CH4: Gynecologic, Reproductive/Sexual, Menopause Flashcards
What is the inframammary ridge
firm transverse ridge of compressed tissue which may be present along the lower edge of the breast(s)
What is a breast lobe
section of breast composed of glandular tissue and surrounded by the fatty and connective tissues of the breast. There are 15-20 lobes in each breast. Each lobe empties into a single lactiferous duct that opens out through the nipple
What is a breast lobule
These are small branching glands within each lobe that contain tiny, hollow sacs called alveoli which are responsible for milk production
What are the breast Montgomery’s glands
sebaceous glands that circle the nipple, located in the areola
Perineal muscle that surrounds the vagina and acts as a weak sphincter
bulbocavernosus
Perineal muscle that surrounds the clitoris and is responsible for clitoral erection
Ischiovernosus
Perineal muscles that converge with the urethral sphincter
superficial and deep transverse perineal muscles
Perineal muscle that surrounds the anus
External anal sphincter
(3) muscle components of the pelvic floor levator ani
pubococcygeus, iliococcygeus, puborectalis
(4) bones of the pelvis
two innominate bones (hip bones), sacrum, coccyx
(3) components of the innominate bones that make up the pelvis
ilium, ischium, pubis
What is the mons pubis
Fatty tissue prominence overlying the symphysis pubis, often covered by coarse hair
What are the name of the glands on each side of the urethral meatus
Skene’s glands
What are the name of the glands with openings posteriorly on each side of the vaginal orifice
Bartholin’s glands
Approximate size dimensions of the vagina
7cm anterior and 10cm posterior in length
What cell type lines the vagina
stratified squamous epithelium
What are rugae
transverse folds in the vaginal sidewall that allow for distention during coitus and childbirth
Why is the vaginal pH normally acidic
prevalence of lactobacilli
Approximate size dimensions of the cervix
2-3cm in diameter and 2.5cm in length
What are the translucent nodules sometimes found on cervixes called
nabothian cyst - no pathologic significance
Expected change to the cervical os after childbirth
change from a round O to larger and slit-like
What is the squamocolumnar junction
juncture of the squamous epithelium covering the ectocervix with the columnar epithelium of the endocervix
Broad band of columnar epithelium surrounding the external os, more common in puberty or in folks on OCPs, is called…
ectropion
What is the process by which columnar cells of the endocervix are replaced by mature squamous epithelium
squamous metaplasia
Approximate size dimensions of the uterus
8cm in length, 5cm in width, 2.5cm in thickness
What type of cells lines the uterus and the endocervix
columnar epithelium
Estrogen, progesterone, and androgens are types of ________ hormones
steroid
Approximate size dimensions of the ovaries
3cm x 2cm x 1cm
Gonadotropin-releasing hormone (GnRH) is released from the…..
hypothalamus
What are the 2 gonadotropins
follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
Where are FSH and LH released from
anterior pituitary
What is the negative HPO-axis feedback loop?
rising E and P –> E/P reaches above set point –> hypothalamus decreases GnRH –> anterior pituitary decreases FSH/LH secretion –> decreasing E and P levels from ovaries –> E/P reaches below set point –> hypothalamus increases GnRH secretion –> anterior pituitary increases FSH/LH secretion –> rising E and P
What is the positive HPO-axis feedback loop?
E reaches a certain peak just before ovulation –> hypothalamus increases GnRH secretion –> FSH and LH from the anterior pituitary surge –> mature ovum is released from the ovary
(3) types of estrogen
estradiol (E2), estrone (E1), estriol (E3)
What are prostaglandins
A group of lipid compounds derived from fatty acids at different sites in the body via enzymatic actions that act at target sites near their area of secretion. In the uterus, they regulate contraction and relaxation of smooth muscle
Where is sex hormone binding globulin (SHBG) produced
liver
What is the role of SHBG
a serum protein made in the liver that binds to estrogens and androgens in the blood, carrying them through general circulation so they can reach their target tissues in the body
(3) factors that increase amount of SHBG
hyperthyroidism, pregnancy, OCPs that contain estrogen
(3) factors that decrease amount of SHBG
obesity, hyperinsulinemia, androgens
Where is prolactin secreted from
anterior pituitary
What is the role of prolactin
Stimulates the synthesis of milk proteins in mammary tissue and epithelial growth in the breast during pregnancy
Which estrogen is the most potent and plentiful in the reproductive years
estradiol
Which estrogen is the major source of estrogen after menopause
estrone
Which estrogen is the least potent and the major source during pregnancy
estriol
Where is estrogen produced in the body?
Primarily ovaries. Also, adrenal cortex, peripheral conversion of androgens in adipose tissues, and the placenta during pregnancy
What are the main functions of estrogen? (6)
Maturation of the reproductive organs
Development of secondary sex characteristics
Closure of long bones
Regulation of menstrual cycle
Maternal physiologic adaptations of pregnancy
Metabolic effects on several other organs
Where is progesterone produced in the body?
Primarily, ovaries. Also, corpus luteum and adrenal cortex
Where are androgens produced in the body?
Ovaries, adrenal cortex
What are the main functions of progesterone? (3)
Contributes to mammary gland development
Regulation of menstrual cycle
Maternal physiologic adaptations of pregnancy
Where is testosterone produced in the female body?
ovaries, adrenal cortex, and through peripheral conversion in adipose tissues
What are the main functions of testosterone in the female body? (3)
Precursor to synthesis of estradiol
Contribute to long bone growth
Growth of pubic and axillary hair
What is androstenedione?
A weak androgen that serves as a precursor for estrogen synthesis that is produced by the ovaries and adrenal cortex
What is activin?
Produced by the ovaries and anterior pituitary gland, this hormone stimulates FSH secretion
What is inhibin?
Produced by the ovaries, this hormone inhibits FSH secretion by binding to activin
What is follistatin?
Produced by the ovaries and anterior pituitary, this hormone inhibits FSH by binding to activin
What is Anti-Mullerian Hormone?
Produced by ovarian follicles, this hormone plays a role in the selective recruitment of follicles that will continue to grow and develop by inhibiting FSH-dependent follicular growth of the primordial follicles. Expect to be elevated in PCOS
What is insulin-like growth factor?
Produced by the liver and ovaries, this hormone is involved in growth and differentiation of tissues in response to growth hormones, and promotes steroidogenesis by stimulating increase in size and number of FSH and LH receptors.
Typical age of puberty onset in females
9yo
Onset of breast development is called…
thelarche
Onset of pubic and axillary hair development is called….
adrenarche
Average age and timing of menarche
average age of 12.5, typically follows peak height velocity
Scale used to assess the progressive sexual maturity changes during puberty
Tanner stages
Definition of “delayed onset of puberty”
No breast growth by age 14yo, or no skeletal growth spurt by age 15yo. Usually a normal variant and catch-up occurs
Definition of “precocious puberty”
Thelarche or adrenarche before age 7yo in Caucasian females and 6yo in African American females - evaluate for congenital or neoplastic causes, however 75% are ideopathic
Average timing, duration, and blood loss during menstrual cycle
28 day cycle (+/-2 days), 4-6 days of bleeding (+/- 2 days), 40cc volume of blood loss
Describe the follicular phase of the menstrual cycle
Begins on Day 1 of the menstrual cycle and is variable in length. E and P levels are low from the end of the last cycle. Sensing low E/P levels, the hypothalamus increases GnRH which stimulates the anterior pituitary to release FSH and LH. FSH in particular stimulates ovarian follicular development, and the maturing follicles produce higher and higher levels of Estrogen. The dominant follicle emerges because it has the highest level of Estrogen Receptors. As the dominant follicle begins producing high levels of E2, the LH surge begins to initiate ovulation
Describe the ovulation phase of the menstrual cycle
After the LH surge, prostaglandins and proteolytic enzymes break down the follicular wall and ruptures the dominant ovarian follicle, releasing an egg (oocyte). The oocyte can be fertilized for 12-24 hours after being released
The oocyte can be fertilized for ________ after being released
12-24 hours
LH surge peaks _________ before ovulation occurs
10-12 hours
Describe the luteal phase of the menstrual cycle
Begins after ovulation occurs and lasts for approximately 14 days (+/- 2 days). The corpus luteum forms from the ruptured follicle and produces high levels of progesterone, which peaks 7-8 days after ovulation. The corpus luteum also produces moderate amounts of estrogen. If a pregnancy does not occur, then the corpus luteum regresses and levels of both E and P will drop, triggering shedding of the endometrial lining called menses.
