Contraception

Question 1

Benefits to Hormonal Contraception

Answer 1

• 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.)

Question 2

Risks to Hormonal Contraception

Answer 2

• 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

Question 3

Drug causes of COC failure

Answer 3

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.

Question 4

DIs of hormones

Answer 4

Estrogen: CYP 1A2
Progesterone: P-gp

Question 5

Combined Hormonal Contraception Contraindications

Answer 5

• 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

Question 6

COC Precautions

Answer 6

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

Question 7

CHC Early Signs of Danger

Answer 7

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)

Question 8

Progestin only pill missed days due to vomitting

Answer 8

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

Question 9

Emergency Contraception

Answer 9

Taken within 3-5 days of unprotected sex can delay or inhibit ovulation and prevent fertilization.
Cannot terminate an existing pregnancy

Question 10

EC: A/Es and DIs

Answer 10

N/V, HA, irregular bleeding.
If vomit <2hrs after taking for levongestrel/yupze method, take another dose, <3hrs for ulipristal

3A4 inducers

Question 11

Copper IUD for EC

Answer 11

First line if BMI >30
Insert within 5-7 days if pregnancy ruled out
Pregnancy rate <0.1% even after ovulation

Question 12

Medical Abortion

Answer 12

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

Question 13

A/E of CHC

Answer 13

Breakthrough bleeding, breast tenderness, weight gain, nausea, headache, acne (should improve in long term after worsening), mood changes, cholasma

Question 14

Signs of estrogen deficiency

Answer 14

Early bleeding/spotting, pelvic relaxation, atrophic vaginitis, vasomotor symptoms, continuous bleeding, nervousness, absence of withdrawal bleeding

Question 15

Signs of progestin deficiency

Answer 15

late bleeding and spotting days 10-21, delayed withdrawal bleeding

Question 16

Signs of estrogen excess +/- progestin deficiency

Answer 16

Hypermenorrhea, menorrhagia, N/V, HA, visual changes, PMS, dizziness, irritability, leg cramps, dysmenorrhea, bloating, edema

Question 17

Signs of excess estrogen

Answer 17

Hypermenorrhea, clotting, menorrhagia, increased breast size, cervical extrophy, fibroid growth, dysmenorrhea, mucorrhea, HTN, UTI, VTE

Question 18

Signs of excess progestin

Answer 18

Depression, breast tenderness, libido decrease, weight gain, increased appetite, hypoglycemia, dizzy, yeast infection, fatigue, leg vein dilation, cervicitis

Question 19

Signs of excess androgen

Answer 19

Oily skin/scalp, increased libido, edema, rash/pruritus, acne, hirsutism, jaundice

Question 20

Acne and CHC

Answer 20

All estrogen/progestin combo products are beneficial

Officially indicated: Try-cyclen, alesse, yasmin, yaz, yaz-plus

Question 21

Which [medication] contraceptive method has the highest failure rate?

Answer 21

CHC, then depo, copper IUD, IUD, and implant

Question 22

What are some reasons some may choose progesterone only?

Answer 22

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.

Question 23

Missed Doses

Answer 23

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

Question 24

When to use back up for initiation

Answer 24

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

Question 25

Depo dosing considerations

Answer 25

Likely effective up to Q14 weeks, it is for 13

Consider dosing every 10 weeks if on strong 3A4 inducer

Question 26

Duration for copper IUD

Answer 26

Shorter if nulliparous, longer if parous

Question 27

Missed doses in extended/continuous regimens

Answer 27

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