Birth Control/Abortion Flashcards
How many unintended pregancies are there each year in the US?
• what populations is this most common in?
About ½ of pregnancies in the U.S. are unintended. Most of these are in marginalized populations who, because of their situation, don’t have access to birth control
What are 3 very common causes of unintended pregnancy?
Common causes of unintended pregnancy = contraceptive nonuse, contraceptive method failure, contraceptive user failure.
In general what types of birth control have the lowest failure rates?
Birth control methods that require little maintence ) have lowest failure rates.
What is the duration of action of the birth control patch?
Patch acts a week at a time
What 3 things should you consider when choosing birth contol with a patient?
Choosing the correct contraceptive means determining if the patient needs:
• a reversible method
• if they are compliant with daily doses
• if they have any contraindications.
Why would you want to give someone with BRCA mutations an OCP?
People with BRCA mutations may benefit from OCPs because because it reduces the risk of ovarian cancer.
Oral Contraceptives
- Why do most people stop taking them?
- Failure rate?
- what is the most feared complication?
- *ORAL CONTRACEPTIVES**
- most people stop taking OCPs because of side effects like nausea and irregular bleeding that leads to a 9% failure rate
- Risks for thromboembolism
- Non-contraceptive benefits: cramps, acne, heavy bleeding, and prevents PID (reduce endometrial secretions that make if fertile for infection) and Cancer
What are some of the non-contraceptive benefits or OCPs?
Non-contraceptive benefits: cramps, acne, heavy bleeding, and prevents PID (reduce endometrial secretions that make if fertile for infection) and Cancer
Depo Provera
- Failure Rate/Duration
- Benefits
- Potential Drawbacks
Depo Provera
- IM Q12 weeks, 6% failure rate from user failure
- no menses, (no protection from osteoporosis)
- Weight Gain of about 3 lbs/yr is a definite side effect, DO NOT GIVE TO WOMEN WORRIED ABOUT WT.
What are LARCs?
- what has been their impact on birth control?
These are Long Acting Reversible Contraceptives - this includes implantables and IUDs
***responsible for reducing teen-age pregnancy and Medicaid births***
What form of birth control/Sterilization has the lowest risk of getting pregnant?
- *Nexplanon-**implantable
- Q3 years (0.05% failure rate)**Lowest failure Rate – even lower than Sterilization
- *- Easy in/Easy out
- Irregular menses may be causes**
What are your ideal forms of birth control in a woman with a factor V leiden mutation?
Depo-Provera and IUDs are imporant in women with Hx of thromboembolic dz.
What contraceptives canNOT be used in the treatment of osteoporosis?
**Important to realize that IUDs only work locally and not systemically so you don’t get the anti-osteoporotic effects of estrogen therapy**BUT THEY (ALONG WITH DEPO-PROVERA, HAVE AN IMPORTANT USE IN FEMALES WHO HAVE A HISTORY OF THROMBOEMBOLYTIC EVENTS**
Mirena IUD
• hormone used?
• Duration or action and failure rate?
• Affect on periods?
• Cost?
Mirena (IUD w/ Levonorgesterol)
- Q5 years (0.2% failure rate)
- amenorrhea
- Costs a good amount to get installed
What IUD is used for patients that have never been pregnant?
• Duration of action?
- *Skyla** (small IUD)
- Q3 yrs
- For Nulliparous (never been pregnant) and younger patients
What IUD should you NEVER give to anyone experiencing menorrhagia?
• Duration of action of this IUD?
- *Copper IUD**
- Q10 years (0.8% failure rate)
Pitfalls
- Dysmenorrhea and HEAVY periods, DO NOT GIVE TO ANYONE COMPLAINING OF INTENSE MENSES
Compare the reversibility and failure rate of male and female sterilization.
Female Sterilization
- 1/200 (0.5%) first year failure rate, 1/100 (1%) ten year failure rate
Male Sterilization
- 0.15% failure rate
- more easily reversed than female tubal ligations etc.
What happens to estrogen and progesterone as birth nears?
Parturition approaches and the estrogen:progesterone ratio increases the receptors for contractile agonists increase in number and number of gap junctions that link myometrial cells also increase.
What endogenous hormone aids in maintaining pregnancy?
• How does this work?
- Maintance of pregnancy is done by Progesterone pregnancy by hyperpolarizing the smooth muscle in the uterus and preventing the release of arachiodonic acid to make PGs. This makes the muscle non-excitable
What two endogenous substances work via the IP3 (Gq) pathway to increase uterine contractility?
• Explain how this IP3 pathway works.
Oxytocin (Pitocin) and PGF2alpha work via the IP3 pathway to increase Ca2+ in cytoplasm. Ca2+ in smooth muscle binds calmodulin, which activates myosin light chain kinase.
