Block 2 Lecture 2 -- Contraception Flashcards
Theoretical vs. actual efficacy of OCs.
99 vs 92
Describe monophasic OC dosing
fixed E + P for 21 days, then 7 placebo
Describe extended cycle OC dosing.
84 active + 7 placebo
What brands are extended-cycle?
seasonale, yaz
When are biphasics, triphasics, multiphasics used?
for breakthrough bleeding
- varied E + P dosing
- no evidence of bleeding improvement though
What is Lybrel?
OC that eliminates hormonal cycle
– 365 active pills
What is the dosing in Lybrel?
20 ug + 90 ug levonorgestrel
What are the progestins with less androgenic activity?
1) desogestrel
2) norgestimate
3) drosperinone
What is the advantage to drosperinone?
anti-aldosterone (MR antagonist) for less bloating, weight gain
What is the disadvantage to drosperinone?
higher risk of VTE vs. levonorgestrel
What is the difference in 3rd/4th gen OCs?
new progestins are less androgenic
Describe efficacy of progestin-only birth controls.
less effective; associated with regular bleeding
- 40% still ovulate (ectopic risk)
- must be taken at same time q day
When are lo-dose OCs preferred?
adolescents, underweight (110 lb), older than 35, perimenopausal
What is defined as very low dose OC?
20-25 ug EE
What is defined as low-dose OC?
less than 35 ug EE (or less than 0.5 mg norethindrone or equivalent)
What is defined as normal dose OC?
35-50 ug
What dose should not be exceeded in any patient for OC?
50 ug (VTE)
When is normal (35-50ug) dosing preferred?
160+ lb
What is first choice in OC selection?
low-dose (since all OCs are equally effective)
When are monophasics preferred?
if easy-management is a must
– can just skip placebo to lengthen cycle
When are bi- and tri-phasics preferred?
when lessening spotting and progestin ADRs is a concern
When are extended formulation OCs preferred?
when dysmenorrhea or menstrual issues are present
When are progestin-only OCs preferred?
if any of the following:
1) migraines w/ aura
2) thromboembolic disease
3) cerebrovascular disease
4) SLE
5) 35+ yo and smoker, obesity, OR HTN
What are the APIs in the transdermal patch (ortho evra)?
EE + norelgestromin, a norgestimate metabolite
When should a transdermal patch be avoided?
1) if 198+ lbs.
2) if thromboembolic risk is a concern
What effect do CHCs have on dyslipidemia?
none
theoretical vs actual efficacy of Ocs
99 vs 92
Describe monophasic OC dosing
fixed E+P for 21 days, then 7 placebo
Describe extended-cycle OC dosing
84 active + 7 placebo
What brands are extended cycle?
seasonale, yaz
When are biphasics, triphasics, multiphasics used?
for breakthrough bleeding. varied E+P dosing; no evidence of bleeding improvement though
What is Lybrel?
OC that eliminates hormonal cycle (365 active pills)
What is the dosing of lybrel?
20 ug EE + 90 ug levonorgestrel
What are the progestins with less androgenic activity?
1) desogestrel; 2) norgestimate; 3) drosperinone
What is the advantage to drosperinone?
anti-aldosterone (MR antagonist) for less bloating, weight gain
What is the disadvantage to drosperinone?
higher risk of VTE vs. levonorgestrel
What is the FDA-required warning on drosperinone?
higher risk of VTE vs. levonorgestrel
What is the difference in 3rd/4th-gen Ocs?
new progestins are less androgenic
Describe efficacy of progestin-only birth controls
less effective; associated with regular bleeding. 40% still ovulation (ectopic risk). Must be taken at same time q day
When are low-dose OC’s preferred?
1) adolescents; 2) underweight (110 lb); 3) older than 35; 4) perimenopausal
What is defined as very low dose OC?
20-25 ug EE
What is defined as low-dose OC?
less than 35 ug EE (or less than 0.5 mg norethindrone or equivalent)
What is defined as normal dose OC?
35-50 ug
What dose should not be exceeded in any patient for OC?
50 ug (VTE risk)
When is normal (35-50 ug) dosing preferred?
160+ lbs
What is first choice in OC selection?
low-dose (since all OC’s are equally effective)
When are monophasics preferred?
if easy-management is a must. Can just skip placebo to lengthen cycle
When are bi- and tri-phasics preferred?
when lessening spotting and progestin ADRs is a concern
When are extended-formulation OC’s preferred?
when dysmenorrhea or menstrual issues are present
When are progestin-only OC’s preferred?
if any of the following: 1) migraines w/ aura; 2) thromboembolic dz; 3) cerebrovascular disease; 4) SLE; 5) 35+ yo and smoker, obesity, or HTN
What are the APIs in the transdermal patch (ortho evra)?
EE + norgestimate (active metabolite = norelgestromin)
When should a transdermal patch be avoided?
1) if 198+ lbs; 2) if thromboembolic risk is a concern
Why does the transdermal patch carry a higher thromboembolic risk?
estradiol 60% higher due to first-pass avoidance
Describe application of ortho evra.
