Contraception 1

Question 1

List the contraceptive methods that keep sperm out.

Answer 1

• Abstinence
• Vasectomy
• Barriers
  
  • male condoms
  • female condoms
  • diaphragm
  • cervical cap
• Spermicides
• Change ovulatory estrogen-dominant mucus
  
  • hormonal contraception
  • progestin IUD

Question 2

List the contraceptive methods that prevent ovulation.

Answer 2

• Depot hormonal
  
  • progestin injectable
  • combo injectable
  • progestin implant
• Hormonal
  
  • oral combination
  • oral progestin-only
  • combination patch
  • combination vaginal ring

Question 3

List the contraceptive methods that prevent fertilization.

Answer 3

tubal ligation

Question 4

List the contraceptive methods that alter tubal motility.

Answer 4

Progestin-only methods

Question 5

List the contraceptive methods that prevent implantation and kill sperm.

Answer 5

• Endometrial inflammation
  
  • spermicidal
  • impedes implantation
  • IUD
• Endometrial atrophy - prevents implantation
  
  • hormonal
    
    • combination
    • progestin-only
    • progestin IUD

Question 6

Define theoretical efficacy and use effectiveness.

Answer 6

• Theoretical efficacy
  
  • perfect use effectiveness
  • consistent and correct use
  • without impact of human error
• Use effectiveness
  
  • typically observed effectiveness
  • includes inconsistent and incorrect use
  • methods that require daily action have lower adherence reates vs. weekly, monthly, or 5 to 10 yearly
  • separation of the act of contraception from the act of intercourse improves efficacy

Question 7

What is the mechanism of action of oral contraceptives?

Answer 7

• Progesterone alone is sufficient to inhibit ovulation through suppression of the mid-cycle LH surge
• In combined estrogen and progestin regimens, both hormones work together to inhibit ovulation
• Additional progestin-induced contraceptive mechanisms:
  
  • endometrial atrophy, which impairs implantation
  • thickening of cervical mucus, which impedes sperm migration
  • decreased tubal ciliary motility, which alters ovum and blastocyst transport

Question 8

What type of estrogen is given in oral contraception?

Answer 8

• Ethinyl estradiol
  
  • most potent estrogen secreted by the ovary
  • addition of ethinyl group at the 17-carbon position of estradiol improves oral absorption
  • primary estrogen used in most combined oral contraceptive pills

Question 9

What are the characteristics of progestins given for oral contraception?

Answer 9

• Multipel different progestins:
  
  • 19-nortestosterone derivatives
  • removal of the 19 carbon from testosterone changes effects to that of progestin
  • many adverse effects associated with nortestosterones are from residual interaction with androgen receptors
  • ethinyl group to 17-carbon improves oral absorption
  • adding cyanomethyl group to 17-C of dienogest (another contraceptive progestin) also improves bioavailability
• Drosperinone
  
  • chemically related to spironolactone
  • both anti-mineralocorticoid and anti-androgen activity
  • approved for treatment of acne

Question 10

What are the types of progestins given for oral contraception?

Answer 10

• First generation
  
  • 19-Nortestosterone derivatives
  • all first generation compounds metabolized to norethindrone
• Second generation
  
  • Nortesosterone derivative
  • Norgestrel - racemic mixture
  • Levonorgestrel - bioactive levo-enantiomer of norgestrel
• Third generation
  
  • less androgenic and more selective for progesterone receptor
  • nortestosterone derivatives
  • desogestrel - etonogestrel prodrug to active compound
  • gestodene (not US)
  • norgestimate

Question 11

What are the common side effects of progestin oral contraceptives?

Answer 11

• Progestin side effects
  
  • androgenic effects from binding of nortestosterones to androgen receptors
  • 2nd gen levonorgestrel > 1st gen northindrone >/= 3rd gen norgestimate/etonogestrel
  • most common:
    
    • acne
    • oily skin
• 19-Nortestosterone metabolic effects
  
  • increased plasma insulin
  • decreased glucose tolerance
  • decreased cholesterol, TG, HDL
  • increased LDL
  • increased sebum production in skin

Question 12

What are the common side effects of progestin oral contraceptives?