***PGF2alpha is probably the more important of these two substances***
How do progesterone and cAMP act to decrease contractility of the uterus?
cAMP and Progesterone work via the Gs pathway to sequester Ca2+ back into the ER and SR and prevents Ca2+ influx into the cytoplasma that leads to calmodulin activation of myosin light chain kinase.
What are the indications for the administration of Oxytocics?
Oxytocics
- *INDICATIONS**
- *Induction of labor**– premature membrane rupture, fetal growth restriction, unteroplacental insufficiency, Pre-eclampsia/eclampsia
- *Control of Postpardum Uterine hemorrhage**
- *Induction of therapeutic abortion**
- *Uterine contraction after C-section or Sx.**
What 3 PROSTAGLANDINS are used as oxytocics in pregnancy?
Prostaglandins
Dinoprostone – PGE2
Misoprostol – PGE1
Carboprost tromethamine – 15methylPGF2
What tocolytics are used to prevent delivery?
Tocolytics -
Magnesium Sulfate
Indomethacin
OTCs: Caster Oil, Blue Cohosh, Black Cohosh, Oil of Evening Primrose etc
What are the indications for giving Tocolytics?
INDICATIONS
Delay or PREVENT PREMATURE PARTURITION – often to administer glucocorticoids for 1-2days to induce sufficient surfactant in premature babies.
Why would you give someone a gonadotropin?
• Females? Risk?
• Males?
Gonadotropin use for infertility:
- Females: these can be used in anovulatory women or women with hypogonadism to increase fertility. There is a risk of overshooting and getting multiple pregnancies.
- Males: these are used less frequently in males because androgens can be used to induce sexual development. Gonadotropins are reserved to increase fertility when trying to conceive.
How long after the LH surge does ovulation occur?
Time of ovulation can be determined using LH (ovulation is 36 hours after LH surge).
What gonadotropins can be used to induce ovulation or enhance male fertility?
• where do these come from?
• Differences in administration?
Menotropin – FSH and LH (from urine of menopausal women), or recombinant FSH (rFSH) is used
• Given SC
Chorionic Gonadotropin – hCG (from urine of pregnant women), BINDS TO THE LH RECEPTOR.
• Given IM
What GnRH agonist can be used to induce gonadotropin release?
Goserelin, Histrelin, Leuprolide, Triptorelin
What 2 drugs are GnRH antagonists?
Anatagonists – Ganirelix, Cetrorelix
What is the use of competitive inhibition of progesterone receptor binding?
• what drugs do this?
Blocking progesterone induces abortion
Antiprogestins
- *Mifepristone (RU-486)**
- *Onapristone**
What two drugs act by blocking estrogen feedback in the hypothalmus?
• How can this therapy increase fertility?
Antiestrogens
Clomiphene and Fulvestrant are anti-estrogens that increase fertility by *blocking estrogen receptors in all tissues, including the HYPOTALMUS so that more GnRH is released
**Note these block estrogen in all tissues not just the hypothalmus****
What might be some symptoms of a male who lacks estrogen receptors?
- Osteoporosis
- Unfused Epiphyses
- Increased bone Turnover
Fulvestrant
• Administration
• MOA
• Side Effects
Fulvestrant
Administration
Monthly IM injections
MOA
SERD not SERM so = PURE ANTAGONIST with NO estrogenic effects, bulky adduct prevents ER receptor dimerization
Adverse Effects
Mostly perimenopausal symptoms of Nausea, asthenia, pain, vasodilation (HOT FLASHES), and headache
Clomiphene
• MOA/use in fertility tx
• Side effects
Clomiphene
MOA
Antagonizes estrogen feedback of the pituitary (and everywhere else, this is a SERD) so that MORE gonadotropins (FSH, and LH) are released
Ultimately this induces ovulation
What synthetic estrogens are used most often in estrogen therapy?
Synthetic estrogens used in therapy include: Ethinyl estradiole, mestranol
What estrogens are used to treat prostate cancer?
Estrogens used to treat prostate cancer: DES (diethylstilbesterol) and Clorotrianisene
Actions of Estrogens (ones that may not be super apparent) – increases HDL and decreases LDL, shapes pelvis, increased libido (even though testosterone is more important), increased synthesis of Thyroid Binding Globulin (TBG), transcortin, Sex Hormone Binding Globulin (SHBG), and CLOTTING FACTORS, VERY important for epiphyseal plate closure in both males and females
Actions of Estrogens (ones that may not be super apparent) – increases HDL and decreases LDL, shapes pelvis, increased libido (even though testosterone is more important), increased synthesis of Thyroid Binding Globulin (TBG), transcortin, Sex Hormone Binding Globulin (SHBG), and CLOTTING FACTORS, VERY important for epiphyseal plate closure in both males and females
What estrogens are most commonly used in contraceptives?