What are the (3) phases of the ovarian menstrual cycle
follicular, ovulation, luteal
What are the (3) phases of the uterine menstrual cycle
menstruation, proliferative, secretory
Describe the proliferative phase of the menstrual cycle
The endometrium grows and thickens under the influence of ESTROGEN. Lasts from the end of bleeding (menses) until ovulation (~10 days)
Describe the secretory phase of the menstrual cycle
After the proliferative phase, the endometrium hypertrophies and becomes more vascularized under the influence of PROGESTERONE from the oocyte’s corpus luteum. This creates a favorable environment for possible implantation. This lasts, on average, 12-16 days
Describe the menstrual phase of the menstrual cycle
After the secretory phase and implantation has not occurred, the corpus luteum regresses. Under the influence of declining E/P, the endometrium undergoes involution, necrosis, and sloughing which causes bleeding. Typically lasts 3-6 days
Expected characteristics of cervical mucus at ovulation
Abundant, highly elastic, thin, clear (under the influence of high estrogen) – clinically, can stretch between thumb and forefingers (spinnbarkeit). Will cause ferning appearance under microscope
Use of basal body temperature in detecting ovulation
BBT is the temperature of the body at rest. It is lowest in the follicular phase and peaks AFTER ovulation under the influence of progesterone. It will remain elevated until 2-4 days before menses
ROUTINE screening pelvic and breast exams are not recommended before age…..
21yo
What are the ACS, ACOG, and USPSTF differences in recommendations for routine clinical breast exams
ACS & USPSTF do NOT recommend for those at average risk of breast cancer. ACOG recommends offering Q1-3 years ages 25-39, and annually >40
What is the basic pap test schedule for patients age 21-29yo
cytology alone Q3 years
What is the recommendation regarding patient self-breast exams
20yo and older, educate about breast self-awareness but it is no longer recommended to teach routine, systematic breast self-exams for any age group
What is the basic pap test schedule for patients age 30-65yo, per ACS, ACOG, and USPSTF
ACS & ACOG: Preferred is co-testing Q5 years; acceptable alternative is cytology alone Q3 years
USPSTF: Option for HPV alone Q5 years
What are the ACS, ACOG, and USPSTF differences in recommendations for mammography screening
ACS: Acceptable to begin earlier at ages 40-44 otherwise offer yearly at 45yo, 55yo+ can continue annual or choose biennial
ACOG: Offer starting at age 40 but acceptable to initiate anywhere from 40 - 49, annual or biennial is acceptable
USPSTF: Biennial screening ages 50-74yo
% of couples having unprotected coitus who will get pregnant by 3, 6, 12, and 24 months
3 months = 57%
6 months = 72%
12 months = 85%
24 months = 93%
Definition of infertility
inability to conceive after 1 year of unprotected coitus ages <35yo, if 35 or older is after 6 months
Estimated infertility rate in the US of females
6-15%
Healthy sperm can survive in female reproductive tract and retain ability to fertilize an egg for ______
3-5 days
% of infertility that is female-factor, male-factor, and unexplained
female factor 25-50%
male factor 25-50%
combined 30%
unexplained 10-25%
Female infertility factors (8)
anovulation, luteal-phase insufficiency, poor ovarian reserve, inadequate cervical mucus, uterine anomalies, surgical adhesions, tubal occlusion, endometriosis
Male infertility factors (10)
low testosterone (hypogonadism), varicocele, toxin exposures (radiation, chemicals, drugs), chronic overheating of testicles, mumps orchitis (testicular inflammation), adhesions, hypospadias, phimosis, retrograde ejaculation, erectile dysfunction
Penile phimosis
tight foreskin that cannot be retracted which can be congenital or a result of recurrent infections
Penile hypospadias
congenital defect in which the urethral meatus is located on the ventral surface of the glans, penile shaft, or perineal area
Varicocele
Abnormal dilation of the peri-testicular veins resulting in varicose veins in the spermatic cord
What (2) tests in the infertility work-up determine ovarian reserve
AMH level (serum) and antral follicle count (US)
Basic laboratory and diagnostics work-up for infertility
HOME: basal body temperature, ovulation prediction kits
LABS: AMH, FSH, LH, estradiol (E2), progesterone, TSH, prolactin, STI screening, semen analysis
IMAGING: pelvic US (for uterine anomalies, antral follicle count, and persistent ovarian cyst), & hysterosalpingogram (for tubal patency, shape of uterine cavity)
How do you manage ovulatory dysfunction as cause of female factor infertility
ovulation induction with clomiphene citrate or letrozole
How do you manage luteal-phase defect as cause of female factor infertility
vaginal or IM progesterone
What is IVF and its success rate
In vitro fertilization is the most common assisted reproductive technology used and has a 15-20% success rate overall. Oocytes are extracted, fertilized in a laboratory, and then transferred through the cervix into the uterus
What is gamete intrafallopian transfer (GIFT)
Placement of oocytes and sperm directly into the fallopian tube, carries a 25% success rate
What is zygote intrafallopian transfer (ZIFT)
Placement of a fertilized oocyte (zygote) into the fallopian tube, carries an 18-20% success rate
What are the only contraceptive options that have <1 pregnancy per 100 users per year with TYPICAL use (3)
progestin-only implant, IUD, sterilization
Examples of common inducers of CYP450 which may lessen the effectiveness of OCPs due to rapid clearance
rifampin, some anticonvulsants, some antiretrovirals and TB medications, griseofulvin (antifungal), St. John’s wort
What is the only birth control method that is not affected in efficacy by concomitant use of CYP450 inducer medications (like anticonvulsants), excepting sterilization?
DMPA (Depo Provera)
What does DMPA stand for
Depot medroxyprogesterone acetate
If you use the “quick start” method for switching between contraceptive medications, do you need back-up contraception?
Yes - follow backup contraception instructions for the new method just as if you had not used the quick start method (~7 days)
How long after taking ulepristal acetate for emergency contraception should you wait before starting a new method of birth control?
ideally, do not start a new hormonal method any sooner than 5 days after taking ulepristal acetate because of concern that it may decrease its efficacy; abstinence or condoms are recommended
Categories 1-4 from the CDC on eligibility for a contraceptive method
Category 1 = no restriction on use
Category 2 = advantages of using the method generally outweigh the theoretical or proven risks
Category 3 = The theoretical or proven risks generally outweigh the advantages (relative contraindication - refer to OB/GYN physician)
Category 4 = unacceptable risk (absolute contraindication)
How long is the copper-releasing IUD effective for?
10 years
How long are the (4) types of hormonal IUDs effective for?
Skyla = 3 years Liletta = 5 years Kyleena = 5 years Mirena = 5 years
MOA copper-releasing IUD
Inhibits sperm capacitation, alters tubal and uterine transport of the ovum, has an enzymatic influence on the endometrium
MOA LNG-IUDs
thickens cervical mucus, produces an atrophic endometrium unfavorable to implantation, slows ovum transport through the tube, inhibits sperm motility and function
Effectiveness of the IUDs, typical use
Copper - 0.8%
LNG - 0.2%
IUD in the postpartum period?
Can be used during lactation and placed immediately postpartum. Specifically, place within 48 hours of delivery or wait 4 weeks postpartum because placement after 48 hours and before 4 weeks is associated with increased risk for uterine perforation
copper-releasing IUD can increase _______ and _______ during menses
blood loss, dysmenorrhea (pain)
What is likely to happen to bleeding and dysmenorrhea with LNG-IUDs
irregular bleeding and spotting for the first 3-6 months of use followed by absence or decrease in bleeding and decrease in dysmenorrhea
The risk of PID is increased for the first _______ after IUD insertion
20 days
Category 4 (Absolute Contraindications) for IUD initiation
- known or suspected pregnancy
- postpartum or post-abortion sepsis
- unexplained vaginal bleeding
- cervical cancer awaiting treatment
- breast cancer within previous 5 years (except for copper)
- uterine anatomic abnormalities that may distort the cavity
- current PID, G/C, or purulent cervicitis
- endometrial cancer
- rare: pelvic TB or gestational trophoblastic disease
Category 3 (Relative Contraindications) for IUD initiation
- ischemic heart disease (except for copper)
- h/o breast cancer >5 years ago (except for copper)
- high risk for GC STIs
- HIV-AIDS unless clinically well on ART
- liver disease
- lupus (except for copper)
- rare: solid organ transplant with complications, pelvic TB
How long should the uterus sound for best placement of the IUDs
6-9cm
How short should you trim the IUD threads after insertion
3-4cm
What type of follow-up is required after placement of an IUD
Advise to return an time to discuss side effects, problems, desire to change method – otherwise, no routine follow-up is required until it is time to remove or replace method
Do you need back-up protection after placement of an IUD?
