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Clinical - Winter > 6 - Hormonal Contraception > Flashcards

6 - Hormonal Contraception Flashcards

1
Q

What is menarchy/menorrhea?

A

When menses begins

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2
Q

What hormone does the hypothalamus release w/ respect to menses?

A
  • GnRH (gonadotropin releasing hormone)
  • Released in a pulsatile fashion
  • Has an affect on anterior pituitary gland
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3
Q

What does the anterior pituitary gland release w/ respect to menses?

A
  • FSH (follicle stimulating hormone)

- LH (luteinizing hormone)

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4
Q

What does FSH do?

A
  • Stimulates follicles to grow
  • One follicle will grow larger than the rest and will take all of the FSH (becomes primary follicle)
  • Primary follicle releases estrogen
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5
Q

What does estradiol do?

A

Works as negative feedback to prevent GnRH release

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6
Q

What is ovulation? What does it occur?

A
  • Primary follicle being released into fallopian tubes

- Occurs on day 14 of menstrual cycle

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7
Q

What does the primary follicle become? When?

A
  • Corpus luteum

- Day 14 of menstrual cycle

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8
Q

What is the lifespan of the corpus luteum?

A

14 days

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9
Q

What occurs on day 1 of menstrual cycle?

A
  • Bleeding begins
  • Estrogen and progesterone levels are low
  • FSH is released, causing follicle to be released and produce estrogen
  • Estradiol levels continue to increase until about day 8, then decrease, then increase around day 20
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10
Q

What is the follicular phase of menses?

A

Days 1-14

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11
Q

What does the corpus luteum do?

A
  • Produces progesterone and some estrogen

- Progesterone levels are low until day 14, then increase and peak around day 25

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12
Q

What does an increase in estrogen cause?

A

Changes in endometrial lining, causing menses to stop

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13
Q

What does a drop in progesterone cause?

A

Uterus to shed endometrial lining

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14
Q

What are the options for combined contraceptives?

A
  • Oral (pill)
  • Transdermal patch
  • Vaginal ring
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15
Q

What are the options for progestin only contraception?

A
  • Oral
  • Injectable
  • IUS
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16
Q

What are the options for non-hormonal contraception?

A
  • Barrier options

- IUD

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17
Q

What are the goals of therapy for hormonal contraception?

A
  • Prevent fertilization to prevent pregnancy
  • Tailor methods to individuals px needs
  • Avoid/minimize adverse effects
  • Ensure adherence by providing oral and written instructions
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18
Q

What are the causes of the 9% failure rate of combined hormonal contraceptives?

A
  • Irregular intake

- Vomiting and/or diarrhea

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19
Q

How long does it normally take to restore fertility after combined oral contraceptives are stopped?

A

About 1-3 months

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20
Q

What are the mechanisms of action for combined oral contraceptives?

A
  • Estrogen and progesterone provide negative feedback mechanism on hypothalamus, so suppresses secretion of FSH and LH
  • Increase production of viscous cervical mucus, impairing sperm transport into uterus
  • Effect secretion and peristalsis in fallopian tubes, decreasing fertilization timeframe
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21
Q

Do combined oral contraceptives have an affect on endometrial lining?

A

No, impaired implantation of fertilized embryos has not been demonstrated

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22
Q

What is the most common estrogen used?

A

Ethinyl estradiol

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23
Q

What are the other types of estrogen besides ethinyl estradiol?

A
  • Estradiol valerate and 7 beta-estradiol

- Estradiol valerate is metabolized rapidly to 7 beta-estradiol

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24
Q

What are characteristics of progestrins?

A
  • Estrogenic
  • Anti-estrogenic
  • Androgenic
  • Anti-androgenic
  • Anti-mineralocorticoid
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25
Q

What are the classifications of progestrins?

A
  • 1st gen = bind to estrogen, progesterone, and androgen receptors
  • 2nd gen = more potent than 1st gen, so may be better tolerated
  • 3rd gen = fewer androgenic effects
  • Newer progesterones = anti-androgenic
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26
Q

What is a monophasic COC? What are examples?

A
  • Fixed amount of estrogen and progestrin

- Ex: Alesse, Marvelon

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27
Q

What is a multiphasic COC? What are examples of each?

A
  • Biphasic = 2 phases of hormones (ex: synphasic)

- Triphasic = 3 phases of hormones (ex: tricyclen)

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28
Q

Is there a difference in efficacy between monophasic and multiphasic COC?

A

No

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29
Q

What does a 24/2/2 dosing regimen mean?

A

24 days active pills, 2 days ethinyl estradiol, 2 day HFI

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30
Q

How long is the cycle for extended-cycle COC? Why is that the cutoff?

