contraception Flashcards
What is it ?
What is it ?
the deliberate use of artificial methods or other techniques to prevent pregnancy as a result of sexual intercourse
Roles of Hormones in contraception
Progestin:
Estrogen
Roles of Hormones in contraception
Progestin:
- blocks the LH surge that stimulates ovulation
- provides most contraceptive effects
- thickens cervical mucus to prevent sperm penetration
- endometrial atrophy (thinning of uterine lining) to prevent implantation
Estrogen
- prevents FSH release which prevents follicular development and maturation
- in birth control, major role of estrogens is to provide cycle control and to regulate endometrial lining (by stabilizing the endometrium, preventing irregular shedding and unwanted breakthrough bleeding)
How to choose a combined hormonal contraceptive
- estrogen component
- Progestin component:
- Monophasic vs Triphasic
a. monophasic;
b. triphasic/multiphase
4. Additional factors
5. Extended regimens
How to choose a combined hormonal contraceptive
1.estrogen component
a. choose by estradiol dose:
I. low dose: 20-25 mcg
II. medium dose: 30-35
III. high dose: 50 mcg
b. usually start with medium dose
c. go lower if pt has AE, or to reduce risk of VTE
d.go higher. if there is breakthrough bleeding early in the cycle or bleeding pattern that is irregular or infrequent
- Progestin component:
a. choose progestin by generation
I. 1st gen: norethindrone, ethynodiol
II. 2nd gen: levonogestrel, norgestrel
III. 3rd gen: desogestrel, norgestimate
IV. 4th gen: drospirenone
b. earlier gens are more androgenic (4th, antiandrogenic).
c.later gens are more thrombophilic (absolute risk difference are small)
androgenic AE: acne, hirsutism, weight gain, anxiety
d. typical initial progestin choice is 2nd or this gen.
e. choose late or go from early to late gen if pt has increased androgenic side effects
f. choose early or go from late to early to decrease VTE risks
g. if pt has BTB later in cycle, consider increasing progestin dose - Monophasic vs Triphasic
a. monophasic;
I.contain same dose of estrogen and progestin in each pill.
II.mainly used for treating medical conditions such as endometriosis or menstrual migraines.
III.minimizes hormonal withdrawal bleeding. (recommended to have withdrawal bleeds at least q3-4mo to prevent endometrial hyperplasia)
IV. can be used to manipulate menses to accommodate women needs (vacation, honeymoon)
V. makes easier to use off label use of emergency contraception
b. triphasic/multiphase formulation
I. vary in doses from beginning of pack to middle to end
II.change in doses mimic “non contracted individual”
III. neither superior or inferior to monophasic formulations. may have increased AE due to changing estrogen doses
IV. not easy to manipulate for pt needs (vacation, honeymoon)
V. not easy to use for off label emergency contraception
- Additional factors
a. products with less hormone free days
b. iron containing tablets. tablets w. iron instead of placebo
c. folic acid containing: all active and inert tabs
d. drospirenone containing: approved for PMDD, acne
5. Extended regimens 3 months (menses q 3 mo.) 1 year (menses q 1 year)
Contraceptive type : Combined Hormonal Contraceptive. (oral)
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers:
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:
things for amy to remember:
Contraceptive type : Combined Hormonal Contraceptive. (oral)
Examples: Many brands/ generics
Administration: oral, daily, menses q 1 month, 3 month, or annually depending on formulation
Advantages:
a. menstrual: regulates blood loss, good for anemia, endometriosis, fibroids, decreased cramps
b. sexual/psychological: increased spontaneity, sexual enjoyment, easy to use
c. cancers: dec chance of ovarian, endometrial, colorectal, and benign breast mass (not breast cancer)
d. others: improved acne effective, improved hirsutisim, inc. in BMD (osteoporosis protection)
Disadvantages:
a. menstrual: spotting (usually goes away in 3 months. post pill amenorrhea (temp or extended amenorrhea that can occur when a woman stops taking CHC
b. sexual/ psychological: mood changes, daily administration, can be expensive, adherence, decreased libido, anorgasmia
c. cancers: cervical and possibly breast cancer
d. others: no STD protection, side effects, DDI
Adverse effects:
common: Nausea, bloating, and break through bleeding. improve after 3 months
serious: ACHES: abdominal pain, chest pain, headache, eye problems, sudden leg pain
Management of bleeding irregularities:
a. hormone free interval for 3-4 consecutive days
I. not recommended in first 21 days of CHC use
II. not recommended more than once per month b/c decreased contraceptive effectiveness
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 7 days
Examinations or tests before initiation: BP measurement
What to do after late or missed dose:
a. if one pill missed <24- <48hours: take as soon as remember. no additional contraception needed
b. if 2 pills or more missed and >48hrs: take most recent pill ASAP. BUM or abstain for 7 consecutive days.
