32. Contraception & Infertility Flashcards
A young female enters the pharmacy. She asks for the best over-the-counter option to protect against sexually transmitted infections (STis). Which of the following represents the best option for STI protection?
A. Latex male condom
B. Delfen Foam
C. Nonoxynol-9
D. Plan B One Step
E. Next Choice
A. Consistent and correct use of male latex condoms, or female condoms, can reduce (though not eliminate) the risk of STI transmission.
nonoxynol-9 - spermacide
Plan B One Step, Next Choice - emergency contraceptive (1.5mg levonorgestrel)
Chantelle started on the contraceptive Ortho Tri-Cyclen Lo five months ago. Initially, she had spotting over several weeks but was instructed by the pharmacist that she should get used to the formulation within 2-3 months. She feels the side effects are better, except that she continues to spot around days 7-8. What is the likely cause of the spotting?
A. Too much estrogen
B. Too little estrogen
C. Too much progestin
D. Too little progestin
E. Using a triphasic formulation
B. If low-dose estrogen pills are used, or if there is insufficient estrogen (the patient may be a fast metabolizer, or be using an enzyme inducer), then she may require a higher estrogen dose.
Picking formulations
Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine
Estrogen preferred when: no contraindication
Drospirenone preferred when: fluid retention/bloating, premenstrual dysphoric disorder (use Yaz or sertraline)
Spotting/”breakthrough bleeding”: If early or mid cycle spotting then increase estrogen dose. If later in the cycle then increase progestin dose. Must wait 3 cycles before switching.
Carol has just been at the pharmacy to pick up a new prescription for combination oral contraceptives. The pharmacist has instructed Carol to be seen at once if she experiences severe chest pain, severe headache, a swollen or painful calf, vision problems, shortness of breath, is coughing up blood or has severe abdominal pain. The pharmacist understands that the use of estrogen may increase risk for these complications: (Select ALL that apply.)
A. Stroke
B. Deep vein thrombosis
C. Clotting
D. Migraine headaches
E. Heart failure
A, B, C. Keep in mind that many women use birth control pills safely for 20+ years with no complications. It is important to consider the rare events as well, and patients are instructed to be on the look-out for these signs of a severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).
A woman is using Alesse combination oral contraceptive pills. She does not enjoy getting a monthly menstrual cycle and has heard about new pill formulations where you get less periods. Choose the formulation/s which results in menstruation once every 3 months: (Select ALL that apply.)
A. Seasonale
B. Amethyst
C. Lybrel
D. Seasonique
E. Camilla
A, D. Seasonale, Seasonique and LoSeasonique are three month birth control pill formulations. They all have a 91-day pill regimen with 84 active pills. The difference is the placebo week: Seasonale has 7 days of placebo, and Seasonique has 7 days of low dose estrogen.
Nonoxynol-9 is the most commonly used spermicide and is present in the contraceptive sponge, film and vaginal spermicides. Choose the correct statements concerning nonoxynol-9. (Select ALL that apply.)
A. Nonoxynol-9 is prescription only.
B. Spermicide kills sperm, but does not reduce the risk of catching a sexually transmitted infection.
C. Some people are allergic to spermicides or get skin irritations from them; this is often mistaken for an allergy to the latex condom (which some people have as well).
D. If Nonoxynol-9 is used many times a day, or if it is used by people at risk for HIV, it can irritate tissue and increase the risk of contracting HIV and other sexually transmitted infections.
E. When used alone, spermicide is not very effective for pregnancy prevention; it is more effective when used with a condom or with a diaphragm.
B, C, D, E. Male-to-male intercourse and sex workers (including those in the porn industry) should not be using nonoxynol-9. If a female is at risk for pregnancy, she needs a more effective method, which can be used safely with condoms. Nonoxynol-9 will irritate the vaginal mucosa (or lining of the anus) and increase the risk of STi transmission. If spermicide is used alone (correctly) 15 of every 100 women will get pregnant/year.
Mark is sixteen years old. He wants to purchase emergency contraception for his girlfriend, who he says is 20 years old. Choose the correct statements. (Select ALL that apply.)
