Estranes (Norethindrone, Norethidrone Acetate, Norethynodrel, Ethynodiol Diacetate). Gonanes (Levonorgestrel, Norgestrel, Desogestrel, Norgestimate). Dienogest
What are the pharmacological actions of Progestin?
Ovarian and pituitary inhibition. Thickening of cervical mucus. Endometrial atrophy/transformation. Cycle control
What are the pharmacologic actions of Estrogen?
Ovarian and pituitary inhibition. Thinning of/increase in cervical mucus. Endometrial proliferation. Cycle control
What is the biologically active form for all estrane progestins?
Norethindrone
What are the different types oral regimens?
Monophasic. Multi-phasic. Extended cycles. Progestin only
What is Monophasic?
Consistent estrogen and progestin dose throughout cycle (may be 21 or more days)
What is Multi-Phasic?
Bi-phasic (estrogen dose is the same for active days of cycle with increased progestin dose in late cycle). Tri-phasic (progestin doses (and/or estrogen) change in three phase cycle
Which oral regimens have a shorter placebo period?
Estrogen only days Mircette, Seasonique, Yaz, Loestrin-24
Which Oral Regimens have extended cycles?
Longer cycles of active pills (84 days). Seasonale, Lybrel, Seasonique, Seasonique-Lo
What is unique about Safyral and Beyaz?
They are both 28 day cycles, but also contain folate in the pills
What is Natazia?
Four-phasic, 28 day cycle oral contraception. Very difficult instructions for missed dose
How does Lo Loestrin Fe differ from Loestrin 24Fe?
Contains a lower dose of estrogen (10mcg vs. 20mcg). Both are 28 day cycles
What are some causes of Break Through Bleeding (BTB)?
Missed pills. Smoking. Infection. Drug interactions. Formulation out of “balance”
What are the main drug interactions with hormonal contraceptives?
P450 Inducers (Rifampin, St. Johns Wort, Carbamazepine, Phenobarbital, etc). Reduce efficacy of HC (?)
How does the Vaginal Contraceptive Ring work?
Release 15ug of ethinyl estradiol and 120ug of etonogestrel daily for 21 days. Begin within 5 days of the onset of menses. The ring is flexible, easy to insert and remove. Worn for 3 weeks and discarded. A new ring is inserted 1 week later (28 day cycle). May also be worn for 28 days and removed/replaced
What should be done if the ring is not replaced at day 8 (left out too long)?
Consider emergency contraception. Rule out pregnancy. Insert new ring. Use back up for 1 week. Dispense NuvaTimer, if not already being used
What should be done if the ring is left in too long (not removed at day 21)?
Remove anytime up to day 28. No back up needed. Replace ring on regularly scheduled date or 7 days after removal
What is Ortho Evra?
Transdermal contraceptive system. 20ug ethinyl estrogen/150ug norelgestromin. 3 patches in a box. Apply 1 patch a week for 3 weeks. Apply each patch same day of the week. 1 week is patch-free
For Ortho-Evra patients now to hormone contraceptives, when do they start?
Sunday start (use back up for 7 days on first cycle). First day start (if within 24 hours of bleeding, no back up needed)
For Ortho-Evra patients, what should be done if the patch falls off?
Place patch back in the same spot. Do not use adhesive. If patch off for more than 24 hours, start new 4 week cycle
For Ortho-Evra patients, what should be done if they forget to apply the patch on time?
Week one: use back up for 7 days, apply ASAP
For Ortho-Evra patients, what should be done if they are late changing the patch?
The patch is effective for 7-9 days of use. 1-2 days: remove patch and replace, no back up. More than 2 days for patch 2 or 3: start a new 4 week cycle, use 7 days back up. More than 2 days late for patch 3 removal: remove patch and apply a new patch on the original schedule
What is Male Sterilization?
No-scalpel vasectomy (NSV) is the standard of care. A small (few mms) opening is made in the skin of the scrotal sac to deliver vas deferens. Ligate/cauterize. No scalpel or sutures required
What are some nonsurgical tubal occlusions that can be used for female sterilization?
Essure (micro-inserts placed into proximal fallopian tubes, looks like a spring). Adiana (low-level radiofrequency delivered to fallopian tubes)
What are LARCs?
Long Acting Reversible Contraception. 3 types: Implanon Implant, Mirena IUD, ParaGard IUD
What is the Levonorgestrel Intrauterine System (LNG IUS)?