LNG - yes, 7 days
Copper - no
Severe cramping or pain after IUD placement, rule out…. (3)
perforation, infection, pregnancy
Rate of IUD expulsion in first year
2-10%
Management of IUD expulsion
remove, rule out pregnancy or infection, replace if desired, and rx doxycycline for 5-7 days
How common is uterine perforation after IUD placement
1 in 1,000 insertions
What do you need to do if someone gets PID with an IUD in place
Treat PID with appropriate antibiotics. There is no evidence to support preventive antibiotics with IUD placement. Also, there is no need to remove the IUD after PID diagnosed unless they have no clinical improvement within 48-72 hours of antibiotic initiation
How long does the progestin-only implant (Nexplanon) work for
3 years
What type of progesterone is in the IUD and in the arm plant
IUD = levonorgestrel
arm implant = etonogestrel
MOA of Nexplanon / progestin arm implant
suppresses LH and thus ovulation in almost all users, produces an atrophic endometrium, and thickens cervical mucus
Effectiveness of the Nexplanon arm implant, perfect AND typical use
0.05%
Does obesity reduce the efficacy of Nexplanon?
“cumulative evidence supports that obesity does not reduce efficacy”
Most users of Nexplanon arm implant ovulate within ____ of removal
6 weeks
Nexplanon arm implant in the postpartum period?
Can be used during lactation and immediately postpartum
Expected bleeding and dysmenorrhea patterns after Nexplanon arm implant insertion
Overall, reduced pain and dysmenorrhea. Pain and bruising is common at the insertion site. Bleeding patterns are likely to become irregular, prolonged, and more frequent in the first few months of use although may become amenorrheic eventually
Category 4 (Absolute Contraindication) for Nexplanon arm implant use
breast cancer within past 5 years
Category 3 (Relative Contraindications) for Nexplanon arm implant use
ischemic heart disease or stroke unexplained vaginal bleeding h/o breast cancer >5 years ago liver disease lupus
What follow-up is needed after insertion of Nexplanon arm implant?
Advise can return at any time to discuss side effects or problems - otherwise, no routine follow-up is required until removal or replacement in 3 years
Do you need back-up contraception after placement of the Nexplanon arm implant?
Not if inserted on days 1-5 of menses; otherwise, use back-up for 7 days
What is the MOA of the estrogen component of oral contraceptive pills?
inhibits ovulation through the suppression of FSH, stabilizes the endometrium for less unscheduled bleeding and spotting
What is the most common type of synthetic estrogen used in OCPs?
ethinyl estradiol
What is the MOA of the progesterone component of oral contraceptive pills?
the progesterone provides most of the contraceptive effect – inhibits ovulation through inhibition of the LH surge, inhibits sperm penetration by thickening cervical mucus
Characteristics of first generation progesterones (3) and common example (1)
norethindrone
- lowest potency
- shortest half-life
- lower doses are more likely to have unscheduled bleeding and spotting
Characteristics of second generation progesterones (4) and common examples (2)
norgestrel, levonorgestrel
- more potent
- longer half-life
- less unscheduled bleeding and spotting (d/t longer half life)
- more androgen-related side effects
Characteristics of third generation progesterone (1) and common example (1)
norgestimate
- maintains the potency of second gen with less androgenic side effects
Characteristics of fourth generation progesterones (1) and common example (1)
drospirenone
- antiandrogenic properties
Effectiveness of OCPs, perfect and typical use
perfect = 0.3% typical = 9%
OCPs reduce lifetime risk of (3) cancers
ovarian, endometrial, colorectal
Antibiotics and OCP use - counseling
Most broad-spectrum antibiotics do NOT lower hormone levels or affect efficacy (ampicillin, metronidazole, doxycycline, fluconazole). There are a few that do induce CYP450 and thus MAY decrease COC effectiveness (rifampin, griseofulvin)
Which (2) antibiotics are most implicated in reducing OCP efficacy
rifampin, griseofulvin
Which (4) anti-convulsants do NOT affect OCP efficacy
gabapentin, pregabalin (Lyrica), clonazepam, valproic acid
Estrogenic side effects of OCPs
nausea, breast tenderness, chloasma, telangiectasias, cervical ectropion, increased BP, blood clots, migraine headache, increased triglycerides & cholesterol concentration in gallbladder bile, hepatocellular adenoma
Progestogenic side effects of OCPs
breast tenderness, fatigue, depressive symptoms, increased insulin resistance, constipation, bloating, gall stones, cyclic weight gain
Androgenic side effects of OCPs
weight gain, hirsutism, acne, increased LDL cholesterol
Category 4 (Absolute Contraindications) to combined OCPs
- > 35yo and heavy cigarette smoker (>15 cigs/day)
- multiple risk factors for CVD
- ischemic heart disease, h/o stroke, valvular heart dz
- uncontrolled hypertension
- acute DVT or PE
- major surgery with prolonged immobilization
- clotting disorder
- migraine with aura
- breast cancer within last 5 years
- diabetes >20 years duration or with complications
- liver disease
- SLE lupus
- solid organ transplant with complications
- peripartum cardiomyopathy ( severe or <6 months pp)
- <21 days postpartum
combination OCPs in the postpartum period?
absolutely contraindicated within 21 days postpartum or with peripartum cardiomyopathy. Otherwise, relative contraindications for …
- 21-42 days pp with other VTE risk factors
- 21-30 days pp and breastfeeding without known VTE risk factors
- 30-42 days pp and breastfeeding WITH VTE risk factors
Category 3 (Relative Contraindications) for combined OCPs
- > 35yo and light cigarette smoking (<15 cigs/day)
- h/o hypertension that is adequately-controlled or less than 160/100
- HLD
- h/o breast cancer NED >5 years
- symptomatic gallbladder disease
- mild liver cirrhosis
- h/o bariatric surgery (malabsorptive)
- h/o DVT or PE with no risk factors for recurrence (provoked)
- moderate to severe IBD with associated risk for clot
- within 21 - 42 days postpartum with any risk factors for VTE and/or breast feeding
- peripartum cardiomyopathy (>6 months or non-severe)
What type of follow-up is required after initiating OCPs?
Advise to return an time to discuss side effects, problems, desire to change method – otherwise, no routine follow-up is required
Is a physical or pelvic exam required prior to starting OCPs?
No (as long as BP is known)
OCPs and St Johns Wort
St Johns Wort is a CYP450 inducer and may increase hepatic metabolism of OCPs, lessening their effectiveness
Weight loss medications and OCPs
Orlistat blocks fat absorption - may reduce intestinal absorption of OCPs as well as induce diarrhea
Drug interactions with OCPs, Patch, and Ring that may reduce OCP efficacy, generally (5)
- anticonvulsants
- antibiotics
- antiretrovirals
- Orlistat
- St Johns Wort
Drug interactions with OCPs, Patch, and Ring whereby the OCP may potentiate the effect of these drugs, generally (3)
- benzodiazepines
- TCAs
- theophylline
OCPs that contain ________ progesterone, specifically, may cause hyperkalemia in combination with these drugs (5) - monitor potassium after first cycle of OCP
drospirenone
- ACEs/ARBs
- potassium-sparing diuretic
- heparin
- aldosterone antagonist
- NSAIDs (chronic daily use)
Unscheduled bleeding/spotting with OCP initiation – initial counseling (2)
reassurance (common side effect in first 3 months, should decrease over time), reinforce taking pills at the same time of day
Pt experiences spotting/bleeding before they finish their active OCPs - what pharmacological strategy may be helpful?
increase the progestin content for more endometrial support
Pt experiences continued spotting/bleeding after their OCP placebos are finished - what pharmacological strategy may be helpful?
increase estrogen content of first pills in the pack OR decrease progestin content of first pills for more estrogen to proliferate endometrium
Pt is taking OCPs continuously and experiences unscheduled bleeding/spotting - what pharmacological strategy may be helpful?
Take at least 21 active pills, then 3-4 days off for withdrawal bleed to start, then restart the active pills
Pt has been taking OCPs for several years and this year has stopped getting a withdrawal bleed. Pregnancy is ruled out and reassurance is provided. However, they would prefer to keep a monthly period. What pharmacological strategy may be helpful?
If on 20mcg estrogen formulation, may increase to 30 or 35mcg. Or try a triphasic formulation with lower progestin levels in the early pill
Pt starts OCPs today, her LMP was >5 days ago, do they need to use back-up method?
Yes, back-up protection for 7 days
Pt starts OCPs today, first few days of her menstrual period. Do they need to use back-up method?
No
Pt experiences nausea when taking OCPs, what initial recommendation?
Take pills with meals or at bedtime
Warning signs with OCPs use - ACHES mnemonic
Abdominal pain (sever) Chest pain Headache Eye problems (blurry vision, scotoma) Severe leg pain (thigh or calf - DVT)
Pt is taking OCPs for contraception. They call the office reporting they missed one pill - they take it every morning at 7am and it is now 7pm of the same day. They just had unprotected sex and is concerned about pregnancy risk.