A. The levonorgestrel EC pill that contains two 0.75 mg tablets can be purchased by Mark as an OTC product.
B. Mark can purchase Plan B One-Step, since it does not have age restrictions.
C. Plan B contains ethinyl estradiol which provides some protection against Chlamydia.
D. Mark can purchase Plan B One-Step, since it does not have sex restrictions.
E. The parents of both individuals should be contacted regarding this request.
B, D. Plan B One-Step is OTC with no sex or age requirements as of June 2013. The FDA has requested that Plan B One-Step be placed in the aisle with other family plannings, such as condoms and spermicide.
The two-step products require prescription.
A woman is hoping to become pregnant. Choose the correct statement. (Select ALL that apply.)
A. If a couple is attempting pregnancy, it should occur in about 25% per month, and most become pregnant within a year.
B. Males are not contributory to infertility; it is always the females, and largely due to the health of her eggs.
C. Women attempting to become pregnant should begin to take folic acid at a recommended daily intake of 400-800 mcg daily.
D. Any women trying to conceive should be started on an ACE inhibitor, as these can increase fertility.
E. If pregnancy has not occurred within six months time, the couple should be referred to a clinician specializing in infertility.
A, C. Ovulation is the most fertile time; when the ovulation predictor kit is positive, it has detected luteinizing hormone, indicating that the egg will soon be released. The sperm need to travel to the fallopian tubes, where fertilization can take place.
Which of the following products requires that the pharmacist dispense a patient package insert (PPI) with each prescription and refill? (Select ALL that apply.)
A. LoSeasonique
B. Diaphragms
C. Norethindrone mini-pill (progestin only pill)
D. Delfen Foam
E. Yasmin
A, C, E. Inform the patient that the PPI has important safety information and instructions on how to use them properly and what to do if pills are missed. The FDA requires that the patient package insert accompany each package dispensed to the patient.
Which of the following birth control pill formulations is a multiphasic formulation?
A. Nor-QD
B. Loestrin 24-Fe
C. Apri
D. Aviane
E. Ortho-Novum 7/7/7
E. As indicated by the name, the Ortho-Novum 7/7/7 has three different weeks of hormone levels-they change over time.
Birth Control Nomenclature:
0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)
Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)
Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)
Fe, contains iron
Progestin only, often have “nor” in the name for norethindrone or “pro” found in HRT products for progestin
A pharmacist remembers that he was taught in school to warn patients using oral contraceptives about watching for severe leg pain, chest pain or trouble breathing. This is due to a risk of:
A. Clots
B. Hemorrhagic strokes
C. Severe depression
D. Liver cancer
E. Breast cancer
A. The thrombogenic risk associated with estrogen has been reduced over the years the pill has been available since the estrogen content used today is much lower than in previous years. Nonetheless, it is still present, particularly in high-risk women who may not be candidates for the pill. If a woman has any history of clotting disorders (DVT, MI, Stroke, PE) she is contraindicated from any estrogen use, including as hormone therapy when she is older.
Keep in mind that many women use birth control pills safely for 20+ years with no complications. It is important to consider the rare events as well, and patients are instructed to be on the look-out for these signs of a severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).
Greg is dispensing Next Choice to a young woman. Greg is aware that nausea is the primary side effect of the EC pills. He asks if she gets easily nauseated, and she replies that she does and states that she vomits easily. Choose the correct recommendation for managing the nausea:
A.He can recommend two tablets of the OTC version of Compazine one hour before the EC is taken.
B. The nausea medication will make her “wired” and could cause insomnia.
C. She will need to get a prescription for a trimethobenzamide suppository.
D. She can use two 25 mg tablets of meclizine an hour before she uses the EC.
E. Emergency contraception pills do not cause nausea since they contain no estrogen.
D. The usual recommendation for nausea from the EC pills is OTC meclizine (Bonine, Dramamine “Less Drowsy”) but the catch is that these are sedating and, if the patient is going to drive home from the pharmacy, it may be unsafe.
OTC Compazine does not exist, it requires a prescription.
Which of the following are correct statements concerning missed pills with an estrogen-progestin birth control pill formulation? (Select ALL that apply.)
A. Back-up methods could include condoms and a spermicide (such as foam).
B. The spermicide contains levonorgestrel.
C. Back-up contraception is generally needed if two or more consecutive hormonal pills are missed.
D. If a single pill is missed anywhere in the packet, the forgotten pill needs to be taken when noticed and the next pill is taken the next day, which may mean taking two pills on the same day.
E. If a single pill is missed in week 1 or 2 the woman should continue the same packet until it is all taken, and use back-up until a new packet is started.