Answer 12

• Too much ethinyl estradiol
  
  • breast tenderness
  • nausea
  • depression, mood lability and/or irritability
  • headaches
  • melasma
• EE too low
  
  • endometrial spotting
• Metabolic effects
  
  • decreased albumin
  • increased globulins
  • increased angiotensinogen and decreased Na excretion
  • increased coagulation proteins
  • increased sex hormone binding proteins
  • increased TG and HDL
  • decreased LDL
  • increased skin pigmentation
  • increased receptors in breast and endometrium

Question 13

What are the dosing regimens for oral contraceptives?

Answer 13

• Traditionally, 21 days of active pills followed by 7 days of placebo pills
  
  • withdrawal bleed uring the 4th week when estrogen and progestin drop
• 24 days of active pills
  
  • extended regimen better suppresses ovarian follicular development
  • decreases break-through bleeding during the rest of the cycle
• 84 days of continuous combined contraceptive pills with a withdrawal period of 7 days every 12 weeks
  
  • regimen reduces frequency of withdrawal bleeding to every 3 months
  • associated with increased break-through bleeding during the rest of the cycle
    
    • due to endometrial instability

Question 14

What are side effects related to estrogen dosing?

Answer 14

• Ovulation suppression at 20 mcg
• Endometrial control at 30-35 mcg
• Thrombotic complications a >/= 50 mcg
  
  • deep vein thrombosis
  • pulmonary embolus
  • thrombotic stroke

Question 15

What are some safety risks of oral contraceptives?

Answer 15

• Increased risk of venous thrombosis
  
  • probability of death 3rd > 2nd > none
  • the greater the increase in SHBG, the greater the risk of thrombosis
    
    • not causal, only a marker
• Increased risk of thrombotic stroke
  
  • only for >/= 50 mcg estrogen
• Increased risk of MI
  
  • smokers over 35 years especially
• Inherited thrombophilia - any dose at risk
• NO proven increases in breast cancer risk

Question 16

What are the beneficial side effects of oral contraceptives?

Answer 16

• Less anemia
  
  • decreased menstrual bleeding
• Decreased risk of endometrial cancer
  
  • atrophy
• Decreased risk of ovarian cancer
  
  • reduced proliferation of ovarian epithelium
• Decreased dysmenorrhea
  
  • reduced endometrial prostaglandin production,
  • decreased endometrial thickness
  • less bleeding
• Decreased PID
  
  • increased viscosity of cervical mucus
• Increased bone density
  
  • consistent higher estrogen levels

Question 17

What is the efficacy and use effectiveness of OCPs? What decreases this use effectiveness?

Answer 17

• Theoretic efficacy - 99.9%
• Use effectiveness 97%
  
  • decreases with:
    
    • late or forgotten pills during pack or at beginning of new pack
    • increased bowel motility

Question 18

What are the risks of hypertension? What are some other important adverse effects?

Answer 18

• Hypertension can be induced in 5% of women with use of 50 mcg estrogen
  
  • Mechanism
    
    • changes in renin angiotensin system - increased plasma angiotensin
• Impaired glucose tolerance
  
  • higher doses of OCs
• Impairment of active transport of biliary components
  
  • active or chronic cholestatic liver disease is an absolute contraindication
• Hepatocellular adenomas can be induced by both estrogens and androgen-based progestins

Question 19

What are progestin only pills? How do they work?

Answer 19

• Northindrone 35 mcg once daily, every day
  
  • no hormone-free periods
  • minimal metabolic effects
• Indication - estrogen avoidance
  
  • lactation
  • women at risk for thromboemboli
  • HTN
• Protestin only mechanism of action
  
  • alters ovulation but inconsistently
    
    • slows frequency of GnRH pulses
    • suppresses LH surge
  • involutes endometrium and prevents implantation
  • thickens cervical mucus - decreases sperm transport

Question 20

What are alternate methods of delivery for hormonal contraception? What are the advantages?

Answer 20

• Injectables - IM/SC
• Implants
• Transdermal patches
• Intravaginal rings
• Benefits
  
  • bypasses GI absorption and first pass metabolism
  • utilizes active drugs rather than oral prodrugs
  • improved compliance compared to oral, daily pills

Question 21

What is the mechanism of action and side effects of the vaginal ring and patch releasing estrogen and progestin?