Take the late pill now/ASAP. Continue taking the remaining pills at the usual time. No back-up contraception is needed. Emergency contraception is not usually needed but may consider if have missed any other pills this cycle or in the last week of their previous cycle
Pt is taking OCPs for contraception. They called the office reporting they missed yesterday’s pill - they take it every morning at 7am and it is now 7am of the following day, and they are wondering what to do. They had unprotected sex last night and are concerned about pregnancy risk
Take the late pill now/ASAP, even if it means taking two pills today (this morning’s and yesterday’s). No back-up contraception is needed. Emergency contraception is not usually needed but may consider if have missed any other pills this cycle or in the last week of their previous cycle
Pt is taking OCPs for contraception. They called the office reporting that they missed 2 pills - they take it every morning at at 7am, today is Wednesday and they missed their morning dose on Monday and Tuesday. They had unprotected sex last night and are concerned about pregnancy risk
Take the most recent missed pill (yesterday’s) as soon as possible and the remaining pills on schedule (so 2 doses today - yesterdays’ pill and today’s pill). Discard the other missed pill (Monday’s). Use back-up protection or avoid intercourse until hormonal pills have been taken for 7 consecutive days. If they are in their last week of pills and do not have 7 consecutive left this cycle, then omit the hormone-free placebo week and start a new pack. Emergency contraception should be considered, especially if hormonal pills that were missed were in the first week of that pill pack.
Pt is taking OCPs for contraception. They called the office reporting that they missed 4 pills - they take it every morning at 7am, today is Friday and they missed doses on Monday-Thursday. They had unprotected sex last night and are concerned about pregnancy risk
Take the most recent missed pill (yesterday’s) as soon as possible and the remaining pills on schedule (so 2 doses today - yesterdays’ pill and today’s pill). Discard the other missed pills (Mondays, Tuesdays, Wednesdays). Use back-up protection or avoid intercourse until hormonal pills have been taken for 7 consecutive days. If they are in their last week of pills and do not have 7 consecutive left this cycle, then omit the hormone-free placebo week and start a new pack. Emergency contraception should be considered, especially if hormonal pills that were missed were in the first week of that pill pack.
What types of estrogen and progesterone are in the transdermal contraceptive patch?
norelgestromin, ethinyl estradiol
What is the schedule for use of the transdermal contraceptive patch?
Apply a new patch every week x 3 weeks, followed by 1 week withdrawal bleed (or continuous). Alternate patch placement sites
MOA of the transdermal contraceptive patch
same as combined OCPs
Perfect and typical use failure rates for the transdermal contraceptive patch
Perfect use - 0.3%
Typical - 9%
Contraindications to transdermal contraceptive patch
same as for combined OCPs with the exception of bariatric surgery is not relevant
Which contraceptive option is known to be less effective for folks who weigh >198lbs
transdermal patch
Where can the transdermal contraceptive patch be applied
buttocks, abdomen, upper torso front or back (excluding breasts), upper outer arm. Alternate patch placement sites
Do you need back-up contraception after starting the contraceptive transdermal patch?
If in first 5 days of period - no
If >5 days since LMP - yes, for 7 days
(same as the combined OCPs)
What type of estrogen and progesterone is in the NuvaRing (contraceptive vaginal ring)
etonogestrel, ethinyl estradiol
What is the schedule for use of the NuvaRing (contraceptive vaginal ring)
worn in the vagina x3 weeks, take out for 1 week withdrawal bleed (or continuous - then replace 4 weeks)
Perfect and typical use failure rates for the NuvaRing (contraceptive vaginal ring)
Perfect use - 0.3%
Typical use - 9%
Contraindications to NuvaRing & Annovera (contraceptive vaginal rings)
same as for combined OCPs with the exception of bariatric surgery is not relevant
Do you need back-up contraception after starting the NuvaRing & Annovera (contraceptive vaginal rings)?
If in first 5 days of period - no
If >5 days since LMP - yes, for 7 days
(same as the combined OCPs)
Pt is using NuvaRing for contraception. They accidentally left the ring in for 6 weeks without remembering to change it. They had unprotected intercourse yesterday and are concerned about risk for pregnancy
If ring is left in vagina for longer than 4 weeks, it may not protect from pregnancy; use a back-up method until the new ring has been in place for 7 days. Consider emergency contraception
Pt is using transdermal patch for contraception. The patch fell off <48 hours ago and they are wondering what they need to do
Apply a new patch as soon as possible, if <24 hours may try either a new patch or the old one to reapply. Maintain the same patch-replace schedule. No back-up contraception is needed. Emergency contraception is generally not needed but may be considered if detachment occurred earlier in the cycle or in the last week of the previous cycle
Back-up protection is not needed if less than ______ combined OCP pills are missed
less than 2
Back-up protection is not needed if the contraceptive patch falls off and is replaced within ____________
48 hours
Back-up protection is not needed if reinsertion of the NuvaRing occurs within _________
48 hours
Pt is using transdermal patch for contraception. The patch fell off and they have only just noticed 3 days later. They are wondering about pregnancy risk and what to do
Apply a new patch as soon as possible. Since it was longer than >48 hours without a patch on, use back-up contraception until a new patch has been worn for at least 7 consecutive days. If the delayed application happened in the third week of patch use (before scheduled withdrawal bleed), omit the hormone-free week by finishing the third week patch use and starting a new patch immediately, again using back-up protection until a new patch has been applied for at least 7 days. Emergency contraception should be considered if delayed application occurred within the first week of patch use and unprotected intercourse happened in the last 5 days, or at other times of the cycle as appropriate.
Pt is using NuvaRing for contraception. They took the ring out for intercourse and forgot to replace it afterwards, which was now 24 hours ago. They are wondering about pregnancy risk and what to do
Insert the ring as soon as possible. Since the ring was only left out for <48 hours, no back-up contraception is needed. Emergency contraception is not usually needed but could be considered if this delayed reinsertion occurred earlier in the cycle. (*** WEBSITE SAYS BACK UP NEEDED FOR 7 DAYS IF OUT >3 HOURS)
Pt is using NuvaRing for contraception. They took the ring out for intercourse and forgot to replace it afterwards, which was now 3 days ago. They are wondering about pregnancy risk and what to do
Insert the ring as soon as possible. Since the ring was out >48 hours, back-up contraception is needed until the new ring has been in for 7 consecutive days. If delayed reinsertion occurred in the third week of the cycle, skip withdrawal bleed and replace with a new ring; otherwise will continue to need back-up contraception until a ring has been in place for 7 consecutive days. Emergency contraception should be considered if the delayed insertion occurred within the first week of the cycle and unprotected intercourse happened in the last 5 days, or at other times as appropriate. (*** WEBSITE SAYS BACK UP NEEDED FOR 7 DAYS IF OUT >3 HOURS)
(2) contraceptive vaginal ring options
NuvaRing, Annovera
What is the difference between NuvaRing and Annovera
Annovera is newer - same diameter as NuvaRing but twice as thick. Different type of progestin is used and one Annovera ring is used for a full year (13 28-day cycles)
What type of estrogen and progesterone is in Annovera (vaginal contraceptive ring)
segesterone acetate, ethinyl estradiol
What is the schedule of use for Annovera (vaginal contraceptive ring)
One ring is used for 13 28-day cycles. Insert the ring, leave in place for 21 days, then remove for 7 days to have a withdrawal bleed. Then, reinsert the same ring No continuous cycling option
Failure rate of Annovera in terms of perfect and typical use
perfect use - 3.0%
typical use - not available
MOA of NuvaRing and Annovera (vaginal contraceptive rings)
same as combined OCPs
Care and keeping of the re-useable Annovera vaginal contraceptive ring
Clean with mild soap and water, pat dry, and place in provided case during the 1 week dose-free interval
MOA for progestin-only OCPs
thickens cervical mucus, produces an atrophic endometrium, inconsistently/variably inhibits ovulation
Failure rates for progestin-only OCPs in terms of perfect and typical use
perfect use - 0.3%
typical use - 9%
Progestin-only OCPs postpartum?
Can be used immediately postpartum and during lactation/breastfeeding
Why is it SO important to take the progestin-only OCPs at the same time every day?
Serum progesterone levels peak shortly after taking the pill, then decline to nearly undetectable levels 24 hours later. Each pill only provides 24 hours of protection
Side effects of progestin-only OCPs
increased ovarian cysts, menstrual cycle irregularities, mastalgia, depression
Category 4 (Absolute Contraindications) for use of progestin-only OCPs (1)
breast cancer within the last 5 years
Category 3 (Relative Contraindications) for use of progestin-only OCPs (6)
- h/o breast cancer NED >5 years
- liver disease
- bariatric surgery with malabsorptive procedure
- ischemic heart disease or a stroke WHILE taking a progestin-only pill
- SLE lupus
- concomitant use of some medications: ART therapy, some anticonvulsants, rifampin antibiotic
Schedule of use for progestin-only OCPs
take one pill at the same time each day, every day - no placebo or off-week
What are the progesterone-only contraceptive options?