c. consider emergency contraception if pils were missed during first week and unprotected sex occurred in the previous 5 days
things for amy to remember: CHC reguate blood oss, cramps,
ACHES, nausea/ anorgasmia, decreased libido,
CHCs: cause spotting. will decrease in 3 months
dec ovarian, endometrial, colorectal, benign breast mass.
increase cervical and breast cancer
serious side effects of CHC
ACHES: abdominal pain, chest pain, headache, eye problems, sudden leg pain
Contraceptive type :Progestin only Pills (POP)
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers:
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:
amys main things to remember: formulations: administration: ae: more:
Contraceptive type :Progestin only Pills (POP)
Examples: Many brands/ generics (norethindrone: 1st gen progestin), Drospirenone
Administration: oral, daily, (norethindrone-no placebo). must be taken at same time every day
Advantages:
a. menstrual:decreased menstrual blood loss, cramps, pain
b. sexual/psychological: increased spontaneity, sexual enjoyment, easy to use
c. cancers: dec endometrial cancer
d. others: preffered for CHC contraindications
Disadvantages:not good for forgetful, adherence, possible increase in depression, anxiety, irritability
c. cancers: –
d. others: fewer contraceptive benefits.
e. Drospirenone: Contraindicated in women with a risk of hyperkalemia (renal impairment, hepatic impairment, adrenal insufficiency
Adverse effects:
common: androgenic AE: acne, hirsutism, weight gain, anxiety, depression
Management of bleeding irregularities: –
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 2 days
Examinations or tests before initiation: none
What to do after late or missed dose:
a. if one pill missed for >/3 hours, must use BUM or abstain for 48 hours
b. Drospirenone: more forgiving. if one missed pill >/=24 hours, use BUM or abstain for 48 hrs
amys main thing to rememnber:
dec. endo. cancer
take at same time everyday
preffered fro CHC CI
progestin side effects like acne, weight gain, hirsutism, depression
progestin menstrual pros and cons: dec menstrual blood loss, cramps, pain. causes menstrual irregularities
drospirenone: CI with increased risk of hyperkalemia, (renal and hepatic impairment, adrenal insufficiency)
can take an NSAID
Contraceptive type : Combined Hormonal Contraceptive Ring
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers:
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:
Contraceptive type : Combined Hormonal Contraceptive Ring
Examples: Nuva Ring, Annovera (NEW)
Administration:
Nuva ring: insert ring into vagina and leave for 3 weeks, week 4 remove ring and menses will occur
Anovera: Insert ring into vagina and leave for 3 weeks, week 4 remove ring and menses will occur. reinsert same ring every 4 weeks ( 3 weeks in, 1 week out) for up to 1 year.
Advantages:
a. menstrual: less spotting than COC, low risk of irregular bleeding
b. sexual/psychological: good for forgetful patients, increased spontaneity
c. cancers: dec chance of ovarian, endometrial, colorectal, and benign breast mass (not breast cancer)
d. others: non latex, nuva ring grace period of 35 days, less AE possible to less hormone. can remove during intercourse for up to 3 hours, have to remember to replace (wash), possible partner awareness, can use with tampon or yeast infection, privacy
Disadvantages:
a. menstrual: spotting (usually goes away in 3 months. post pill amenorrhea (temp or extended amenorrhea that can occur when a woman stops taking CHC
b. sexual/ psychological: insertion and removal, discomfort during intercourse
c. cancers: none
d. others: no STD protection, side effects, DDI, can’t feel it for the most part. nuva ring requires refrigeration
Adverse effects:
common: Nausea, bloating, and break through bleeding. improve after 3 months, device related events
serious: ACHES: abdominal pain, chest pain, headache, eye problems, sudden leg pain
Management of bleeding irregularities:
a. hormone free interval for 3-4 consecutive days
I. not recommended in first 21 days of CHC use
II. not recommended more than once per month b/c decreased contraceptive effectiveness
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 7 days
Examinations or tests before initiation: BP measurement
What to do after delayed vaginal insertion:
a. delayed insertion <24- <48hours: insert as remember. no additional contraception needed
b. delayed insertion >48hrs: insert ring ASAP. BUM or abstain for 7 consecutive days.