A
  • 84 days plus 7 day HFI

- Longer than that can cause unpredictable spotting

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31
Q

What is the maximum length of HFI?

A

7 days

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32
Q

What is the suggestion when choosing a COC?

A

Start w/ COC containing 20 mcg ethinyl estradiol and an older progestrin (levonorgestrel or norethindrone) b/c of safety and efficacy

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33
Q

When can COC pills be started?

A

Any time during menstrual cycle, as long as possibility of pregnancy is ruled out

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34
Q

What can be done to avoid weekend periods?

A

Start COC 1st sunday after period starts

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35
Q

What are some contraindications for COC?

A
  • Less than 4 weeks postpartum if breastfeeding; less than 21 days in not breastfeeding
  • Smokers over 35 y/o
  • Vascular disease
  • Hypertension
  • Acute DVT/PE; history of DVT/PE not on anticoagulant
  • Current and/or history of ischemic heart disease
  • Migraine w/ aura
  • Current breast cancer
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36
Q

Can CHCs be used in women over 35 y/o?

A
  • Yes, less than 50 mcg of estrogen can be used in healthy, non-smoking women over 35 y/o
  • Shouldn’t be used in women w/ migraine, uncontrolled hypertension, smoking, or diabetes w/ vascular disease
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37
Q

What contraceptive methods can be used for women over 35 y/o that smoke?

A

Progestin only

38
Q

Can COCs be used in women w/ hypertension?

A

Low-dose CHC can be used in women under 35 y/o w/ well controlled and frequently monitored hypertension

39
Q

Can COCs be used in women w/ dyslipidemia?

A

Low dose CHCs can be used in women w/ controlled dyslipidemia

40
Q

Can COCs be used in obese women?

A
  • Low dose COCs have shown decreased efficacy in obese women

- Benefit outweighs risk

41
Q

Which contraceptives should be considered in women at high risk of CV disease?

A

Non-estrogen contraceptives

42
Q

Which women are at high risk of DVT/PE? What contraceptive should they use?

A
  • Over 35 y/o and smoker; history of clots

- Other methods besides COC

43
Q

What are the signs and symptoms of a blood clot?

A
  • Leg pain or swelling
  • Severe chest pain
  • Shortness of breath
44
Q

What symptoms can too much estrogen cause?

A
  • PMS like symptoms
  • Nausea, bloating
  • Breast tenderness
  • Melasma
  • Irritability
45
Q

What symptoms can too little estrogen cause?

A
  • Early or mid-cycle spotting
  • Hypomenorrhea
  • Headaches
  • Depression
  • Nervousness
46
Q

What symptoms can too much progestin cause?

A
  • Breast tenderness
  • Headache
  • Fatigue
  • Changes in mood
  • Increased appetite
47
Q

What symptoms can too little progestin cause?

A
  • Late breakthrough bleeding
  • Dysmenorrhea
  • Heavy flow
48
Q

What symptoms can too much androgen cause?

A
  • Increased appetite
  • Weight gain
  • Oily scalp/skin
  • Acne
  • Hirsutism (hair growth)
  • Rash
  • Increased LDL
49
Q

When is breakthrough bleeding a concern w/ CHC?

A

If it continues after 3-6 months of use, consider changing to another OC w/ increased estrogen and/or progestin (depending on when bleeding occurs)

50
Q

When is breast tenderness a concern w/ CHC?

A

If continues after first 3 months, consider changing to option w/ less estrogen

51
Q

Is CHC associated w/ weight gain?

A

No, but may increase appetite in first month

52
Q

When is nausea a concern w/ CHC?

A

If continues after first 3 months, consider changing to option w/ less estrogen

53
Q

When is a women likely to experience ovulation?

A

If the HFI exceeds 7 days

54
Q

When are vomiting or severe diarrhea a concern w/ CHC?

A
  • If occurs in 1st week, use back-up contraception for 7 consecutive days after vomiting/diarrhea has resolve
  • Consider EC if unprotected intercourse in previous 5 days
55
Q

What are some drugs that decrease COC effectiveness?

A
  • Carbamazepine
  • Phenytoin
  • Primidone
  • Rifampin
  • St. John’s Wort
56
Q

What are the active ingredients of the transdermal contraceptive patch?

A

Estrogen and progestin (combined hormonal)

57
Q

How is the transdermal contraceptive patch used?

A

Apply 1 patch weekly for 3 consecutive weeks followed by 1 patch free week

58
Q

Where can the transdermal contraceptive patch be applied?