LNG-IUDs, injection (depo provera), progestin-only pills
Route of administration: DMPA
IM - deltoid or gluteal muscle
SQ - anterior thigh or abdominal wall
Schedule of dosing for DMPA contraceptive injection
Q3 months
MOA of DMPA contraceptive injection
inhibits ovulation through the suppression of LH/FSH, produces an atrophic endometrium, thickens cervical mucus
Which of the birth control options inhibit ovulation
DMPA: yes Combined OCPs: yes Patch: yes Ring: yes Arm Implant: yes - in almost all users
Copper IUD: no
LNG-IUDs: no, possibly variably
Progestin-only pills: possibly variably
Failure rates for DMPA contraceptive injection in terms of perfect and typical use
perfect use - 0.2%
typical use - 6%
Drug interactions with DMPA contraceptive injection
minimal! the only known interaction is aminoglutheimide, a drug to treat Cushing’s disease
% of folks who lose their period on DMPA
50% by 1 year, 70% by end of 2nd year
DMPA and postpartum?
Can be used immediately postpartum and during lactation and breastfeeding
Benefits of DMPA is that it may reduce risk of (5)
- intravascular sickling in sickle cell disease
- incidence of seizures in folks with seizure disorder
- pain from endometriosis (SC formulation)
- risk for PID
- risk of endometrial cancer
Side effects & disadvantages of DMPA
- WEIGHT GAIN (av. 5 lbs in 1 year, 14 lbs after 4 years)
- amenorrhea (50% in 1 year, 70% in 2)
- irregular bleeding
- mastalgia
- depression
- decreased bone density with long term use (>5 years)
- increase in LDL and total cholesterol, decrease in HDL
- delayed return to fertility
Expected weight gain with DMPA use
5lbs in year one, 14lbs after 4 years of use
How long is DMPA use recommended for and what is the limiting factor?
Up to 5 years of use given its propensity for decreasing bone density with >5 years of use (returns to normal after discontinuation)
Expected return to fertility after DMPA use
3 months, in some individuals 6-12 months
Category 4 (Absolute Contraindications) for DMPA use (1)
breast cancer within the last 5 years
Category 3 (Relative Contraindications) for DMPA use
- multiple risk factors for CVD
- uncontrolled HTN and/or vascular disease
- H/o ischemic heart disease or stroke
- H/o breast cancer NED >5 years
- unexplained vaginal bleeding
- diabetes >20 years in duration and/or with complications
- liver disease
- SLE lupus
- Rheumatoid arthritis or long-term corticosteroid therapy due to risk for fractures/bone loss
Do you need back-up protection when initiating DMPA birth control?
within 5 days since LMP - no
>5 days since LMP - yes, back-up for 7 days
DMPA injection can be given up to ______ late from last injection without needing additional back-up protection
2 weeks late (up to 15 weeks from last injection)
Pt is using DMPA injection for birth control. She was on vacation and so the earliest she could come for her next appointment was 16 weeks since last injection. She is wondering what to do and if she is at risk for pregnancy
Since she is more than 2 weeks late (>15 weeks since last injection), give the next injection ASAP if reasonably certain she is not pregnant and use back-up method for protection until 7 days after next injection is given. Consider use of emergency contraception as appropriate
(4) emergency contraceptive options
levonorgestrel pill (Plan B), ulipristal acetate pill (UPA, Ella), combined OCPs (ethinyl estradiol and norgestrel or levonorgestrel), copper IUD
MOA of emergency contraceptive pills
inhibits or delays ovulation, however will not disrupt an established pregnancy
MOA of copper IUD for emergency contraception
prevents fertilization and interferes with implantation
Efficacy of the emergency contraceptive pills
Variable, depending on a number of factors such as baseline fertility, timing of intercourse during cycle, timing of taking the pill. May be less effective for overweight and obese individuals.
Overall, studies demonstrate that the risk of pregnancy after a single act of unprotected intercourse is 5.5-8% which is reduced to 1-2.2% after taking emergency contraceptive pills
How long after unprotected intercourse will the emergency contraceptive pills be effective?
Overall, 3-5 days.
ulipristal acetate (UPA) pill has no decrease in effectiveness up to 120 hours (5 days) after intercourse. The levonorgestrel pill (Plan B) and COCs should be taken as soon as possible, may be less effective if delayed beyond 72 hours (3 days), with only moderate effectiveness between 72-120 hours (3-5 days).
How effective is the copper IUD as emergency contraceptive?
reduces risk of pregnancy by more than 99%
Side effects of emergency contraceptive pills
nausea and vomiting are the most common. This is less common with the levonorgestrel (Plan B) or ulipristal acetate (UPA) pills than with the COCs. May also cause a change in bleeding pattern for the next cycle
Is any follow-up visit required after prescription for emergency contraceptive?
No
Instructions for use of oral combined contraceptive pills as emergency contraception
Make sure to take within 3-5 days for optimal effectiveness. Take 2 pills that day, each one 12 hours apart. Consider taking anti-nausea medication 1 hour before first dose. If vomits within 2 hours of taking a pill, may need a repeat dose. Wait until the next day to resume OCPs or start a new method of ongoing birth control. Abstain from intercourse or use back-up for 7 days.
Instructions for use of ulipristal acetate (UPA) pill as emergency contraception
Make sure to take within 3-5 days for optimal effectiveness. Take UPA. Do not start another method of hormonal birth control until 5 days after UPA, as this may reduce the effectiveness of its emergency contraception. Use a back-up method until have been on a method for 7 days.
Do you need to take a pregnancy test after taking emergency contraceptive pills?
Advise patient to have a pregnancy test if they do not experience a withdrawal bleed within 3 weeks of taking
The copper IUD can be inserted up to _______ after unprotected intercourse to be effective as emergency contraception
5 days
MOA of vaginal spermicides for contraception
nonoxynol-9 is the active ingredient. Destroys the sperm membrane
Failure rate of vaginal spermicides for contraception
Perfect use - 18%
Typical use - 28%
Vaginal spermicides are not recommended for individuals at high risk for, or diagnosed with, this condition
HIV/AIDS
Instructions on use of vaginal spermicides as contraception
Use with each act of intercourse. Place deep inside the vagina and allow adequate time for the spermicide to dissolve if using the film, tablet, or suppository. The instructions will designate how long before intercourse can be used. Leave spermicide in place for at least 6 hours after intercourse. Use with condoms to increase effectiveness
Failure rate of male condoms for contraception
Perfect use - 2%
Typical use - 18%
What type of male condom should be recommended for folks with a latex allergy
polyurethane condom
What type of male condoms may not protect against STIs and HIV
natural membrane (made from lamb’s cecum/intestine)
What type of lubricants are okay to use with latex condoms
water-soluble lubricants are preferable (KY jelly, astroglide, egg whites). Oil-based lubricants should be avoided (i.e., baby oil, vegetable or mineral oils, petroleum jelly)
Failure rate of female condom
Perfect use - 5%
Typical use - 21%
What is the female condom made of
nitrile sheath, alternative to latex (contraindicated with nitrile allergy)
Instructions for use of female condom
Insert inner ring deep into the vagina. Outer ring should rest outside the vulva. Do not use male condom with using the female condom as these may adhere together and cause dislodgement
Which diaphragm has essentially replaced all earlier dome-shaped diaphragm contraceptives in the US
Caya diaphragm
Failure rate for Caya diaphragm
perfect use - 14%
typical use - 17%
How long can you use a Caya diaphragm or FemCap cervical cal for
1-2 years
Folks at high risk for these (2) conditions, diaphragm (Caya), cervical cap (FemCap), and contraceptive sponge are not advised for contraception
HIV (because of the spermicide you are supposed to use with it) and h/o toxic shock syndrome (diaphragm can cause)
Caya diaphragm, FemCap cervical cap, or sponge for contraception in the postpartum period?
Wait until 6 weeks postpartum or until uterine involution is complete. Same for after a second-trimester abortion, wait 6 weeks
Instructions for use of Caya diaphragm for contraception
Insert just prior to intercourse or up to 2 hours prior. Place 1 tsp of spermicidal gel into each fold of the diaphragm and a small amount around the rim. Insert it such that the cervix is completely covered and it is positioned behind the symphysis pubis. If repeated intercourse, you can leave the diaphragm in place but reinsert spermicide. Make sure the leave the diaphragm in place for at least 6 hours following intercourse but do not leave in place for >24 hours. Wash with plain soap and water after each use. Replace at least every 2 years. Assess for holes or breakdown periodically by filling with water and inspecting for leaks. Consider emergency contraception if it is dislodged <6 hours after sex.