1-2x/week to ab/hip/butt for 3 weeks
What are the APIs in nuvaring?
EE + etonorgestrel
What are the advantages to nuvaring?
as effective as COC’s but lower systemic estrogen dose
Describe administration of nuvaring?
insert x 3 weeks then remove
What is the actual effectiveness of depo provera (DMPA)?
97% (better)
What is the MoA of DMPA?
suppress estradiol production to inhibit ovulation for 3 months
What are ADRs of DMPA?
1) 10-18 month delay to fertility upon cessation; 2) decreased BMD; 3) menstrual irregularities with spotting/heavy bleeding (30% in first year, 10% after, may get amenorrhea)
Describe dosing of DMPA.
150 mg DMPA IM or SQ
What are the warnings for DMPA?
don’t use longer than 2 yrs (BMD) and monitor bone density
What is the API in the implant (implanon)?
etonorgestrel
What is the dosing of the implant?
3 yr implant in skin of upper arm
What is the effectiveness of the implant?
suppresses ovulation in 97%
What are the ADRs of the implant?
irregular menstrual bleeding/spotting; BMD effect and fertility delay probable
What is the most widely used form of contraception?
IUD
What is the actual effectiveness of IUDs?
99% (paragard has slightly higher failure rate)
What is the MoA of IUDs?
1) reduce sperm motility by thickening mucous; 2) interfere with implantation; Paragard also reduces sperm viability
What are the active ingredients in IUDs?
mirena/skyla/liletta = levonorgestrel; paragard = cu ions
How long is paragard active?
10 years
How long is mirena active?
5 years
What is the dosing in mirena?
10 ug/day
What is an ADR of paragard?
PID, may increase blood flow by 35% leading to dysmenorrhea
What is an ADR of mirena?
PID, overall reduced menstrual blood flow, but may increase spotting in first year
When should progestin-only emergency contraception be used?
within 72h (89% effective); but may be effective up to 5 days
What is the MoA of progestin-only EC?
prevent ovulation and reduce sperm motility; effective in early stages of LH surge still (no effect on implantation or post-implantation)
What is the dosing of progestin-only EC?
1.5 mg levonorgestrel in 2 doses; or 1 dose in OneStep
What are ADRs of progestin-only EC?
nausea, withdrawal bleeding in 7 days, 2-3 day delay in menstruation
How is progestin-only available?
to all-age patients without rx
What is the Yuzpe regimen?
within 72h: 2 doses of 100 ug EE + 0.5 mg levonorgestrel 12h apart
When was the Yuzpe regimen approved?
1997
Describe the effectiveness of the Yuzpe regimen.
74%
What is a disadvantage to Yuzpe regimen?
worse ADRs vs. progestin only; also only 74% effective
When can a copper IUD be used for EC? What is the effectiveness?
up to 5 days post-sex (99% effective)
How does a copper IUD work for EC?
may also prevent implantation in addition to motility and viability of sperm
What are the options for EC?
1) progestin-only; 2) yuzpe; 3) anti-progestins; 4) copper IUD
What are the anti-progestins?
ulipristal (Ella) and mifepristone (off-label)
What is the MoA of anti-progestins in EC?
block ovulation; impair endometrial proliferation; embrotoxic (but probably not abortifacient at 30 mg dose w/o prostaglandin)
Describe timeframe of anti-progestin use.
60% effective if within 5 days; effective up to day of LH surge
Describe ADRs of anti-progestins in EC.
minimal - ab pain, menstrual irregularity
Describe metabolism of anti-progestins.
3A4 (do not use in severe liver disease)
What are the sxs of estrogen excess?
nausea, breast tenderness, HA, fluid retention
what are the sxs of estrogen deficiency?
breakthrough bleeding, amenorrhea, vasomotor sxs, anxiety, decreased libido
What are the sxs of progestin excess?
appetite, weight gain, bloating, acne, oily skin, hirsuitism, depression, fatigue, irritability
What are the sxs of progestin deficiency?
dysmenorrhea, late-cycle breakthrough bleeding/spotting
Solution to excess estrogen:
decrease E dose, use progestin-only, use IUD
Solution to estrogen deficiency:
increase E dose
Solution to progestin excess:
decrease P dose or use less-androgenic progestin
Solution to progestin deficiency:
increase P dose, use extendend-cycle/continuous regimen, progestin-only, or IUD
How do CHCs differ?
1) estrogenic effects (metabolism); 2) androgenic effects (direct and indirect -SHBG)
Function of progestins in CHCs
most of effect: 1) block LH surge; 2) inhibit ovulation; 3) thicken mucous; 4) induce endometrial atrophy
Function of estrogens in CHCs:
1) suppress LH, 2) prevent LH surge, 3) stabilize endometrium
How does mestranol compare to EE?
50% less potent but converted to EE in liver
What are the non-contraceptive benefits of CHCs?
these effects persist after discontinuation.. 1) reduce dysmenorrhea and acne; 2) reduce risk of ovarian/endometrial cancer, 3) reduce risk of ovarian cysts, PID
