47. Contraception + Infertility Flashcards
1
Q
A normal menstrual cycle ranges from ____ days (average ___ days)
A
23-35 days
Avg 28 days
2
Q
____ indicated that the next cycle has begun and is counted as day 1 of the cycle
A
Start of bleeding (menses)
3
Q
Describe follicular phase of the menstrual cycle
A
Follicle stimulating hormone (FSH) spurs follicle development and causes estrogen to surge. Estrogen peaks by the end of the phase.
The surge in estrogen causes LH and FSH to increase
4
Q
Describe ovulatory phase of the menstrual cycle
A
LH surger triggers ovulation 24-36hrs later
5
Q
Describe luteal phase of the menstrual cycle
A
The start of ovulation begins the luteal (last) phase which lats ~14 days. Progesterone is dominant in this phase
6
Q
Lutenizing hormone causes ___ development in the ovary
A
corpus luteum
7
Q
The mid-cycle ___ surge results in the release of the oocyte (egg) from the ovary into the fallopian tube
A
Lutenizing hormone (LH)
8
Q
The oocyte lives for ___ once released and sperm can survive for ~____
A
24 hrs
3 days
9
Q
A person wishing to concieve should have intercourse when the LH surge is detected and for the following ____
A
2 days (based on sperm survival of ~3 days)
10
Q
___ is released when a fertilized egg attaches to the lining of the uterus (called implantation)
A
Human chorinoic gonadotropin (hCG)
11
Q
Detecting hCG in the urine or blood indicates___
A
pregnancy
12
Q
When is hCT level highest for woman using pregnancy test?
A
First urine in the morning (hCT level is highest)
13
Q
Folic acid requirements preconception and during pregnancy?
A
Preconception: 400mcg of dietary folate equivalents (DFE) per day
Pregnancy: 600 mcg DFE/day
14
Q
A prompt return to fertility occurs when most contraceptives are d/c. The only reversible contraceptive method that has a delay in return to fertility is ____
A
Medroxyprogesterone INJECTION
15
Q
T/F: male external condoms provide more STI/STD protection than female internal condoms
A
False - female internal condoms provide more protection
Condoms provide protection from some infections, female internal > male external condoms
16
Q
___ is the only 100% effective way to prevent pregnancy and STDs
A
abstinence
17
Q
Why do people keep track of body temp and cervical mucus?
A
To avoid pregnancy by abstaining from intercourse on days when a woman is fertile
Basal body temp is used to predict ovulation (normal 96-98ºF, ovulation 97-99ºF)), measure first think each morning
18
Q
Temperature methods work best when done in conjunction with ____
A
tracking changes in the cervical mucus (color, texture, volume)
19
Q
Barrier methods of contraception include ___
A
condums, diaphragms, caps, and shields
20
Q
Condoms help protect against many STDs (only if ___ condoms, not ____)
A
latex or syntehtic condoms
not “natural” sheepskin
21
Q
Only recommend ____-based lubricants
A
Water or silicone-based
22
Q
Other contraceptive methods like foams, film, creams, suppositories, sponges, and jellies contain spermicide ___ (don’t use spermicide with anal sex)
A
nonoxynol-9
23
Q
Hormonal contraceptives work by inhibiting the production of ____ which prevents ovulation
A
FSH and LH
24
Q
The estrogen/progestin combination pills are called ____. Non-oral contraceptives that contain both estrogen and progestin are referred to as ____
A
Combination oral contraceptives (COCs)
Combined hormonal contraceptives (CHC)
25
Available hormonal contraceptive treatments include ___
Progestin-only (pill, injectable, implant, IUD)
Estrogen/progestin (pill, patch, vaginal ring)
26
FDA require that ___ be dispensed with oral contraceptives
Patient package insert (PPI)
27
Most COCs contain the estrogen ____ and progestin (e.g. _____)
Ethinyl estradiol (EE)
Norethindone, levonorgestrel (LNG), drospirenone)
28
____ COCs have same dose of estrogen and progestin throughout the pill pack
Monophasic
29
Biphasic, triphasic, and quadriphasic pill packs mimic ____
estrogen and progesterone levels during menstrual cycle
30
___ is a unique progestin that is used in some COCs to reduce adverse effects commonly seen with oral contraceptives. It is a mild ___ diuretic which decreases ______
Drospirenone
K-sparing diuretic
Bloating, PMS symptoms, and weight gain (also a/w less acne d/t anti-adronergic activity)
31
Progestins with low androgenic activity include ____
Drospirenone, norgestimate, desogestrel, and dienogest
32
COCs are used for other indications besides pregnancy prevention including ___