Warning signs of toxic shock syndrome from contraceptive diaphragm
fever, nausea, vomiting, diarrhea, syncope, weakness, arthralgias, myalgias, rash
What is the contraceptive cervical cap (FemCap) made out of
silicone
Cervical cap and sponge is LESS effective for __________ women
parous (have given birth before)
Failure rate for cervical cap (FemCap)
perfect use: 10-20%
typical use: 20-40%
FemCap cervical cap, Caya diaphragm, and sponge should not be used during…..
menses
Instructions for use of FemCap cervical cap for contraception
Insert at least 15 minutes prior to intercourse to create suction. Fill 1/3 of the cap with spermicide, compress the rim to insert, and advance into vagina until it slides over cervix. Check to ensure the cap covers the cervix. Not necessary to reinsert spermicide with repeated intercourse. Make sure to leave in place for at least 6 hours after intercourse but for no more than 48 hours.
What is the contraceptive sponge and what is it made of?
Small, pillow-shaped polyurethane sponge that contains 1g of nonoxynol-9 spermicide. Only comes in one size.
Failure rate for contraceptive sponge
perfect use: 10-20%
typical use: 20-25%
Instructions for use of contraceptive sponge
Moisten the sponge with tap water before use. Insert deep into vagina with concave side fitting over the cervix. Check to ensure cervix is covered by the sponge. Leave in place for at least 6 hours after intercourse; repeated spermicide is not required for repeated intercourse. Do not wear the sponge longer than 24-30 hours. Discard after use.
How do fertility awareness-based methods work? (FABMs)
Method of contraception using abstinence during estimated fertility period based on: Menstrual cycle pattern (calendar), basal body temperature, evaluation of cervical mucus, cervical position. Based on the understanding that the ovum remains fertile for 24 hours, sperm for 72 hours.
Most pregnancies occur when intercourse occurs [BEFORE vs. AFTER] ovulation
before!
Failure rate for fertility awareness based methods
typical use for all methods - 24%
“Standard days method” of fertility awareness-based contraceptive method assumes fertile period between days…..
8-19 of cycle
Fertility awareness-based methods are less effective for folks who have irregular cycles, such as (3)
recent menarche, perimenopausal, recently postpartum
Instructions for the use of the calendar method (FABMs) for birth control
Keep a record of your menstrual cycles for several months. From the shortest cycle length, subtract 18 days (first fertile day). From the longest cycle length, subtract 11 days (last fertile day). Use these numbers to determine days of abstinence for every cycle.
Instructions for the use of BBT (FABMs) for birth control
Take temperature every morning before rising. Record on a BBT chart. Temperature will increase by 0.4 degrees F or more at ovulation. You can assume ovulation has occurred when the temperature remains elevated for 3 or more days - abstain for at least 3 of these days. (You are most fertile 2 days before the increase)
What (3) conditions must be true for lactational amenorrhea to be effective
- within 6 months postpartum
- has not had return of period
- breastfeeding around-the-clock without supplementation (i.e., once baby is sleeping through the night, may not be often enough to afford protection)
MOA of lactational amenorrhea
elevated prolactin leads to inhibited GnRH pulsatile release, LH is low, meaning there is no ovarian follicular development and anovulation occurs
Which app is an FDA-approved FABM method?
Natural Cycles
Failure rate for lactational amenorrhea
perfect use - 0.5 to 1.5%
typical use - data is not available
Does milk expression by hand or pumping afford the same fertility-inhibiting effect in lactational amenorrhea as breast feeding?
No
Failure rate for withdrawal method
perfect use - 4%
typical use - 22%
What type of procedures are used for female sterilization, or fallopian tube occlusion contraception?
Outpatient surgical procedure, or postpartum prior to discharge. The fallopian tubes are obstructed to prevent union of sperm and egg, can be done transabdominally or laparoscopically via….
- surgical ligation (Pomeroy procedure)
- surgical ligation and attachment to uterine body (Irving procedure)
- electrocauterization
- excision of a section of the tube (Pritchard procedure, fimbriectomy)
- Occluded with a compressive silastic bang (Falope Ring) or clip (Filshie)
Failure rate for fallopian tube occlusion sterilization
perfect & typical: 0.5%
Risks of fallopian tube occlusion sterilization
reversal is difficult, expensive, and often unsuccessful. procedure can come with operative complications such as injury to the bladder, uterus, or intestines. Wound infection. Higher risk that the pregnancy would be ectopic if pregnancy occurs. Anesthesia complications such as death (rare)
Follow-up required after fallopian tube occlusion sterilization
1-2 weeks after procedure, assess for healing and s/s infection
Instructions for use of fallopian tube occlusion sterilization
Nothing by mouth 8 hours before procedure. Will need transportation home. Rest for 24 hours after procedure. Abstain from exercise or intercourse for 1 week. Notify for s/s infection
What type of procedures are used for male sterilization, or vas deferens surgery contraception?
Occlusion of vas deferens prevents transmission of sperm through semen; the ejaculate will be without sperm. Can be done with only local anesthesia and via no-scalpel, no-sutures method. Most commonly the vas deferens is ligated with sutures and a section is excised. Other methods include electrosurgical or thermal cautery, application of clips, or a combination of methods.
Failure rate of male sterilization
0.10-0.15%
Risks of male sterilization procedure (vasectomy)
should be considered irreversible. would infection is possible. Extensive research has identified no significant long-term physical or mental health effects with vas surgery.
What follow-up is required after male sterilization procedure?
3 months after procedure, confirm success with semen analysis
Instructions for use of male sterilization procedure (vasectomy)
Use scrotal support (i.e., brief-style underwear) for at least 2 days to reduce pain. Apply an ice pack to scrotum for a minimum of 4 hours after procedure. Notify for s/s infection. Avoid ejaculation for 1 week. Avoid exercise or heavy lifting for 1 week. Continue a back-up method for 3 months until can confirm with semen analysis
How long after procedure for male vs. female sterilization must use back-up or abstain?
female - 1 week
male - 3 months
On average, the first ovulation occurs ______ days post partum in non-lactating folks. But may occur as early as ….
average = 45 days (1.5 months)
early as = 25 days (1 month)
VTE risk is increased for the first few weeks postpartum, generally declining to baseline level after _____
42 days (1.5 months)
Combined hormonal contraceptives in the postpartum period, timeline for NON-LACTATING women
0-21 days = absolute contraindication
21-42 days w/ addl VTE risk = relative contraindication
21-42 days w/o addl VTE risk = likely okay
>42 days = best
Combined hormonal contraceptives in the postpartum period, timeline for LACTATING women
0-21 days = absolute contraindication
21-30 days = relative contraindication
30-42 days w/ addl VTE risk = relative contraindication
30-42 days w/o addl VTE risk = likely okay
>42 days = best
Progestin-only hormonal contraceptives in the postpartum period, timeline for LACTATING women
0-21 days = likely okay
21-30 days = likely okay
>30 days = best
Progestin-only hormonal contraceptives in the postpartum period, timeline for NON-LACTATING women
okay immediately
IUDs in postpartum period, timeline (regardless of lactation status or method of delivery)
0-10 minutes = likely okay for LNG, best for copper
10 minutes to 4 weeks = likely okay
>4 weeks = best
Combined hormonal contraceptives come in these routes/methods (3)
pills, patch, ring
Combined hormonal contraceptives in the peri-menopausal years?
Safe option if non-smoking, non-obese, healthy. May be especially attractive for relief of vasomotor symptoms and menstrual regulation. May even reduce risk of endometrial hyperplasia and cancer associated with anovulatory cycles during perimenopause
Progestin-only contraceptive methods in the peri-menopausal years?
There are no age-related contraindications. They may provide some relief from vasomotor symptoms. They may reduce the risk of endometrial hyperplasia and cancer. DMPA specifically may reduce bone density (however, these folks then don’t tend to undergo the typical rapid loss of bone density following menopause)
IUDs in the peri-menopausal years?
Safe. Long-acting and as effective as sterilization. May also be therapeutic for perimenopausal folks with heavy bleeding
When should a peri-menopausal patient d/c their hormonal contraceptive method?
There are no definitive answers for when to d/c.
- CHC - continue to age 50-55 years. If you are going to measure hormone levels, must be off of the method for >14 days to eliminate it’s effect on FSH and estradiol
- POP, IUD - can continue to age 55. If you are going to measure hormone levels, check FSH on 2 occasions between ages 50-54 at least 1-2 months apart and if both are >30, then continue the method one more year before stopping
- Copper IUD - continue use until amenorrheic for 1 year (post-menopausal). If less than 50 yo, continue until amenorrheic for 2 years OR 1 year but with hormone confirmation (two FSH levels >30 at least 1 -2 months apart)
Can gender-affirming hormone therapy with testosterone and GnRH analogues be counted on for birth control in trans folks?
No - they suppress ovarian function, but cannot be relied on for contraceptive protection (or is this because we don’t have good enough data/studies??)