• Administration
• Metabolism
Ethinyl Estradiol and Mestranol => ESTROGEN COMPONENTS IN COMBINATION CONTRACEPTIVES
ADMINISTRATION
Oral, Parenteral, or Transdermal
**Note: Metabolism relies on P450s and Enterohepatic Recirculation so watch out for CYP inducers and antibiotics.
**Modifications prevent elimination from occurring as quickly as it does with regular estrogen
Ethinyl Estradio and Mestranol
• MOA in preventing pregancy?
MOA
Suppression of GnRH release leading to loss of gonadotropin (LH – mostly, and FSH) surge that leads to ovulation
What Estrogens are used in OCPs?
• adverse effects?
ADVERSE EFFECTS
Breakthrough bleeding, nausea, breast tenderness
THROMBOEMBOLISM (women over 35 who smoke), Gallbladder disease, Hyptriglyceridemia, HTN
Potential for Endometrial Hyperplasia (if unopposed)
What is a major contraindication for administration of synthetic estrogens?
Hx of Thromboembolism or Thromboembolic disease
What synthetic progestins are used in birth control?
Progestins
SYNTHETIC PROGESTINS: norethindrone, norgestrel, levonorgestrel
What are physiologic actions of progesterone?
Actions of Progesterone (not so obvious): Synthesized by the placenta to aid in maintaining pregnancy and inhibiting urterine contraction. DECREASES HDL and INCREASES LDL. Responsible for INCREASE IN BODY TEMPERATURE at ovulation.
Norgesterol
• Administration
• MOA
• AEs
Norgestrel
ADMINISTRATION
Oral, parenteral, or Transdermal
**Like estrogen it relies on CYP metabolism and enterohepatic cycling
MOA
Activates progesterone receptors leading to changes in the rates of transcription of progesterone-regulated genes.
ADVERSE EFFECTS
Weight gain, reversible decrease in bone mineral density at high doses
In what cases is progesterone added to estrogen replacement therapy?
Replacement Therapy: Estrogens, progestins added for ovarian failure
What are the most effective and least effective methods or contraception?
MOST EFFECTIVE CONTRACEPTION:
* IUDs, Progestin implants, and Sterilization
* There is no problem with compliance in these medications
LEAST EFFECTIVE CONTRACEPTION:
* Barrier methods
What are some non-contraceptive benefits of oral contraceptives?
Non-Contraceptive Benefits:
1) Dysmenorrhea
2) Menstrual Regularity (increasing Hbg)
3) raises SHBG leading to a decrease in androgens making it EFFECTIVE FOR counteracting ACNE and HIRSUITISM
4) PCOS (combo pills only)
What are some contraindications for Combined Oral Contraceptives?
*what should these women use instead?
Contraindications for COMBINATION ORAL CONTRACEPTIVES
* Vascular Disease (thromboembolic, cerebrovascular, CAD)
* Congenital Hyperlipidema
* Suspected Breast Cancer or Endometrial Cancer
* Smoking in women over 35
***these women should use a progesterone only contraceptive**
What is the “mini-pill”?
• how effective is it?
Mini-Pill (Progesterone only)
Efficacy: only has a slightly higher fail rate than the combo pill
Progesterone only (mini-pill)
• MOA
• Benefits over combination pill?
• Adverse effects
MOA:
Blocks ovulation in 60-80% of cycles, but still effective because when not blocking ovulation it impairs sperm transport by thickening the cervical mucus, decreases motility of ovules in the oviduct, and alters the endometrium to impair implantation.
Benefits over Combination Pill: best for women breast-feeding, women over 35 WHO SMOKE
AE’s: acne and weight gain
Transdermal Patch
• what does it contain
• Frequency of dosing
• Problems with using this method
Transdermal Patch
Contains: ethinyl estradiol and progestin
Benefits: Once a week dosing (3 weeks on, one off)
Problems: Less effective in Fat women (penetration of adipose), Skin Irritation, Break though bleeding more common early on.
Vaginal Contraceptive Rings
• Are these considered IUDs?
• Contents?
• Frequency of Dosing
• Benefits
• Problems
Vaginal Contraceptive Rings ***These are NOT IUDs***
Contains: ethinyl estradiol and progestin
Benefits: Self application (intravaginal by pt), Remove once every 3 weeks, Rapid return to fertility after removal
Problems: Not effective for first 7 days, Do not remove for more than 3 hr
Depo-Provera
• Contents?
• How long does it take to return to fertility?
• Adverse effects?
Injectables (Depo-provera)
Contains: Progesterone ONLY usually MEDRYOXYPROGESTRONE
Benefits: 3 month dosing, Reversible Amenorrhea, Delayed return to fertility (6-12 mo)
Problems: Weight gain, HA, decreased bone density (not much though), Discontinue after 2 years (not really necessary)
Implants
• Contents
• Duration of Action
• Benefits
• Problems
Implants
Contains: Progesterone ONLY usually ETONGESTREL
Benefits: Effective for 3 years
Problems: Weight gain, HA, decreased bone density (not much though), Discontinue after 2 years (not really necessary)
Copper IUD
• Contents
• How long is it effective?
