Birth Control Flashcards
What are the most effective birth controls?
Etonogestrel implant (Nexplanon)
Intramuscular medroxyprogesterone acetate (Depo-primavera)
Sterilization
IUDs
Several factors that should be considered when discussing which birth control with the patient
Effectiveness, safety, and personal preference.
Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method
Which birth control should women who engage in coitus frequently use?
ORAL or a long term method
Combination Oral Contraceptives
Types and MOA
There are two types
- Combination (estrogen plus progestin)
- Mini pills (progestin only)
MOA: Combination OCs reduce fertility primarily by inhibiting ovulation.
- the estrogen in combination OC suppress his release of follicle stimulating hormone from pituitary in there by inhibits follicular maturation
- the progestin Ask in the hypothalamus and pituitary to suppress the mid cycle LH surge (ovulation)
-Secondary mechanisms include thickening of the cervical mucus and alteration of the endometrium making it less hospitable for implantation
Prototype drugs for Birth Control
Combination oral contraceptive: ethinyl estradiol/norethindrone
Progesterone-only oral contraceptive:
Norethindrone
Long acting contraceptives:
subdermal etonogestrel implant (nexplanon)
Drugs for emergency contraceptive: Levonorgestrel alone (Plan B) and ulipristal acetate (Ella)
Effectiveness in oral contraceptives
With perfect use, the failure rate is only 0.3% however with typical use the failure rate is 8%
Women of higher weight efficiency is someone reduced due to decreased what levels of the hormones in adipose tissue
Components of oral contraceptives :
estrogen and progestins
There are only 3 estrogens used: ethinyl estradiol, mestranol, and estradiol valerate
Combination OCs employ 8 different progestins that can be grouped into four generations, all four generations are equally effective
- 1st gen: norethindrone, ethynodiol diacetate
- 2nd gen: norgestrel, levonorgestrel
- 3rd gen: desogestrel, norgestimate
- 4th gen: DIENOGEST, Drospirenone (this one is risk for hyperkalemia)
Absolute contraindication of oral contraceptives
If the history reveals an absolute contraindication OC should not be prescribed.
Absolute contraindications include:
- Thromboembolic disorders
- Cerebral vascular disease, coronary occlusion or a past history of these conditions or a condition that predisposes to these conditions
- Abnormal liver function
- Known or suspected breast cancer
- Undiagnosed abnormal vaginal bleeding
- Known or suspected pregnancy
- *Smokers older than 35 years
Relative Contraindications of oral combination contraceptives
If the medical history of a patient has a relative contraindication OC should be used with caution
Relative contraindications include:
- Hypertension
- Cardiac disease
- Diabetes
- History of cholestatic jaundice a pregnancy
- Gall bladder disease
- Uterine leiomyoma
- Epilepsy
- Migraines
Adverse effects of combination OCs:
Thromboembolic disorders
Combination OCs have been associated with *increased risk for venous thromboembolism, arterial thromboembolism, pulmonary embolism, myocardial infarction and thrombotic stroke
The overall risk is quite low but major factors that increases the risk are heavy smoking, history of thromboembolism, and thrombophilia’s
Non-smokers may continue use of low estrogen level OCs until menopause with no greater risk for MI then younger women
Combination OCs promote thrombosis by raising levels of clotting factors - both estrogen and progesterone can contribute to this
**specifically the progestins drospirenone (4th gen) and desogestrel (3rd gen)
These two progesterone drugs should generally be avoided because they may pose a higher risk for developing VTE
-OCs should be discontinued at least four weeks before surgery in which post operative thrombosis might be expected
Symptoms of thrombosis and thromboembolism that should be educated to patients include
Leg tenderness or pain, sudden chest pain, shortness of breath, severe headache, sudden visual disturbances. We should instruct patient to consult the prescriber if these occur
Adverse effects of combination OCs
Cancer
OCs do not cause breast cancer, but estrogen’s can promote the growth of existing breast carcinoma, so women with this disease should not take OCs.
OCs do increase the risk for breast cancer for some women, specifically women who have the BRCA1 gene mutation
OCs protect against ovarian and endometrial cancer and have no effect on cervical cancer
Adverse effects of combination OCs:
Hypertension
Combination OCs can cause hypertension, but the risk with today’s low estrogen preparation is very low.
OCs raise blood pressure by increasing blood levels of the two components: *angiotensin and aldosterone
Adverse effects of oral OCs
Abnormal uterine bleeding
OCs May decrease or eliminate menstrual flow
Breakthrough bleeding may occur and spotting during first 3 months.