Warning regarding testosterone in trans folks with reproductive capacity
testosterone is a teratogen that is contraindicated in pregnancy
Selecting a birth control method for trans folks on masculinizing hormone therapy with reproductive capacity
the estrogen components of combined hormonal methods may counteract the masculinizing effects of testosterone.
The Copper IUD and progestin-only methods (POPs, arm implant, LNG IUDs) will not interfere with testosterone effects. :)
Approximately ____% of pregnancies in the US are unintended
50%
Medication abortions are FDA-approved up to _____ days from LMP
70 days (10 weeks, ~2.5 months)
What (2) medications are used in a medical abortion, first line
mifepristone (200mg PO) + misoprostol (800mcg)
MOA of mifepristone as a medical abortion agent
19-norsteoid, progesterone antagonist
- blocks the action of progesterone needed to establish and maintain the placental attachment
- softens the cervix
- stimulates prostaglandin synthesis by cells of the early decidua
MOA of misoprostol as a medical abortion agent
prostaglandin analog
- softens cervix
- stimulates uterine contractions
Common short-term side effects of misoprostol as a medical abortion agent
nausea, vomiting, diarrhea, temporary elevation of body temperature. Importantly, prenatal exposure to misoprostol is associated with major congenital abnormalities (although absolute risk is low, about 1%)
What is the dosing/regimen/fup of medication abortion with mifepristone and misoprostol
mifepristone 200mg PO (in clinic, at initial visit - also give Rh immunization depending on Rh status) followed by misoprostol 800 mcg (vaginal, buccal, or sublingual at home 24-48 hours later). Follow-up in clinic 1-2 weeks later to assess for complete abortion. May repeat the misoprostol or provide aspiration if it is not complete by 1-2 weeks, by 2-3 weeks after would require aspiration abortion.
[MISPROSTOL - VAGINAL: 6-48 hours later; BUCCAL: 24-48 hours later; SUBLINGUAL: 24-48 hours later].
Effectiveness of mifepristone + misoprostol medical abortion therapy
96-98% through 9 weeks EGA
Contraindications to medication abortion
known or suspected ectopic pregnancy, IUD in place (remove before giving medication), hemorrhagic disorder, anticoagulant therapy, chronic kidney disease, long-term use of systemic corticosteroids, inherited porphyrias
Second line medication abortion options (2), less commonly used
methotrexate + misoprotol
MOA of methotrexate in medication abortion
folic acid analogue. Inhibits the enzyme necessary for DNA synthesis and acts on the rapidly dividing cells of the placenta.
How effective is methotrexate + misoprostol for medication abortion?
92-96% effective up to 7 weeks (49 days) EGA
Patient counseling/warnings with use of methotrexate plus misoprostol for medication abortion
It may take up to 1 month for expulsion of the gestational sac. It is a known teratogen. Discontinue breastfeeding for 72 hours after taking it. Avoid use of folic acid for 1 week after the procedure, as it may inhibit the action of methotrexate.
Contraindications for methotrexate + misoprostol medication abortion regimen
known or suspected ectopic pregnancy, IUD in place (remove before giving medication), hemorrhagic disorder, anticoagulant therapy, chronic kidney disease, long-term use of systemic corticosteroids, inherited porphyrias, acute inflammatory bowel disease, uncontrolled seizure disorder
What is the dosing/regimen/fup of medication abortion with methotrexate and misoprostol
Methrotrexate IM injection or orally at initial visit (also give Rh immunization, depending on Rh status), followed by the misoprostol per vagina at home 3-7 days later. Follow-up in clinic 1-2 weeks later to assess for complete abortion. May repeat the misoprostol or provide aspiration if it is not complete by 1-2 weeks, by 2-3 weeks after would require aspiration abortion.
Surgical options for elective abortion (2)
vacuum aspiration, dilation & evacuation (D&E)
Through how many weeks EGA is vacuum aspiration an option for surgical abortion
first trimester (13-14 weeks)
Through how many weeks EGA is D&E an option for surgical abortion
up to 20 weeks
Laboratory/diagnostic tests the WHNP should complete prior to referral for surgical abortion
- Pregnancy dating by LMP and/or TVUS
- urine pregnancy test (beta HCG)
- Hgb/hct
- Blood type and Rh status
- STI evaluation
Warning signs for patients to call clinic to report after medical or surgical abortion
fever, persistent or increasing lower abdominal pain, prolonged or excessive vaginal bleeding, purulent vaginal discharge, no return of menses within 6 weeks
Average age of menopause in the US
52yo
Definition of menopause
12 months without a period
Definition of premature menopause
cessation of ovulation and menses before age 40yo, whether spontaneous or induced
STRAW (Stages of Reproductive Aging Workshop) - what changes define the menopausal transition?
Principal criteria = menstrual cycle changes Other characteristics = - vasomotor symptoms - symptoms of urogenital atrophy Supportive characteristics = endocrine changes - AMH (low) - FSH (high) - LH (high) - estradiol (low) - inhibin B (low) - antral follicle count (via US - low)
What is the relationship of AMH to menopause
AMH is produced exclusively by granulosa cells of the ovarian follicles; as such, it is a marker of ovarian reserve. AMH begins to decrease as early as a female’s 20s, and will be undetectable about 5 years after menopause
What is the relationship of inhibin B to menopause
inhibin B is an ovarian peptide that works in a negative feedback loop with FSH. As the number of ovarian follicles declines towards menopause, inhibin B levels will fall as FSH rises
What laboratory findings for FSH, LH, and E2 are indicative of menopause
FSH >40 mIU/mL
LH >3x elevation (20-100 mIU/mL)
E2 <20 pg/mL
What is the relationship between menopause and weight gain
There is no data to support that menopause hormonal changes are responsible for weight gain, it is more likely the result of aging and lifestyle. There is some evidence that hormonal changes of menopause may be related to changes in fat composition and fat distribution from subcutaneous stores to visceral abdominal fat
Menopausal transition - effects on the skin
The skin has a significant number of estrogen receptors. As estrogen declines, there are corresponding declines in skin collagen and thickness. Scalp, pubic, and axillary hair becomes thinner and drier.
Menopausal transition - effects on bone
There is increased bone loss associated with the decrease in estrogen, greatest loss occurs in the first few years after menopause and then slows (but continues)
Menopausal transition - effects on labia
The labia decrease in subcutaneous fat and tissue elasticity
Menopausal transition - effects on vagina
The vaginal microbiome changes in response to decreasing estrogen with increases in vaginal pH from acidic to alkaline (pH >5.0). Additionally, the vaginal epithelium develops a higher proportion of parabasal cells than mature superficial cells, leading to a thinner, less vascular, and less elastic epithelium. The vaginal walls may appear more thin, smooth, and pale and may have small petechiae and be friable to touch.
Menopausal transition - effects on cervix
Decreases in size, os may become flush with the vaginal walls and may also become stenotic
Menopausal transition - effects on ovaries
Ovaries decrease in size, usually not palpable
Menopausal transition - effects on urethra and bladder
The urethra and trigone of the bladder have high concentrations of estrogen receptors thus may experience atrophic changes. The urethral meatus may become more prominent as the labia minora thins and the introitus retracts, additionally urethral caruncles are common
Effects of HRT on cognitive function?
It is unclear how estrogen or estrogen+progesterone affects cognitive function with younger menopausal individuals. However, the Women’s Health Initiative Memory Study (WHIMS) found the risk of dementia was increased in healthy women aged 65-79yo who were using estrogen+progesterone therapy
Menopausal transition - effects on cardiovascular system
- Increases in LDL, VLDL-C, triglycerides, and possibly a decrease in HDL
- Increase in certain fibrinolytic and pro-coagulation factors that regulate clotting processes
- the extent of the impact of estrogen levels of CVD is not definitively established
Height loss greater than 1.5 inches in older folks may be associated with…..
vertebral compression fractures and osteoporosis
Post-menopause - pelvic exams needed?
pelvic exam can be conducted if a pap test is needed or otherwise symptomatically indicated. Otherwise, routine pelvic exams should be a shared, informed decision between patient and provider
Post-menopause - CBE needed?
ACOG recommends annually for folks 40yo and older. ACS and USPSTF does not recommend for average-risk females at any age
Colorectal cancer screening should begin at age…
45yo
Screen once for Hepatitis C if the patient was born between ______
1945 to 1965
When and how often does the American Diabetes Association (ADA) recommend diabetes screening
Q3 years starting at age 45yo
When/how can you stop cervical cancer screenings in someone with no history of abnormals, or only low-grade changes?
Stop screening at age 65yo if adequate prior screening which is defined as three consecutive negative cytology results OR two consecutive negative co-testing results within the last 10 years, the most recent of which was within the past 5 years
When/how can you stop cervical cancer screenings in someone with h/o CIN2 or higher?
