6 - Hormonal Contraception Flashcards
What is menarchy/menorrhea?
When menses begins
What hormone does the hypothalamus release w/ respect to menses?
- GnRH (gonadotropin releasing hormone)
- Released in a pulsatile fashion
- Has an affect on anterior pituitary gland
What does the anterior pituitary gland release w/ respect to menses?
- FSH (follicle stimulating hormone)
- LH (luteinizing hormone)
What does FSH do?
- 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
What does estradiol do?
Works as negative feedback to prevent GnRH release
What is ovulation? What does it occur?
- Primary follicle being released into fallopian tubes
- Occurs on day 14 of menstrual cycle
What does the primary follicle become? When?
- Corpus luteum
- Day 14 of menstrual cycle
What is the lifespan of the corpus luteum?
14 days
What occurs on day 1 of menstrual cycle?
- 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
What is the follicular phase of menses?
Days 1-14
What does the corpus luteum do?
- Produces progesterone and some estrogen
- Progesterone levels are low until day 14, then increase and peak around day 25
What does an increase in estrogen cause?
Changes in endometrial lining, causing menses to stop
What does a drop in progesterone cause?
Uterus to shed endometrial lining
What are the options for combined contraceptives?
- Oral (pill)
- Transdermal patch
- Vaginal ring
What are the options for progestin only contraception?
- Oral
- Injectable
- IUS
What are the options for non-hormonal contraception?
- Barrier options
- IUD
What are the goals of therapy for hormonal contraception?
- Prevent fertilization to prevent pregnancy
- Tailor methods to individuals px needs
- Avoid/minimize adverse effects
- Ensure adherence by providing oral and written instructions
What are the causes of the 9% failure rate of combined hormonal contraceptives?
- Irregular intake
- Vomiting and/or diarrhea
How long does it normally take to restore fertility after combined oral contraceptives are stopped?
About 1-3 months
What are the mechanisms of action for combined oral contraceptives?
- 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
Do combined oral contraceptives have an affect on endometrial lining?
No, impaired implantation of fertilized embryos has not been demonstrated
What is the most common estrogen used?
Ethinyl estradiol
What are the other types of estrogen besides ethinyl estradiol?
- Estradiol valerate and 7 beta-estradiol
- Estradiol valerate is metabolized rapidly to 7 beta-estradiol
What are characteristics of progestrins?
- Estrogenic
- Anti-estrogenic
- Androgenic
- Anti-androgenic
- Anti-mineralocorticoid
What are the classifications of progestrins?
- 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
What is a monophasic COC? What are examples?
- Fixed amount of estrogen and progestrin
- Ex: Alesse, Marvelon
What is a multiphasic COC? What are examples of each?
- Biphasic = 2 phases of hormones (ex: synphasic)
- Triphasic = 3 phases of hormones (ex: tricyclen)
Is there a difference in efficacy between monophasic and multiphasic COC?
No
What does a 24/2/2 dosing regimen mean?
24 days active pills, 2 days ethinyl estradiol, 2 day HFI
How long is the cycle for extended-cycle COC? Why is that the cutoff?
- 84 days plus 7 day HFI
- Longer than that can cause unpredictable spotting
What is the maximum length of HFI?
7 days
What is the suggestion when choosing a COC?
Start w/ COC containing 20 mcg ethinyl estradiol and an older progestrin (levonorgestrel or norethindrone) b/c of safety and efficacy
When can COC pills be started?
Any time during menstrual cycle, as long as possibility of pregnancy is ruled out
What can be done to avoid weekend periods?
Start COC 1st sunday after period starts
What are some contraindications for COC?
- 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
Can CHCs be used in women over 35 y/o?
- 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
What contraceptive methods can be used for women over 35 y/o that smoke?
Progestin only
Can COCs be used in women w/ hypertension?
Low-dose CHC can be used in women under 35 y/o w/ well controlled and frequently monitored hypertension
Can COCs be used in women w/ dyslipidemia?
Low dose CHCs can be used in women w/ controlled dyslipidemia
Can COCs be used in obese women?
- Low dose COCs have shown decreased efficacy in obese women
- Benefit outweighs risk
Which contraceptives should be considered in women at high risk of CV disease?
Non-estrogen contraceptives
Which women are at high risk of DVT/PE? What contraceptive should they use?
- Over 35 y/o and smoker; history of clots
- Other methods besides COC
What are the signs and symptoms of a blood clot?
- Leg pain or swelling
- Severe chest pain
- Shortness of breath
What symptoms can too much estrogen cause?
- PMS like symptoms
- Nausea, bloating
- Breast tenderness
- Melasma
- Irritability
What symptoms can too little estrogen cause?
- Early or mid-cycle spotting
- Hypomenorrhea
- Headaches
- Depression
- Nervousness
What symptoms can too much progestin cause?
- Breast tenderness
- Headache
- Fatigue
- Changes in mood
- Increased appetite
What symptoms can too little progestin cause?
- Late breakthrough bleeding
- Dysmenorrhea
- Heavy flow
What symptoms can too much androgen cause?