dysmenorrhea (cramps), PMS, acne (in females), anemia, peri-menopausal symptoms (hot flashes, night sweats), and menstrual-associated migraine ppx
33
The use of ___ to regulate menses is first line treatment for PCOS and endometriosis
COCs
34
COC Natazia and levonorgestrel-releasing IUD Mirena are indicated for ___
heavy menstrual bleeding (menorrhagia)
35
Progestin-only pills (POPS, mini pills) contain no estrogen and have 28 days of active pills in each pack. POPs prevent pregnancy by ____
suppressing ovulation, thickening the cervical mucus to inhibit sperm penetration and thinning the endometrium
36
Progestin-only pils are primarily used in women who are lactating because ____
estrogen decreases milk production
37
Progestin-only pills require good adherence; the pill must be taken within ____ of schedule time
3 hrs
38
Progestin-only pills are sometimes used for migraine ppx and are safe in women who have ___
migraines with aura (estrogen cannot be used with this type of migraine d/t risk of stroke)
39
Patches have the same side effects, contraindications, and drug interactions as COCs, but patches causes a higher systemic ___ exposure
Estrogen
40
Contraceptive patches should NOT be used in anyone with ___
high clotting risk (pts > 35yo who smoke, pts with cerebrovascular disease or past blood clots, postpartum pts)
Women with BMI≥30 (d/t increased risk of thromboembolism (Zulane, Zafemy) or decreased efficacy (Twirla))
41
Xulane and Zafemy may also be less effective in women who weigh > ____ lbs
>198lbs
42
Depo-Provera is ____, a progestin that is given by ____ every ___
depot medroxyprogesterone acetate (DMPA)
IM or SC injection every 3 months
43
Extended cycle COCs involve ____ of active hormonal pills followed by 7 days of inactive or very low dose estrogen pills. With this schedule, bleeding occurs every ___
84 days of active hormonal pills
bleeding occurs every 3 months
44
___ is approved for continuous contraception (suppress menses altogether)
Amethyst
45
____ occurs commonly with continuous contraception (can lead to d/c). It is important to counsel pts that this typically resolves after ___
Spotting (breakthrough bleeding)
3-6 months
46
Contraceptive names: "lo" indicates ___ (ex. Loestrin)
≤ 35 mcg of estrogen (less estrogen = less estrogenic side effects)
47
Contraceptive names: "fe" indicates ___ (ex. Loestrin Fe)
Iron supp is included
48
Contraceptive nameS: "24" indicates ____ (ex. Minastrin 24 Fe)
Shorter placebo time 24 active + 4 placebo
49
Examples of monophasic COC pills
Junel Fe 1/20, Microgestin Fe 1/20, Sprintec 28, Loestrin 1/20, Yasmin 28
Loestrin 24 Fe, Yaz
Loestrine Fe
50
Examples of Biphasic, Triphasic COC pills
Tri-Sprintec
51
Example of quadriphasic COC pills
Natazia
52
Examples of extended cycle formulations
Seasonique
53
Example of continuous COC pills
Amethyst
54
Example of drospirenone containing formulations
Yasmin 28, Yaz
55
Example of transdermal contraceptives
Xulane
56
Compare AUC for patches vs pills? Vaginal ring vs pills?
Patches higher AUC than pills
Vaginal ring lower AUC than pills
57
Examples of Progesin-only pills
Errin, Camila, Nora-BE
58
Contraceptive nameS: "nor" indicates ____
contains norethindrone
59
Slynd contains ____ only
Drospirenone
60
Depo-Provera contains ___ only
progestin
61
Side effects of estrogen
Nausea
Breast tenderness/fullness, bloating, weight gain, increased BP (may all be d/t fluid retention)
Melasma (dark skin patches, most often on face)
Thrombosis (serious but rare)
62
Reducing estrogen dose can reduce side effects but a dose too low will cause ___
spotting
63
What estrogen formulation has higher risk of clotting risk
Higher estrogen dose or exposure (e.g. with Xulane transdermal patch) = higher clotting risk
64
S/sx DVT, PE, and less common clots for pts on estrogen
ACHES
Abdominal pain that is severe (ruptured liver tumor or cyst, mesenteric or pelvic vein thrombosis, or pain could be d/t liver or gallbladder problems or ectopic pregnancy)
Chest pain (sharp, crushing, or heavy pain can indicate heart attack. SOB can indicate PE)
Headaches (sudden and severe with vomiting or weakness/numbness on one side could mean stroke)
Eye problems (blurry vision, flashing lights, or partial/complete vision loss can indicate blood clot in eye)
Swelling or sudden leg pain (DVT)
65
Which progestin has a slightly higher risk of clotting and should not be used in women with clotting risk?