If history of cervical intraepithelial neoplasia 2 (CIN2) or higher, continue screening for 20 years after spontaneous regression or appropriate management
Your 70yo pt presents for an annual. They stopped cervical cancer screening at age 65yo with adequate prior screening. They report this year having a new sexual partner, and they are wondering if they ought to receive another pap test?
Once screening has stopped, do not resume even if individual reports a new sexual partner
When/how should you stop mammogram screening?
No definitive age to discontinue screening. Per ACS, ACOG base on an individual’s health and whether they would be a candidate for treatment of breast cancer. Per USPSTF, stop after age 74yo
Schedule for bone mineral density screening
start at age 65yo unless risk factors; no definitive specific recommendations on frequency of screening or when to discontinue
What are the vasomotor symptoms of menopause
Recurrent, transient episodes of flushing accompanied by sensation of warmth to intense heat on the upper body and face. May include profuse sweating and heart palpitations. May awaken during the night, leading to insomnia, sleep disturbance, cognitive (memory) and affective (anxiety) disruptions with loss of REM sleep
% of folks who experience vasomotor symptoms during perimenopause
75%
Expected timing and duration of vasomotor symptoms of menopause
usually begins in the late menopause transition, with the greatest frequency and severity within the first 2 years after the final menstrual period. They typically last 5-7 years but may continue for some folks 10+ years
Non-pharm options for management of vasomotor symptoms of menopause
Likely to be useful:
CBT, hypnosis
May be useful, needs more study:
weight loss, mindfulness-based stress reduction, derivatives of soy isoflavones (phytoestrogens)
Unlikely to be useful:
exercise, yoga, acupuncture, paced respiration, black cohosh, dong quai, evening primrose oil
What is the main purpose of including progesterone in menopausal hormone therapy formulations
to reduce the risk of endometrial cancer in folks with a uterus associated with unopposed estrogen
How is conjugated equine estrogen made
mixture of estrogens isolated from urine of pregnant mares (horses)
What is the only human estrogen available in an FDA-approved, single-estrogen formulation
17 beta-estradiol
Which progesterone is “bioidentical” and what is the difference between this and progestins
micronized progesterone, which is a compound identical to endogenous steroid hormone produced by the ovaries.
This is in contrast to progestins, which are a synthetic product that have progesterone-like activity but are not identical to endogenous progesterone
Hormonal pharmacotherapeutic options for vasomotor symptoms of menopause (classes - 2)
- hormone therapy (estrogen or estrogen + progesterone)
- selective estrogen receptor modulators (SERM; bazedoxifene)
Bazedoxifene
SERM with estrogen antagonist effect on the endometrial and breast tissue, with estrogen agonist effects on the bone.
Counseling on bioidentical hormone therapies that are specifically compounded for an individual
Custom-compounded bioidentical hormone products are not FDA approved, there is no evidence that they are safer than conventional HT, and the same contraindications apply to their use. There is no evidence that saliva testing is effective for customizing hormone therapy dosing regimens
Contraindications to the use of hormone therapies for menopausal symptoms
- undiagnosed abnormal vaginal bleeding
- known, suspected, or history of breast cancer
- known or suspected estrogen-dependent cancer
- active or history of DVT or PE
- active or history of arterial thromboembolic disease, like a stroke or an MI
- liver disease
- clotting disorder (protein C, protein S, or antithrombin deficiency)
- pregnancy
Breast cancer survivors and vaginal estrogen?
For survivors of beast cancer with bothersome genitourinary syndrome of menopause not relieved by non-hormonal therapies, low-dose vaginal estrogen with minimal systemic absorption may be considered in consultation with oncologist
(4) potential risks of menopausal hormone therapy, generally
endometrial hyperplasia/cancer (estrogen alone), breast cancer, thromboembolic disorders (CAD, stroke, blood clot), dementia
Counseling on risk of breast cancer with menopausal hormone therapy use
Relationship is inconclusive - possible small but significant increase of breast cancer with long-term use (~>5 years)
Counseling on risk of thromboembolic event with menopausal hormone therapy use
Relationship is inconclusive - folks who start HT closer to menopause have less risk than those starting several years after menopause. Generally, transdermal formulations have less risk than oral routes. No hormone therapies should be used for the prevention of cardiovascular disease or stroke and it should be avoided in individuals at high risk for stroke
Counseling on risk of dementia with menopausal hormone therapy use
Relationship is inconclusive - possible small but significant increase in risk if estrogen-progesterone therapy is initiated at >65yo
How to discontinue menopausal hormone therapy use
There is no data available regarding the choice of abrupt cessation vs. tapering. Approximately 50% of folks will experience a recurrence of symptoms with discontinuation no matter age or length of time hormones were used
Effects of oral estrogen-progesterone or estrogen-only menopausal hormone therapies on cholesterol levels
POSITIVE: increases HDL, lowers LDL
NEGATIVE: increases triglycerides, increases CRP
Differences between Femring and Estring
Femring is vaginal estrogen ring approved for the treatment of vasomotor symptoms of menopause and vulvovaginal atrophy. It has a 99-day duration and systemic absorption, thus MUST SUPPLEMENT WITH PROGESTERONE IF HAS INTACT UTERUS
Estring is a vaginal estrogen ring with only local effect, given little to no systemic absorption. It will treat vulvovaginal atrophy but does not provide relief from vasomotor symptoms of menopause. Do not need to supplement with progesterone for folks with intact uterus
Side effects of menopausal hormone therapy (5) and tips on managing them
- breast tenderness (usually subsides after first few weeks; can be caused by both E and P components)
- nausea (from E component - take with meal or at bedtime)
- skin irritation with transdermal patch
- fluid retention and bloating (both E and P components)
- mood alterations (likely P component)
May try lowering the dose, changing the route, or changing to a different formulation
Bleeding and continuous-combined menopausal hormone therapy?
Erratic spotting and light bleeding of 1-5 days duration may occur in the first year o fuse; need an endometrial evaluation if the bleeding is heaver or longer than usual, or if it resumes after several months of amenorrhea
Non-hormonal pharmacotherapeutic options for vasomotor symptoms of menopause, classes (3)
SSRIs, SNRIs, gabapentin (anticonvulsant)
Which is the only non-hormonal prescription medication approved by the FDA for vasomotor symptoms of menopause
paroxetine 7.5mg QHS at bedtime (SSRI; Paxil)
Symptoms of genitourinary syndrome of menopause
- genital dryness, burning, and irritation
- lack of lubrication, dyspareunia, sexual dysfunction
- urinary frequency, nocturia, urgency, dysuria, and recurrent UTIs
% of folks who experience genitourinary syndrome of menopause symptoms
50%
Menopausal transition – effect on the vaginal flora
Decreased estrogen leads to decreased vaginal lactobacilli which increases the vaginal pH (more alkaline/basic)
Nonhormonal therapies for treatment of genitourinary syndrome of menopause (4)
- vaginal lubricants
- vaginal moisturizers
- regular sexual activity with a partner
- regular sexual activity that is non-coital (i.e., masturbation)
Why are vaginal moisturizers helpful for genitourinary syndrome of menopause
Applied several times weekly, they can provider longer-term relief of vaginal dryness than lubricants and they help maintain vaginal moisture and a lower vaginal pH (more acidic)
(3) types of vaginal lubricants
water, silicone, or oil-based
Why is regular sexual activity helpful for genitourinary syndrome of menopause
promotes blood flow to the genital area
(3) types of hormonal therapies that can be used for genitourinary syndrome of menopause
- vaginal estrogen
- ospemifene (Osphena; SERM)
- prasterone (Intrarosa; steroid pro-hormone)
Counseling about ospemifene (Osphena) for genitourinary syndrome of menopause
A SERM approved for the treatment of moderate to severe dyspareunia related to vulvovaginal atrophy. Has estrogen agonist effects on the vaginal tissue (thickens and makes less fragile, decreases vaginal pH to more acidic), with weak estrogen agonist effects on the uterus and breasts (thus, same contraindications for use as with systemic estrogen). It may take several weeks for full relief of symptoms.
Administration = daily oral pill.
Common side effects = hot flashes, vaginal discharge, muscle spasms, increased sweating
No FDA indication for improving bone health. Has not been evaluated in combination with progesterone for those with intact uterus. Should not be used with another estrogen or another SERM.
Counseling about prasterone (Intrarosa) for genitourinary syndrome of menopause
Approved for the treatment of moderate to severe dyspareunia related to vulvovaginal atrophy. It is an inactive endogenous steroid prohormone that is converted into active androgen and estrogen locally in the vaginal cells to improve vaginal epithelium maturation index and to lower the vaginal pH.
Administration = once daily vaginal dose at bedtime
Most common side effect - vaginal discharge
Contraindicated with abnormal genital bleeding of unknown cause.
Has not been studied for use in those with a h/o breast cancer.