Mirena. 20mcg levonorgestrel/day. Approved for 5 years of use. Amenoorhea in ~20% of users by 1 year
What is the Copper-T IUD?
ParaGard. Copper ions. Approved for 10 years of use. Can be used as emergency contraceptive
What are the characteristics of intrauterine contraception?
One of the highest patient satisfaction among methods. Rapid return to fertility. Safe. Long-term protection. Highly effective. May be inserted after delivery or abortion
What are some characteristics of the Copper-T IUD?
Wants regular menses. Does not want to use hormones. No history of dysmenorrhea. No history of menorrhagia
What are some characteristics of LNG-IUS (Mirena)?
Amenorrhea acceptable. Irregular bleeding tolerable. History of dysmenorrhea. History of menorrhagia
What is Nexplanon?
Implant under the skin. Contains etonogestrel. Effective for 3 years
What is the timing for IUD/IUS/Implant insertion?
Anytime during menstrual cycle when pregnancy can be excluded (confirmed by negative pregnancy test and no report of unprotected sex in past two weeks)
What are the general characteristics of combined oral contraceptives?
Contain estrogen and progestin. Most newer formulations contain 20-35mcg of ethinyl estradiol + 1 of 8 available progestins
What are the general characteristics of progestin-only oral contraceptives?
Called the “mini-pill”. Two formulations: Norethindrone & Norgestrel. No placebo week. Timing of pill-taking is crucial
What are the general characteristics of extended hormonal contraception?
Delays or eliminates menstruation. Menstrual and nonmenstrual benefits. Extended methods: continuous use of COCs, transdermal patch, vaginal ring. Seasonale, Seasonique, Lybrel (dedicated extended OC regimen)
What should be done for missed or late combined oral contraceptive pills?
Take missed pill as soon as remembered and next pill at regular time. Use back-up method for one week if missed 1-2 pills at the start of pack or 3 or more pills in the first 3 weeks of pack
What should be done for missed or late progestin only pills?
Take missed pill as soon as remembered and next pill at regular time. Use back-up method for two days if pill is taken more than 3 hours past regular time
What should be done for missed or late transdermal patch?
Use back-up method for one week if patch has been on more than 9 days, off more than 7 days, or falls off and is not reaffixed within 24 hours
What should be done for missed or late vaginal ring?
Use back-up method for one week if ring has been in more than 5 weeks, out more than 7 days or falls out and is not reinserted within 3 hours
What are some key points about Depot Medroxyprogesterone Acetate (DMPA): DepoProvera?
No evidence it causes fracture increase. Bone mineral density returns to baseline after cessation of DMPA. Bone health largely dependent on nutrition and exercise. ACOG and WHO support long term use. Not the best to use in older people since it can reduce BMD. Injection, given IM or SQ every 3 months
How should breakthrough bleeding be managed?
Check for missed or mistimed pills. Rule out pregnancy and infection. Review medications. Evaluate for gastrointestinal disturbances. Change formulations, delivery route. Continue COC formulation with addition of NSAIDs or estrogen support
How are the typical failure rates for COC pills in obese women?
COC failure rate is much higher in obese women than in normal weight. Risk is higher with lower estrogen doses. Risk of contraceptive failure is about 50% higher among obese women. Combined hormonal methods are still good options
How is DMPA for obese women?
Effectiveness same if woman is obese
How is the Patch for obese women?
Effectiveness may be lower if woman is obese
Besides COCs and the Patch, what are some other contraceptive options for obese women?
Copper IUDs. LNG-IUS. Barrier methods. Sterilization
What is the only contraceptive to give immediate protection from pregnancy?
Copper-T IUD. All others require backup for 7 days
How does the Sponge work?
Polyurethane sponge contains 1 gram of nonoxynol-9 spermicide. A dimple on one side that fits over the cervix and a loop on the opposite side for removal. Single use only - remains effective in place without additional spermicide for 24 hours. Must stay in place for at least 6 hours
When do Diaphragms need to be refitted?
Full-term pregnancy (and should not be used postpartum until uterine involution is complete). Abdominal or pelvic surgery. Miscarriage, or abortion after 14 weeks of pregnancy (and should be used until 6 weeks after a second-trimester abortion). Weight change after pregnancy of 20 percent or more
What is the Cervical Mucous Method?
During ovulation cervical mucous becomes a slippery, clear discharge (like raw egg white). This change is recorded of several months on a menstrual calendar. Once a women become familiar, avoid intercourse or use contraception immediately before and after ovulation