c. consider emergency contraception if delayed insertion during first week and unprotected sex occurred in the previous 5 days
Contraceptive type : Combined Hormonal Contraceptive Patch
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers:
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:
Contraceptive type : Combined Hormonal Contraceptive Patch
Examples: Xulane, Twirla, Ortho Evra (D/C)
Administration: Place a patch on dry, hairless area of the upper arm, shoulder abdomen or buttocks. should not be placed on breasts, rotate site each week. one patch per week for 3 weeks, then week 4 is patch free
Advantages:
a. menstrual: regulates blood loss, good for anemia, endometriosis, fibroids, decreased cramps
b. sexual/psychological: good for forgetful pts, increased spontaneity
c. cancers: dec chance of ovarian, endometrial, colorectal, and benign breast mass (not breast cancer)
d. others: grace period up to 9 days, ok if forget to change patch after 7 days, can bathe, swim, etc with it on, readily reversible and readily effective
e. Twirla. has lower estrogen component than Xulane (lower risk of blood clots)
Disadvantages:
a. menstrual: spotting (usually goes away in 3 months. post pill amenorrhea (temp or extended amenorrhea that can occur when a woman stops taking CHC
b. sexual/ psychological: mood changes, daily administration, can be expensive, adherence, decreased libido, anorgasmia
c. cancers: cervical and possibly breast cancer
d. others: clot risk (even more than COC), skin irritation, need to rotate site (butt, upper arm,, abdomen, shoulder), may not like appearance, less privacy, patch detachment (like a bandaid)
e. Xulane: less effective in pts. >198lb/90 kg (don’t use)
Twirla: CI in BMI>30 kg/m^2.
Adverse effects:
common: Nausea, bloating, and break through bleeding. improve after 3 months, irritation at patch site
serious: ACHES: abdominal pain, chest pain, headache, eye problems, sudden leg pain. HIGHER RISK OF BLOOD CLOTS
Management of bleeding irregularities:
a. hormone free interval for 3-4 consecutive days
I. not recommended in first 21 days of CHC use
II. not recommended more than once per month b/c decreased contraceptive effectiveness
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 7 days
Examinations or tests before initiation: BP measurement
What to do if delayed application or detachment:
a. if delayed application or detatchent <48hours: apply as remember. no additional contraception needed
b. if delayed application or detachment >48hrs: apply new patch ASAP. BUM or abstain for 7 consecutive days.
c. consider emergency contraception if delayed application or detachment during first week and unprotected sex occurred in the previous 5 days
Contraceptive type :Progestin only Injection (DMPA)
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers: –
d. others:
Adverse effects:
common: n)
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:–
Clinical Pearls
Contraceptive type :Progestin only Injection (DMPA)
Examples: Depo Provera, Depo SQ
Administration: 1 mL crystalline suspension of 150 mg of depot medroxyprogesterone acetate (DMPA) injected IM into deltoid or gluteus maximus muscle every 11-13 weeks or 104 mg of SQ DMPA every 11-13 weeks
Advantages:
a. menstrual:dec. cramping, amenorrhea lightened menstrual blood loss, decreased endometrial pain
b. sexual/psychological: increased compliance
c. cancers: dec endometrial cancer
d. others: good for patient on AED, post partum, etc.
Disadvantages:
a. menstrual: irregular menses (due to not having estrogen component)
b. sexual/ psychological: risk of depression
c. cancers: –
d. others: dec bone mineral density, weight gain, slow return to fertility, provider visit
Adverse effects:
common: androgenic AE: acne, hirsutism, weight gain, anxiety, depression, progressive, significant weight gain, severe depression (rare), BBW: bone loss (due to decreased production in estrogen)
Management of bleeding irregularities:
a. for unscheduled spotting or light bleeding, NSAIDS for 5-7 days
b. for heavy or prolonged bleeding:
I. NSAIDS for 5-7 days
II. hormonal treatment if medically elligible, with COCs or estrogen (10-20 days of treatment)
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 2 days
Examinations or tests before initiation: none
What to do after late or missed dose:–
Clinical Pearls
1. do not massage areas for a few hours after shot was given
2. expect irregular bleeding or spotting, but will decrease overtime
3.return in 11-13 weeks for injection, can be given early or up to 15 weeks without BUM, use BUM >15 weeks
4. may have delayed return to fertility for up to 18 months, use caution in women >35 years who express interest in future conception.