• How long to return to fertility?
• Problems?
• Use as emergency contraception?
Copper IUD
Contains: Copper only – copper is spermicidal
Benefits: Effective for 15-20 years, Fertility Restored Quickly after removal, can be used in emergency contraception if placed within 5 days
Problems: Cramping
Progestin Releasing IUD
• Contents
• Benefits?
• Problems
• How long to return to fertility?
Progestin Releasing IUD
Contains: IUD coated in progesterone usually LEVONORGESTREL
Benefits: Fertility Restored Quickly after removal
Problems: Release rate of progesterone decreases with time
Problems: Irregular bleeding
A woman places her nuva ring on monday and has sex on tuesday. Is she in the clear from getting pregnant?
NO, vaginal contraceptive rings must be in place for 7 days before they are effective
T or F: IUDs are useful in the treatment of dysmenorrhea.
True - but they must be coated with progesterone, copper IUDs increase dysmenorrhea
In what time frame must diaphragms and cervical caps be in place to be effective?
Diaphragms and Cervical Caps – WITH SPERMICIDE
Disadvantages: Must be in place for 6 hours before and after, Less effective than hormone contraceptives or IUDs, risk of TOXIC SHOCK
Spermicides
• Active Ingredient
• Application
• Adverse Effects
SPERMICIDES
Active Ingredient: Nonoxynol-9 (surfactant)
Application: must reapply every hour, MUST be in contact with cervix
AEs: Less effective, irritation,
Sponges
• Active ingredient
• Application
• Advantages
• Disadvantages
SPONGES
Active Ingredient: Nonoxynol-9
Application: Placed Over Cervix
Advantages: Effective Immediately up to 24 hours
Disadvantages: Must remain in place for 6 hours after intercourse, Inferior to diaphragms , Toxic Shock
What is the active ingredient in the morning after pill?
• When should it be taken?
• MOA
• Adverse Effects
EMERGENCY CONTRACEPTION
*Should always take these AS SOON AS POSSIBLE after intercourse and definitely not longer than 72 hours
Active Ingredient: Progestins (LEVONORGESTREL) 2 doses 12 hours apart
MOA: Turns surface of the endometrium into a surface that is hard to implant onto
Adverse Effects: HA, Breast tenderness, Abdominal Pain
Besides using levonorgestrel, what are 2 other methods of emergency contraception?
taking additional oral contraceptive (ethinyl estradiol may induce N/V), Copper IUD within 5 days
If you need to terminate a pregnancy between 3 and 49 days, what drugs should be used?
• How do these drugs work?
• Potential Side Effects?
• Differences in the two drugs used?
ABORTIONISH CONTRACEPTION
Mifepristone (RU 486) / Onapristone
MOA:
Mifepristone – BLOCKS PROGESTERONE RECEPTORS causing a lack of endometrial maintenance and abortion. ALSO, blocks GLUCOCORTICOID RECEPTORS (can be used in T2DM + CUSHINGS, INOPERABLE CUSHINGS)
Onapristone – more pure antagonist of progesterone
What testosterone derivatives are used for treatment with testosterone?
methyltestosterone
testosterone propionate
testosterone cypionate
What weakly androgenic compound is useful in the treatment of endometriosis and PMS?
Danazol
Oxandrolone
What is it?
Anabolics – Oxandrolone (less conversion to estrogen, less inhibition of testosterone synthesis)
Cryproterone Acetate
MOA
Indication
Cryproterone acetate:
MOA: competes with DHT and prevents receptor nuclear translocation
Indication: Acne, baldness, hirsuitism, virilizing syndrome, inhibition of libido
Androgen Receptor Blockers
• Name Them
• MOA
Bicalutamide, Enzalutamide, Flutamide, Nicalutamide – the “lutamides”
ADMINISTRATION
Oral - daily
MOA
Blockage of androgen receptors to prevent receptor stimulation on cancer cells. Administered concurrently with GnRH agonist
Androgen Receptor Blockers
Name Them
Adverse Effects (which has the least?)
Indication
_Lutamides - Flutamide, Bicalutamide, Nicalutamide
ADVERSE EFFECTS_
- *Castration Effects**: Hot flashes, decreased libido, ED, gynecomastia, osteoporosis
- NICLUTAMIDE – replacing flutamide because of 1x day dosing and lower hepatic toxicity*
INDICATION
Prostate Cancer
FLUTAMIDE ALSO USED TO TREAT HIRSUTISM OR POLYCYSTIC OVARIAN SYNDROME