A
  • Buttocks
  • Upper outer arm
  • Lower abdomen
  • Upper torso (excluding breast)
59
Q

What is important to note about the transdermal contraceptive patch and weight of the px?

A

May have decreased effectiveness in women 90 kg and over

60
Q

What are some side effects of the transdermal contraceptive patch?

A
  • Local skin reaction
  • Breast discomfort or pain
  • N/V
  • Dysmenorrhea (pain during menstruation)
61
Q

How long can the transdermal contraceptive patch be worn?

A

Up to 9 patches in a row, followed by 7 day patch free period

62
Q

What are the active ingredients of the vaginal contraceptive ring?

A

Estrogen and progestin (combined hormonal)

63
Q

How is the vaginal contraceptive ring used?

A

Insert for 3 continuous weeks then remove for 1 week

64
Q

What are some side effects of the vaginal contraceptive ring?

A
  • Less irregular bleeding
  • Shorter duration of menstrual bleeding
  • More vaginal symptoms (irritation, discharge, vaginitis)
65
Q

Can tampons be used w/ the vaginal contraceptive ring?

A

Not recommended, but can be done

66
Q

Can vaginal spermicides and antifungals be used w/ the vaginal contraceptive ring?

A

Yes, appear to have no effect on each other

67
Q

What are disadvantages to the progestin only pill?

A
  • Less effective than COC

- Associated w/ irregular and unpredictable menstrual bleeding

68
Q

What are advantages to the progestin only pill?

A
  • Safe in lactation

- Useful for women w/ contraindication to estrogen

69
Q

How is the progestin only pill used?

A
  • Take 1 pill each day, no HFI

- Take pill at same time each day w/in 3 hours

70
Q

What is the mechanism of the progestin only pill?

A
  • Increases cervical mucus viscosity and endometrial atrophy

- Reduces sperm motility

71
Q

Do women ovulate while on the progestin only pill?

A

About 40% of women do

72
Q

What are some side effects of the progestin only pill?

A
  • Amenorrhea, irregular bleeding

- Bloating, headache, breast tenderness

73
Q

What should be done if a progestin only pill is taken later than 3 hours after it should have been?

A
  • Take pill ASAP and continue taking pack
  • Use backup protection for 48 hours
  • Consider EC if unprotected intercourse in past 5 days
74
Q

How often is the depo-provera shot administered?

A

Every 3 months

75
Q

What is the mechanism of the depo-provera shot?

A
  • Inhibits secretion of gonadotropins
  • Inhibits ovulation
  • Increases cervical mucus viscosity and endometrial atrophy
76
Q

What are the indications for the depo-provera shot?

A
  • Women who desire 3 month contraception

- Women w/ contraindications or intolerance to estrogen

77
Q

What are contraindications for the depo-provera shot?

A
  • Pregnancy
  • Unexplained vaginal bleeding
  • Current diagnosis of breast cancer
78
Q

What are some side effects of the depo-provera shot?

A
  • Menstrual cycle disturbance
  • Hormonal (headache, decreased libido, nausea)
  • Weight gain
  • Decreased mood
79
Q

How long does it take to regain fertility after discontinuing the depo-provera shot?

A

Average 9-12 months b/c of decreased bone mineral density

80
Q

What is the only LARC option?

A

Intrauterine systems/devices (IUSs or IUDs)

81
Q

What are the 2 types of IUSs?

A
  • Copper IUD

- Levonorgestrel containing IUS

82
Q

How are IUSs inserted?

A

By OB/GYN or trained GP

83
Q

How is the vaginal contraceptive ring inserted?

A

By the px

84
Q

What are contraindications for an IUS?

A
  • Pregnancy
  • Current pelvic inflammatory disease
  • Current STI
  • Uterine abnormalities
85
Q

What are the risks of an IUS?

A
  • Uterine perforation w/ insertion

- Expulsion of IUS

86
Q

What is the mechanism of the copper IUD and levonorgestrel IUS?

A
  • Creates hostile environment for sperm through immune response
  • Reduces formation of mature eggs
  • Levonorgesterel also suppresses endometrium and thickens cervical mucus
87
Q

How long can a copped IUD remain in the uterus?

A

Maximum 30 months

88
Q

Does backup protection need to be used w/ the levonorgestrel IUS?

A

For 7 days after insertion if it has not been inserted w/in 7 days of onset of menses

89
Q

What are examples of the levonorgestrel IUS?

A
  • Mirena
  • Jaydess
  • Kyleena
90
Q

How long can the levonorgestrel IUS remain in the uterus?

A
  • Mirena and Kyleena can remain in for up to 5 years

- Jaydess can remain in for up to 3 years

Clinical - Winter (24 decks)

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