- Increased appetite
- Weight gain
- Oily scalp/skin
- Acne
- Hirsutism (hair growth)
- Rash
- Increased LDL
When is breakthrough bleeding a concern w/ CHC?
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)
When is breast tenderness a concern w/ CHC?
If continues after first 3 months, consider changing to option w/ less estrogen
Is CHC associated w/ weight gain?
No, but may increase appetite in first month
When is nausea a concern w/ CHC?
If continues after first 3 months, consider changing to option w/ less estrogen
When is a women likely to experience ovulation?
If the HFI exceeds 7 days
When are vomiting or severe diarrhea a concern w/ CHC?
- 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
What are some drugs that decrease COC effectiveness?
- Carbamazepine
- Phenytoin
- Primidone
- Rifampin
- St. John’s Wort
What are the active ingredients of the transdermal contraceptive patch?
Estrogen and progestin (combined hormonal)
How is the transdermal contraceptive patch used?
Apply 1 patch weekly for 3 consecutive weeks followed by 1 patch free week
Where can the transdermal contraceptive patch be applied?
- Buttocks
- Upper outer arm
- Lower abdomen
- Upper torso (excluding breast)
What is important to note about the transdermal contraceptive patch and weight of the px?
May have decreased effectiveness in women 90 kg and over
What are some side effects of the transdermal contraceptive patch?
- Local skin reaction
- Breast discomfort or pain
- N/V
- Dysmenorrhea (pain during menstruation)
How long can the transdermal contraceptive patch be worn?
Up to 9 patches in a row, followed by 7 day patch free period
What are the active ingredients of the vaginal contraceptive ring?
Estrogen and progestin (combined hormonal)
How is the vaginal contraceptive ring used?
Insert for 3 continuous weeks then remove for 1 week
What are some side effects of the vaginal contraceptive ring?
- Less irregular bleeding
- Shorter duration of menstrual bleeding
- More vaginal symptoms (irritation, discharge, vaginitis)
Can tampons be used w/ the vaginal contraceptive ring?
Not recommended, but can be done
Can vaginal spermicides and antifungals be used w/ the vaginal contraceptive ring?
Yes, appear to have no effect on each other
What are disadvantages to the progestin only pill?
- Less effective than COC
- Associated w/ irregular and unpredictable menstrual bleeding
What are advantages to the progestin only pill?
- Safe in lactation
- Useful for women w/ contraindication to estrogen
How is the progestin only pill used?
- Take 1 pill each day, no HFI
- Take pill at same time each day w/in 3 hours
What is the mechanism of the progestin only pill?
- Increases cervical mucus viscosity and endometrial atrophy
- Reduces sperm motility
Do women ovulate while on the progestin only pill?
About 40% of women do
What are some side effects of the progestin only pill?
- Amenorrhea, irregular bleeding
- Bloating, headache, breast tenderness
What should be done if a progestin only pill is taken later than 3 hours after it should have been?
- Take pill ASAP and continue taking pack
- Use backup protection for 48 hours
- Consider EC if unprotected intercourse in past 5 days
How often is the depo-provera shot administered?
Every 3 months
What is the mechanism of the depo-provera shot?
- Inhibits secretion of gonadotropins
- Inhibits ovulation
- Increases cervical mucus viscosity and endometrial atrophy
What are the indications for the depo-provera shot?
- Women who desire 3 month contraception
- Women w/ contraindications or intolerance to estrogen
What are contraindications for the depo-provera shot?
- Pregnancy
- Unexplained vaginal bleeding
- Current diagnosis of breast cancer
What are some side effects of the depo-provera shot?
- Menstrual cycle disturbance
- Hormonal (headache, decreased libido, nausea)
- Weight gain
- Decreased mood
How long does it take to regain fertility after discontinuing the depo-provera shot?
Average 9-12 months b/c of decreased bone mineral density
What is the only LARC option?
Intrauterine systems/devices (IUSs or IUDs)
What are the 2 types of IUSs?
- Copper IUD
- Levonorgestrel containing IUS
How are IUSs inserted?
By OB/GYN or trained GP
How is the vaginal contraceptive ring inserted?
By the px
What are contraindications for an IUS?
- Pregnancy
- Current pelvic inflammatory disease
- Current STI
- Uterine abnormalities
What are the risks of an IUS?
- Uterine perforation w/ insertion
- Expulsion of IUS
What is the mechanism of the copper IUD and levonorgestrel IUS?
- Creates hostile environment for sperm through immune response
- Reduces formation of mature eggs
- Levonorgesterel also suppresses endometrium and thickens cervical mucus
How long can a copped IUD remain in the uterus?
Maximum 30 months
Does backup protection need to be used w/ the levonorgestrel IUS?
For 7 days after insertion if it has not been inserted w/in 7 days of onset of menses
What are examples of the levonorgestrel IUS?
- Mirena
- Jaydess
- Kyleena
How long can the levonorgestrel IUS remain in the uterus?
- Mirena and Kyleena can remain in for up to 5 years
- Jaydess can remain in for up to 3 years