Answer 21

• Mechanism of action
  
  • combined release through ring or transdermal patches
  • supprssion of ovulation and regular menses
  • bypasses metabolism and decreases intensity of hepatic stimulation
  • coagulation changes reduced
  • patch applied weekly for 3 weeks then off for one week
    
    • same with the vaginal ring
    • withdrawal bleeding occurs during the non-hormonal 4th week
• Side effects
  
  • similar to OCPs

Question 22

What are long acting progestins?

Answer 22

• Depot-medroxyprogesterone acetate (DMPA)
  
  • IM or SC once every three months
• suppresses ovulation and causes atrophic thinning of endometrial lining
• irregular uterine bleeding and spotting is common early in use
• by the end of 12 months 55% of women are amenorrheic
• weight gain due to appetite stimulation
• extended use may adversely affect bone mass
• can be a delay in return of menstrual cyclign and fertility due to persistence of the drug after 3 months

Question 23

What are sub-dermal progestin-releasing implants?

Answer 23

• Nexplanon - single-rod etonogestrel-releasing sub-dermal implant
• requires insertion and removal every 3 years
• does not suppress ovulation or follicular development well
• highly effective due to its ability to change the endometrium and cervical mucus
• bone mass is not effected due to higher endogenous estradiol levels
• main side effect is irregular bleeding, though amenorrhea can occur

Question 24

How do spermacides work?

Answer 24

• Nonoxyl 9
  
  • surfactant - damages the cell membrane of sperm
• Formulations
  
  • foam
  • gel
  • foaming suppository
  • film
  • sponge

Question 25

What are the advantages of barrier contraception?

Answer 25

• few side effects
  
  • allergy
  • topical irritation
  • diapragm - UTI
• over the counter availability
• protection from STDs (condoms)

Question 26

What are the uses of intrauterine devices?

Answer 26

• Long term contraception - 5/10 years
  
  • long-active reversible contraception (LARC)
• Failure rate
  
  • theoretical 0.8%
  • observed < 1%
• Copper IUD
  
  • increases inflammation
    
    • thought to aslo be spermicidal
  • increases menstrual flow and uterine cand
• Progestin-releasing
  
  • ​impede sperm transport by increasing viscosity of the cervical mucus

Question 27

What are the side effects of IUDs?

Answer 27

• No systemic side effects
• Risk of pelvic infection related to insertion, and more importantly, non-monogamous behavior
• Copper containing IUDs
  
  • heavy menses
  • cramping
  • irregular bleeding

Question 28

What is natural family planning and how is it used for contraception?

Answer 28

• Basal body temperature charting
  
  • rise in temprature AFTER ovulation
  • progesterone dependent
• Cervical mucus changes
  
  • duration of estrogent dominant mucus - varies
• Viability of ovum is 12-24 hours
• Spermatozoan lifespan is 48h to 5 days
• Use
  
  • must be used correctly
  • very unforgiving
  • increased risk of pregnancy during periods of stress
    
    • potential ovulatory irregularity
  • increased risk of pregnancy when “rules” are broken

Question 29

What are the hormonal regimens given for emergency contraception?

Answer 29

• Regimens given within 72 hrs
  
  • historic - high dose EE and progestin (Yuzpe)
  • high dose levonorgestrel - plan B
    
    • OTC for all women
    • 1.5 mg once or 0.75 mg 12 hours apart
• Regimen given within 120 hrs
  
  • ulipristal acetate 30 mg
• Mechanism of action
  
  • delays ovulation or inhibits ovulatory follicular rupture
  • may impede tubal transport
  • may prevent implantation - endometrial changes
    
    • most likely mechanism for the 5 day indication

Question 30

What IUD is used for emergency contraception?

Answer 30

• Insertion of Cu IUD within 7 days of unprotected intercourse
• Protects against implantation for this occurence plus provides future contraception

Question 31

What is the efficacy of emergency contraception?

Answer 31

• 8/100 women will become pregnant
• E and P EC - 2/100, 75% reduction
• P EC - 1/100, 89% reduction
• Antiprogestins - as effective as P regiments
• Cu-IUD - more effective than hormonal