A, C, D. Most women miss early due to not picking up the refill. Pills taken daily can be hard to remember for many and a different formulation may be useful.
Certain medications taken concurrently with birth control pills can reduce the contraceptive’s efficacy. Which of the following medications, if taken with birth control pills, could cause this problem and require back-up contraception or a different method of contraception with long-term therapy? (Select ALL that apply.)
A. Rifampin
B. Carbamazepine
C. Erythromycin
D. Azithromycin
E. Mycophenolate
A, B, E.
Decreases hormone efficacy:
ABX: rifampin, rifapentine, rifabutin
Anticonvulsants: barbiturates, carbamazepine, oxcarbazepine, phenytoin, topiramate, felbamate
St. John’s wort, several protease inhibitors and NNRTIs, bosentan (Tracleer), mycophenolate (CellCept), mycophenolic acid (Myfortic)
Which combination oral contraceptive product comes in a patch formulation?
A. Mircette
B. Ortho Evra
C. NuvaRing
D. Lybrel
E. Yasmin
B.
Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.
Which of the following birth control pill formulations is not a mini-pill?
A. Camila
B. Nor-QD
C. Errin
D. Cyclessa
E. Nora-BE
D. “Cycle” in the name indicates changing hormone dose. The POPs have the same dose of a progestin only, taken daily.
Birth Control Nomenclature:
0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)
Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)
Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)
Fe, contains iron
Progestin only, often have “nor” in the name for norethindrone or “pro” found in HRT products for progestin
The following are contraindications to the use of estrogen therapy, in any dose or formulation. (Select ALL that apply.)
A. History of myocardial infarction
B. History of deep vein thrombosis
C. Unexplained vaginal bleeding
D. History of pregnancy
E. History of cerebrovascular accident
A, B, C, E. There are other contraindications
Contraindications & Boxed Warning: Clotting, Hormone-dependent cancer anywhere in the “reproductive” tissues and liver cancer, cigarette smoke and serious cardiovascular events.
Keep in mind that many women use birth control pills safely for 20+ years with no complications. It is important to consider the rare events as well, and patients are instructed to be on the look-out for these signs of a severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).
If a patient finds that she cannot tolerate estrogen for any reason, which products might be used as alternatives? (SelectALL that apply.)
A. Nor-QD
B. Intrauterine device
C. Depo-Provera
D. Ortho Evra
E. Seasonique
A, B, C. Depo-Provera contains the progestin medroxyprogesterone; it is an acceptable option as there is no estrogen. The shot lasts for three months. Depo-Provera decreases bone density. About half the women using the shot stop menstruating and the rest have light menstrual bleeding.
Birth Control Nomenclature:
0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)
Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)
Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)
Fe, contains iron
Progestin only, often have “nor” in the name for norethindrone or “pro” found in HRT products for progestin
When do patients begin a Seasonale or Seasonique packet?
A. Start on the Sunday after the period has started.
B. Start on the Monday after the period has started.
C. Start on the Tuesday after the period has started.
D. Start on the Wednesday after the period has started.
E. Anytime is acceptable.
A. Most pills (including these formulations) are started on the Sunday following the period. Most couples are more likely to have intercourse on the weekends and with a “Sunday starter” the bleeding during the placebo week will occur on weekdays (it generally starts on Monday).
Holly is a 30 year-old woman who just had a baby. She has been prescribed the progestin-only mini-pill, Nor-QD. Her doctor told her that she will use this type of birth control pill until she is done breastfeeding her baby. Which of the following counseling points on the “mini pill” should be relayed to the patient?
A. The mini pill can be started at any time.
B. Use another method of birth control for the first 7 days.
C. If more than 6 hours have elapsed from the regularly scheduled time you take your pill, you could get pregnant.
D. This method offers better protection against pregnancy than estrogen and progestin combination pills, for most women.
E. This formulation causes more nausea than most estrogen and progestin combination pills.
A. Progestin-only pills (The mini-pill, or POPs) are used primarily by women who are lactating, since estrogen decreases milk supply. Progestin-only pills are occasionally used by patients who have contraindications to estrogen (such as a clotting disorder) or who cannot tolerate the estrogen side effects. They must be taken at about the same time each day or pregnancy can occur.
Starting POP: Start at any time, takes 2 days to gain protection. All come in 28-day packs and all pills are active. POPs need to be taken exactly around the same time every day; if 3 hours have elapsed from the regular scheduled time, back up is needed for 48 hours after taking the late pill. If dose is missed, patient could be pregnant and EC may be suitable.
Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine
Holly is a 30 year-old woman who has been using Nor-QD for contraception since she had her baby. Holly was primarily breast-feeding, but she stopped when the baby was seven months. The baby is now eight months old. Holly knows that she needs to be switched to a pill that includes estrogen but she has been too busy to see the doctor. She forgot to take her Nor-QD this morning and had intercourse later that evening. Is she at risk for pregnancy?
A. No, unless she has missed 2 consecutive pills.
B. No, unless she has missed 3 consecutive pills.
C. No, unless she has missed 4 consecutive pills
D. Yes, pregnancy could result, and the patient may wish to use emergency contraception.
E. This cannot be determined because it depends on the date of the last menstrual cycle.
D. Patients must take the pill at the same time of day; if three hours have elapsed from the regular scheduled time, back up is needed for 48 hours after taking the late pill. If a dose is missed, and sexual intercourse has taken place, pregnancy could result, and the patient may desire emergency contraception.
Starting POP: Start at any time, takes 2 days to gain protection. All come in 28-day packs and all pills are active. POPs need to be taken exactly around the same time every day; if 3 hours have elapsed from the regular scheduled time, back up is needed for 48 hours after taking the late pill. If dose is missed, patient could be pregnant and EC may be suitable.
Jane has just received the Ortho Evra patch at the pharmacy. It is a good choice for her because she sometimes forgets to take the pill. Counseling points for Ortho Evra should include all of the following recommendations: (Select ALL that apply.)
A. The patch provides some protection from sexually transmitted infection, but not as much as condoms.
B. Ortho Evra cannot be used in women with a history of blood clots, or > 198 pounds.
C. One patch is placed on the upper outer arm, abdomen, buttock or back-when applying press firmly for ten seconds.
D. If the patch is left off for more than 36 hours, you may not be protected from pregnancy.
E. Start the patch on the first Sunday after the period begins or apply during the first day of the period.
B, C, E. The patch has reduced efficacy if off for longer than 24 hours.
Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.
What is the primary reason that Yaz and Yasmin became best-selling drugs (and this reason could also be considered a “side effect” of the drug)?
A. They prevent pregnancy more than some of the older formulations.
B. They prevent monthly bleeding.
C. They lower potassium.
D. They cause less headaches.
E. They do not contribute to pre-menstrual and water-weight gain.
E. There is no pre-menstrual and water-weight gain with these products, which has made them best-sellers. However, these formulations can elevate clotting risk. There also seems to be fewer PMS and menstrual symptoms with Yaz.
Picking formulations
Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine
Estrogen preferred when: no contraindication
Drospirenone preferred when: fluid retention/bloating, premenstrual dysphoric disorder (use Yaz or sertraline)
Spotting/”breakthrough bleeding”: If early or mid cycle spotting then increase estrogen dose. If later in the cycle then increase progestin dose. Must wait 3 cycles before switching.
The pharmacist is dispensing the Ortho Evra contraceptive patch to Sue-Ellen. The patient’s vitals today include a blood pressure of 106/68 mmHg, pulse 72 BPM, height 5’6” and weight 212 pounds. Select the correct statement:
A. A new patch is applied daily.
B. This patient is not a good candidate to use the Ortho Evra patch.
C. The patch has a low risk of blood clots compared to the orally administered contraceptives.
D. One patch stays on for three weeks; on the fourth week the patch is left off.
E. The patch should be applied to either breast.
B. The patch is not recommended for women over 198 pounds due to lower efficacy. The patch is linked to a higher risk of blood clots than low-dose oral contraceptives.
Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.
A young female enters the pharmacy. She is using birth control pills. She asks if she is protected against HIV and other STIs. Which advice should be provided? (Select ALL that apply.)
A. Birth control pills reduce the risk of gonorrhea.
B. Birth control pills reduce the risk of chlamydia.
C. Birth control pills reduce the risk of HIV.
D. Birth control pills do not protect against sexually transmitted infections.
E. The best protection against STIs is abstinence; the second-best protection is to use condoms (in addition to another contraceptive method, for efficacy against pregnancy).
D, E. Birth control pills, patches and rings are intended to prevent pregnancy. They do not protect against transmission of HIV (AIDS) or other sexually transmitted diseases (STIs), including chlamydia, genital herpes, genital warts, gonorrhea and syphilis.
