Contraception Flashcards
Benefits to Hormonal Contraception
- Simple and highly effective
- Reduces need for sterilization and abortion
- Significantly improves menstrual symptoms and regularity (dysmenorrhea, etc)
- Decreases relative incidence of disease (endometriosis, osteoporosis, cancers, etc.)
Risks to Hormonal Contraception
- VTE
- Arterial thrombosis (MI and stroke)
- Breast Cancer
- Cervical cancer
- BMD (<20mcg estradiol associated with low BMD)
- Does not prevent against STIs
- May impact sexual function
- May precipitate HTN, DM, etc.
- Failure
Drug causes of COC failure
Alcohol, ABX (rifamycin), anticonvulsants (not gabapentin, levetiracetam, pregablin. Use progesterone IUDs, depo, or >30mcg estrogen with continuous dosing or tricycling), antivirals (ritonavir, efanvirenz), bosentan.
Ulipristal (wait 5 days before starting COC as may decrease effectiveness of Uli.
DIs of hormones
Estrogen: CYP 1A2
Progesterone: P-gp
Combined Hormonal Contraception Contraindications
- Active VTE, current or past
- Heart disease
- Uncontrolled HTN
- History of cerebrovascular accident
- DM with microvascular issues
- Undiagnosed uterine bleeding
- Liver disease
- Known or suspected breast cancer
- Pregnancy or post partum
- Smoker over 35
- Migraine with aura
COC Precautions
HTN, DM, Epilepsy, hepatitis, symptomatic gall bladder disease, IBD (diarrhea decreases PO absorption and IBD increases VTE risk in mod-sev), lupus, smoker, older age, obese, history of embolic events, bariatric surgery, porphyria
CHC Early Signs of Danger
ACHES
A- abdominal pain (gallbladder disease, thrombosis, etc)
C- Chest pain (PE, acute MI)
H- Headaches (stroke, HTN, migraine)
E- Eye problems (blurred vision, flashing, etc)
S- Severe leg pain (DVT)
Progestin only pill missed days due to vomitting
V/D within 3 hours of taking pill, take another if able to tolerate and continue as usual.
Consider back up method until 2 days after symptoms resolve or until pills have been taken consistently for 2 days
Emergency Contraception
Taken within 3-5 days of unprotected sex can delay or inhibit ovulation and prevent fertilization.
Cannot terminate an existing pregnancy
EC: A/Es and DIs
N/V, HA, irregular bleeding.
If vomit <2hrs after taking for levongestrel/yupze method, take another dose, <3hrs for ulipristal
3A4 inducers
Copper IUD for EC
First line if BMI >30
Insert within 5-7 days if pregnancy ruled out
Pregnancy rate <0.1% even after ovulation
Medical Abortion
May offer to terminate <10 weeks
Mifepristone and Misoprostol
Take 1 200mg tab of Mife, then 800mcg (4 tabs) or buccal miso 1-2 days later
CI: ectopic pregnancy
A/E: cramping, bleeding HA, N/V, fever/chills
A/E of CHC
Breakthrough bleeding, breast tenderness, weight gain, nausea, headache, acne (should improve in long term after worsening), mood changes, cholasma
Signs of estrogen deficiency
Early bleeding/spotting, pelvic relaxation, atrophic vaginitis, vasomotor symptoms, continuous bleeding, nervousness, absence of withdrawal bleeding
Signs of progestin deficiency
late bleeding and spotting days 10-21, delayed withdrawal bleeding
Signs of estrogen excess +/- progestin deficiency
Hypermenorrhea, menorrhagia, N/V, HA, visual changes, PMS, dizziness, irritability, leg cramps, dysmenorrhea, bloating, edema
Signs of excess estrogen
Hypermenorrhea, clotting, menorrhagia, increased breast size, cervical extrophy, fibroid growth, dysmenorrhea, mucorrhea, HTN, UTI, VTE
Signs of excess progestin
Depression, breast tenderness, libido decrease, weight gain, increased appetite, hypoglycemia, dizzy, yeast infection, fatigue, leg vein dilation, cervicitis
Signs of excess androgen
Oily skin/scalp, increased libido, edema, rash/pruritus, acne, hirsutism, jaundice
Acne and CHC
All estrogen/progestin combo products are beneficial
Officially indicated: Try-cyclen, alesse, yasmin, yaz, yaz-plus
Which [medication] contraceptive method has the highest failure rate?
CHC, then depo, copper IUD, IUD, and implant
What are some reasons some may choose progesterone only?
Many reasons
- estrogen CI (VTE risk factors, migraine with aura, breastfeeding/postpartum)
- amenorrhea with most methods, depo being the best
- less failure rates, most cheaper in the long run (IUDs)
- much less drug interactions
- can have higher rates of acne and depo can decrease BMD
- pill must be taken at the same time every day within 3 hours, but other methods are q3m, or q5yrs, etc.
Missed Doses
CHC:
Week 1: take/apply/insert asap and continue as usual, consider back up for 7 days
Week 2/3: Take/apply/insert asap and continue as usual to end of cycle. Start new cycle without hormone free interval. Consider EC and back up if 3+ days missed
Missed days after cycle: resume ASAP, if ring >28 days skip hormone free and get back on track, restart new patch on usual patch change day if late taking it off and consider EC if pill cycle delayed, patch not removed until after hormone free interval, and ring left in for more than 35 days and back up
Ovulation rarely occurs after 7 days of continuous CHC
Detachment of patch <24 hrs fine, just reattach same patch, can be 2 days late in changing
Progestin only: >3hrs late in taking, use EC if unprotected sex in the last 5 days, and use back up for 2 days
Depo: if >14 weeks since last injection, test for pregnancy, consider EC if sex in last 5 days, use back up for 7
When to use back up for initiation
Use back up for 7 days if not started on same day as menses with CHC options
Use back up for 2 days if not started within 5 days of menses for progestin only pill
Use for 7 days if not started within 5 days for depo and implant
Use for 7 if not started within 7 for IUD, not necessary for copper
Depo dosing considerations
Likely effective up to Q14 weeks, it is for 13
Consider dosing every 10 weeks if on strong 3A4 inducer
Duration for copper IUD
Shorter if nulliparous, longer if parous
Missed doses in extended/continuous regimens
Up to 7 straight days can be missed as long as 21 days have been taken consecutively
Do not be hormone free for more than 7 days