Drospirenone
66
Why should dropirenone not be used with kidney, liver, or adrenal gland disease?
Can increased potassium
67
Which progestin can cause loss in BMD? Can be important for teens and young women who are still accumulating bone mass, may require calc+vitD supp
Injectable depot medroxyprogesterone acetate
68
If spotting persists and currently taking < 30mcg estrogen daily, what should you do?
increase estrogen dose
69
If spotting persists and currently taking ≥ 30mcg estrogen daily, what should you do?
try a different progestin
70
Boxed warnings for all estrogen-containing products
Do NOT use in women > 35yo who smoke d/t risk of serious CV events
71
Boxed warning for estrogen + progestin transdermal patch
do not use in women with BMI≥30 d/t increased risk of thromboemobolism (Xulane, Zafemy) or decreased efficacy (Twirla)
72
Boxed warning for Depo-Provera
Loss of BMD with long-term use
73
Which conditions should pts NOT use estrogen
Hx of DVT/PE, stroke, CAD, thrombosis of heart valves of acquired hypercoagulopathies
Hx of breast, ovarian, or liver cancer, migraines with aura (esp if > 35yo)
Others: liver disease, uncontrolled HTN (>160/100), severe HA or migraines with aura (esp if > 35yo), diabetes with vascular disease, unexplained uterine bleeding
74
Considerations for contraception selection: Acne or hirsutism
Use COC with progestin that has lower androgenic activity (norgestimate (Sprintec 28)) or none (drospirenone (Yaz, Yasmin))
75
Considerations for contraception selection: Breastfeeding
Progestin-only or nonhormonal method
76
Considerations for contraception selection: estrogen contraindication (including clotting risk)
Progestin-only or nonhormonal method
77
Considerations for contraception selection: Migraine
If with aura, progestin-only or nonhormonal
If without aura, any
78
Considerations for contraception selection: Fluid retntion/bloating
Choose product containing drospirenone
79
Considerations for contraception selection: Heavy menstrual bleeding
COC Natazia and levonorgestrel-releasing IUD Mirena indicated
COCs with only 4 placebo pills (rather than 7) or continuous/extended regimens will minimize bleeding time
80
Considerations for contraception selection: HTN
If BP uncontrolled, progestin-only or nonhormonal method
81
Considerations for contraception selection: Mood changes/disorder
Monophasic COC - extended or continous with drospirenone is preferred
82
Considerations for contraception selection: Nausea
Take at night, with food
Consider decreases estrogen dose or switching to progestin-only method, vaginal rin, or nonhormonal method
83
Considerations for contraception selection: Overweight
Any method
Do NOT use DMPA if trying to avoid weight gain
Do not use contraceptive patch if BMI ≥ 30
84
Considerations for contraception selection: Postpartum
Do not use CHCs for 3 weeks or for 6 weeks if pt has additional risk factors for VTE
Can use progestin-only or nonhormonal
85
Considerations for contraception selection: Premenstrual dysphoric disorder
Choose product containing drospirenone (e.g. Yaz)
SSRI antidepressant may be needed
86
Considerations for contraception selection: Spootting
If early or mid-cycle spotting occurs, estrogen may need to be increased
If later in cycle, progestin dose may be need to be increased
87
Considerations for contraception selection: Wishes to avoid monthly cycle/menses
Use extended (91 day) or continuous formulations
Alternative: monophasic 28-day formulation and skip placebo
88
Which contraceptive formulation has lower drug interaction risk?
Injection bc it bypasses first-pass metabolism and achieves higher serum ocnc
89
Which abx are a/w DDIs that decrease hormonal contraception efficacy?
Rifampin, rifabutin
With rifampin, induction can be prolonged, back-up contraception method is needed for 6 weeks after rifampin is d/c
90
Which anticonvulsants are a/w DDIs that decrease hormonal contraception efficacy?
Carbamazepine, oxcarbazepine, phenytoin, primidone,t opiramate, lamotrigine, barbituates, perampanel
91
Which natural medicine are a/w DDIs that decrease hormonal contraception efficacy?
St. John's wort
92
What affect dose smoking have on contraception efficacy?
Decreases
93
Which transplant meds are a/w DDIs that decrease hormonal contraception efficacy?
Ritonavir-boosted protease inhibitors, bosentan (Tracleer), mycophenolate (Cellcept, Myfortic)
94
Mavyret cannot be used with any formulation containing ethinyl estradiol d/t risk of ___
liver toxicity
95
If COCs are started today or on sunday, how many days of back-up nonhormonal contraception is required?
7 days
96
If COCs are started within 5 days after the start of the period, how many days of back-up nonhormonal contraception is required?