-if spotting or break through bleeding is early or midcycle there is an estrogen deficiency in dosage
-if breakthrough bleeding occurs late in cycle or amenorrhea then there is a progestin deficiency in dosage.
Adverse effects of ORAL combination OCs: Pregnancy and lactation
OCs are contraindicated in pregnancy women
Women need to be a educated that use of OCs early in pregnancy does not harm fetus
Combination OCs enter breastmilk and reduce milk production
-progestin only BC is used for lactating women
Adverse effects of combination OCs:
Stroke and Migraines
When women with migraines use combined OCs the risk for thrombotic stroke can increase, but increase is low
OCs generally safe in women with headaches provided they are YOUNGER THAN 35, DONT SMOKE, and don’t have auras
Effects related to Estrogen Imbalance
Excess estrogen in dosage can cause :
- nausea
- great tenderness
- edema
- bloating
- hypertension
- migraine
- polyposis
Deficiency in estrogen
- early or mid cycle breakthrough bleeding
- increased spotting
- hypomenorrhea (periods occur less often than the monthly 28 day cycle)
Effects related to Progesterone Imbalance
Signs there is a progestin EXCESS:
- increase appetite
- weight gain
- depression
- tiredness
- fatigue
- breast regression
- vaginitis
- acne, oily skin
- hair loss
- hirituism
DEFICIENCY
- late break through bleeding
- amenorrhea
- hypermenorrhea
Adverse effects on Glucose Intolerance with combined oral OCs
OCs can ELEVATE blood glucose levels, caused by the progestin
Diabetics can still use as long as taking insulin
Less likely to occur with desogestryl and norgestimate
NonContraceptive Benefits Of combination OCs
Can decrease the risk for ovarian cancer, endometrial cancer, ovarian cyst, PID, benign rest of these, iron deficiency anemia, and acne, and rheumatoid arthritis
Also can reduce symptom severity of menses
Drug interactions with oral contraceptives
Drugs that induce hepatic cytochrome P3A4 can reduce the effects of oral birth control- causing breakthrough bleeding or spotting
-high estrogen OCs should be used in these women
OCs can REDUCE the effects of warfarin by increasing levels of clotting factors and and increasing glucose levels with hypoglycemic agents.
TOXIC risks: OCs can INCREASE effects of hepatica metabolism causing increase im drug levels -theophylline -tricyclic anti depressants -diazepam -chlordiazepoxide
Levomefolate
A metabolite of Folic Acid
BeYaz, YAZ plus, Safyral, and Tydemy
all contain estrogen and progestin and ALSO levomefolate
Indication: to reduce risk of fetal neural tube defects, like anencephaly and spina bifida, if pregnancy should occur despite contraceptive use
Natazia
Fourth generation progestin with estradiol
Contains estradiol valerate and the progestin dienogest
-like drospirenone, dienogest has a strong pro gestational activity and anti-androgenic activity, but in contrast does not cause
potassium retention
Natazia has a four phase dosing schedule where estrogen decreases and progestin increases
Can reduce blood loss with patients who experience heavy menstrual bleeding
Dosing with combined OCs
OCs are dosed in a cyclic pattern that is 28 days long and subdivided into four groups:
-Monophasic: The daily doses of estrogen and progesterone remain constant throughout the cycle
- Biphasic, triphasic, and Quadri phasic :
- Estrogen and progesterone change as the cycle progresses
- schedules reflect efforts to more closely stimulate ovarian production of estrogen and progesterone progesterone
- There are 21 days of an active pill followed by seven days on which either no pill is taken, an insert pillows taken, or an iron containing pills taken.
When to start the first day of OCs
Begin on either the first day of the menstrual cycle
-protection is immediate
Or the first Sunday after the onset of menses
-use backup protection for first 7days of pill pack
Extended cycle can be used for withdrawal bleeding associated with pain and premenstrual symptoms by purchasing 4 packs at a time and taking active pills only for 84 days straight.
What to do if Doses are missed
- If one or more pills are missed in the first week, take one pill as soon as possible use an additional form of contraception for seven days
- If one or more pills are missed during the second or third week, take one pill a soon as possible and then continue with the active pills in the pack but skip the placebo pills and go straight to the new pack
-If three or more pills are missed during second and third week, Take one pill as soon as possible and then continue with the active pills in the pack but skip the placebo pills and go straight to the new pack
but ALSO use backup for 7 days
Extended use: Up to seven days can be a mess with little or no increased risk for pregnancy provided that the pills have been taking continuously for the past three weeks