median time: 10 months.
range: 4-31 months
5. take calcium 1000-1200 mg/day
Progestin only implant
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:–
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers: –
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:–
clnical pearls
amys main things to remember
Contraceptive type :Progestin only Implant
Examples: Nexplanon
Administration: rod inserted SQ in the upper arm
Advantages:
a. menstrual:dec. amenorrhea , menorrhagia improves
b. sexual/psychological: adherance, increased spontaneity
c. cancers: –
d. others: readily reversible (immediate) effective for up to 3 years, MRI safe, various BMI’s studied. most effective form of BC
Disadvantages:
a. menstrual: irregular menses for first 6 months possible (due to not having estrogen component)
b. sexual/ psychological: none
c. cancers: –
d. others: expulsion, increased risk of infection 20 days after insertion, foreign body, progestin related AE
Adverse effects:
common: androgenic AE: acne, hirsutism, weight gain, anxiety, depression, bleeding irregularities
site reactions: inflammation, hematoma, pain, redness at site (3.6%), difficulty removing rod, rod breaks, fibrosis (1.7%)
Management of bleeding irregularities:
a. for unscheduled spotting or light bleeding or for heavy or prolonged bleeding:
I. NSAIDS for 5-7 days
II. hormonal treatment if medically elligible, with COCs or estrogen (10-20 days of treatment)
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 2 days
Examinations or tests before initiation: none
What to do after late or missed dose:–
Clinical Pearls
- indicated for long term prevention of pregnancy
- up to 3 years
- most effective form
Amys main things to remeber:
long term prvention: 3 years. readily reversible
progestin related side effects: acne, hirsutisim, depression, menstrual irregularirty
increased risk of infection due to foreign body
progestin only IUD (LNG IUD)
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers:
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:
Contraceptive type :Progestin only (LNG) IUD
Examples: Myrena, Kyleens, Skyla, Liletta
Administration: inserted into uterus by a health car professional and usually stays in place for 3-6 years; Mirena indicated for contraception and mennorhagia. Kyleena, Skyla, and Liletta indicated for contraception
Advantages:
a. menstrual: amenorrhea , menorrhagia improves, endometriosis improves
b. sexual/psychological: adherance, increased spontaneity
c. cancers: dec endometrial
d. others: extremely effective, readily reversible (immediate), approved efficacy for 3-6 years, possibly longer
I. Mirena: up to 6 years (but possibly up to 7)
II. Liletta: uptown 6 years
III. Kyleena: up to 5 years
IV.skyla up to 3 years
Disadvantages:
a. menstrual: irregular menses for first 6 months possible (due to not having estrogen component)
b. sexual/ psychological: none
c. cancers: –
d. others: expulsion, (decreases with time, increased if prior expulsion), increased risk of pid 20 DAYS AFTER INSERTION, foreign body
Adverse effects:
common: androgenic AE: acne, hirsutism, weight gain, anxiety, depression, bleeding irregularities
Serious: PAINS(IUD warning signs): Period late, Abdominal pain, Infection (STI)-abnormla discharge, Not feeling well (fever, chills), String missing
Management of bleeding irregularities:
a. counsel on alternative methods and offer another method, if desired
When to start:
anytime: if more than 5 days after start of menses, use back up method (BUM) or abstain for 7 days
Examinations or tests before initiation: Biamanual examination and cervical inspection
What to do after late or missed dose:–
Clinical Pearls
- LNG causes cervical muscus thickening
- string of IUD stays outside of the cervix
- sometimes trimmed strings are given to the patients to be able to check if the IUD is still inserted
- skyla may interfere with some MRI’s
- mirena has increased risk of expulsion in pts who have not had children
- placement may be easier with the use of lidocaine spray
Copper IUD
Examples:
Administration:
Advantages:
a. menstrual:
b. sexual/psychological:
c. cancers:
d. others:
Disadvantages:
a. menstrual:
b. sexual/ psychological:
c. cancers:
d. others:
Adverse effects:
common:
serious:
Management of bleeding irregularities:
When to start:
Examinations or tests before initiation:
What to do after late or missed dose:
Contraceptive type :Copper IUD