None, protection is immediate
97
If progestin-only pills are started today, how many days of back-up contraception is required?
48 hrs (2 days)
98
How many COC pills do you need to miss where back-up contraception is required?
more than 1 pill
99
If missed COC pills/days are in the third week of the cycle, what should you do?
Omit the hormone-free week and start next package of pills right away without skipping any days
Back up contraception should be used for 7 days
100
Pt missed 1 pill of COC (<48 hrs since last dose). What do you recommend?
Take ASAP and take next dose on schedule (even if that makes 2 pills in 1 day)
No back-up contraception required
101
Pt missed 2 pill of COC (≥48 hrs since last dose). What do you recommend?
Take most recent missed pill ASAP (discard other missed pills) and take dose on schedule (even if that makes 2 pills in 1 day)
If during Week 3: Omit hormone-free week and start next pack
7 days of back-up contraception required
102
Pt missed 1 pill of POPS (> 3 hrs past scheduled time). What do you recommend?
Take pill asap and take next dose on schedule
Back up contraception required x48 hrs
103
Examples of hormonal IUDs
Mirena, Kyla, Kyleena, Liletta
104
Example of copper-T IUD
Paragard
105
T/F: Paragard cooper-T IUD can be used for birth control only
False - Emergency contraception and/or regular birth control
Can be used up to 10 yrs but causes heavier menstrual bleeding and cramping, some prefer this nonhormonal method
106
Which IUD is a non-hormonal option?
Copper-T IUD (Paragard)
107
Example of implant contraceptive
Nexplanon (goes into the arm), releases progestin etonogestrel for 3 years
108
Nexplanon releases progestin ___ for ___ years
etonogestrel for 3 years
109
Which emergency contraception is most effective (99.9%)
Copper IUD (Paragard)
110
Emergency Contraception (EC) options
Copper IUD (Paragard)
Ullipristal (Ella)
Levonorgestrel (Plan B One-Step)
111
Emergency contraception ulipristal (Ella) is best used within ____ and levonorgestrel (Plan B) is best used within ___. Sooner EC is used, higher the efficacy
Ella = 5 days
Plan B = 3 days
112
Plan B are packaged as one __mg tab of levonorgestrel
1.5mg
113
T/F: Plan B requires 18yo or older to purchase OTC and can only purchase 2 at one time
False - no restrictions
114
MOA of Plan B
Primarily works by preventing or delaying ovulation and thickens cervical mucus
115
Primary side effect of Plan B and recommendation
Nausea
OTC antiemetic (1 hr prior to use)
116
If pt vomits within ___ of taking Plan B, she should consider repeating the dose
2 hrs
117
Ulipristal (Ella) is a chemical cousin of ____
mifepristone (Mifeprex) "abortion pill" or RU-486
118
Compare Ulipristal vs mifepristone
Ulipristal lower potency and used to delay ovulation
Mifepristone used for pregnancy terminations and other non-contraceptive uses
119
Ulipristal (Ella) is given as a single __mg dose. Requires Rx
30mg
120
How is NuvaRing use?
Insert on first day of menstrual bleeding (if inserted on days 2-5 of cycle, back0up contraception should be used for 7 days)
Put in for 3 weeks, out for 1 week
If the ring is kept in for > 4 weeks, confirm no pregnancy, insert new ring, and use back-up contraception until new ring has been in place for 7 continuous days
121
Infertility is defined as not being able to get pregnancy after ___ or longer of unprotected sex
1 year
122
what are some options to induce ovulation in pts with infertility?
Clomiphene (selective estrogen receptor modulator SERM)
Letrozole (aromatase inhibitor)
Gonadotropin drugs - Menopur, Follistim AQ, Gonal-f, Pregnyl, Novarel, and Ovidrel
123
MOA clomiphene
Acts like estrogen (acts as estrogen agonist/antagonist depending on type of tissue) , causes LH and FSH to surge >> triggers ovulation
124
Side effect Clomiphene
Hot flashes >> clotting risk
125
MOA Letrozole
aromatase inhibitor
suppresses estrogen to increase FSH >> causes ovulation
126
MOA gonadotropin drugs
Act as LH, FSH, or hCG (similar to LH) >> causes ovulation
127
Risk with fertility medications
Canc ause multiple eggs to be released >> multiple births
128
Gonadotropin drugs formulations
SC or IM injection
129
Brand names of gonadotropin drug names include parts of the words ___
REPROduce, FOLLicle, GONadrotropin, PREGnancy, and OVary
Ex: Menopur, Follistim AQ, Gonal-f, Pregnyl, Novarel, and Ovidrel