Examples:Paragard
Administration: inserted into uterus by a health car professional and usually stays in place for 10 y years; works primarily as a spermicide
Advantages:
a. menstrual: none, cycle remains regular
b. sexual/psychological: adherance, increased spontaneity
c. cancers: –
d. others: cost effective, readily reversible (return to fertility almost immediately), approved efficacy for 10 years, although likely effective for up to 12 years
Disadvantages:
a. menstrual: dysmenorrhea, spotting, cramping, monthly bloodless increased by 50% (may be diminished by NSAIDS or return to normal with continuous use)
b. sexual/ psychological: discomfort with strings or presence of foreign body
c. cancers: –
d. others: expulsion, (decreases with time, increased if prior expulsion), increased risk of pid 20 DAYS AFTER INSERTION, foreign body
Adverse effects:
common: –
Serious: PAINS (IUD warning signs): Period late, Abdominal pain, Infection (STI)-abnormla discharge, Not feeling well (fever, chills), String missing
Management of bleeding irregularities:
a. for unscheduled spotting or light bleeding or for prolonged or heavy bleeding, NSAIDS 5-7 days of treatment
When to start:
anytime: BUM not needed
Examinations or tests before initiation: Biamanual examination and cervical inspection
What to do after late or missed dose:–
Clinical Pearls
1. strings of IUD stay outside of the cervix
2.may be used as emergency contraception
creates a sterile inflamatory reaction that pairs implantation, is toxic to sperm and ova, impairs sperm motility, capacitation and survival and increases sperm phagocytosis
Contraceptive type : Emergency Contraceptive-Yuzpe method
Examples:
Administration:
Advantages:
Disadvantages:
Adverse effects:
Management of bleeding irregularities:–
When to start:
Examinations or tests before initiation: –
What to do after late or missed dose:–
Clinical Pearls
Contraceptive type : Emergency Contraceptive-Yuzpe method
Examples:
Administration: within 3 days, dose depends on formulation
Advantages: pt may have on hand
Disadvantages:
a. 2 doses
b. high insolence of N&V,
c. uses home COC
Adverse effects:
1. N&V, breast tenderness, headache
Management of bleeding irregularities: –
When to start: within 3 days unprotected sex
Examinations or tests before initiation: –
What to do after late or missed dose:–
Clinical Pearls
1. may take with food or meclizine (antiemetic) 50 mg prophylactically 30-60 min before each dose
Contraceptive type : Emergency Contraceptive-Levongestrel (oral)
Examples:
Administration:
Advantages:
Disadvantages:
Adverse effects:
Management of bleeding irregularities:–
When to start:
Examinations or tests before initiation: –
What to do after late or missed dose:–
Clinical Pearls
Contraceptive type : Emergency Contraceptive-Levonorgestrel (oral)
Examples:
Administration: 1.5 mg tab once within 3 days
Advantages: accessible to all ages in all pharmacies otc
Disadvantages:
a. cost
b. access
Adverse effects:
1. N&V, menstrual cycle changes
Management of bleeding irregularities: –
When to start: within 3 days unprotected sex
Examinations or tests before initiation: –
What to do after late or missed dose:–
Clinical Pearls
- on going need fo rocntraception
- need to get checked for STI
- menstrual cycle irregularities
- need for medical followup
- restart contraception: BUM x 7 days
- multiple times per menstrual cycle
Contraceptive type : Emergency Contraceptive-Ulipristal (Ella)
Examples:
Administration:
Advantages:
Disadvantages:
Adverse effects:
Management of bleeding irregularities:–
When to start:
Examinations or tests before initiation: –
What to do after late or missed dose:–
Clinical Pearls
Contraceptive type : Emergency Contraceptive- Ulipristal (Ella)
Examples:
Administration: 30 mg tab once within 5 days
Advantages: more effective than oral LNG
Disadvantages: a.cost b. access c. DI: CYP3A4 substrate D. prescription
Adverse effects:
1. N&V, menstrual cycle changes, headache, abdominal pain, dysmenorrhea
Management of bleeding irregularities: –
When to start: within 3 days unprotected sex
Examinations or tests before initiation: –
What to do after late or missed dose:–
Clinical Pearls
- on going need fo rocntraception
- need to get checked for STI
- menstrual cycle irregularities
- need for medical followup
- restart contraception: BUM x 14 days or until end of cycle
- ONCE per menstrual cycle
