Contraception Flashcards
Type of available contraception methods;
Non-hormonal; barriers, fertility awareness, spermicides, copper IUD
Hormonal; pops, CHC,
How contraceptives work?
- Inhibit the viable sperm from coming into contact with a mature ovum (barriers, inhibit ovulation)
- Preventing fertilized egg from implanting successfully in the endometrium (unfavorable uterine environment)
Method of contraception; failure type associated with it
Oral contraceptives, depot, vaginal ring; user failure (failure is more common)
IUD, progestin implant; method failure
Protection against STDs;
Condoms (female and males) full protection
Diaphragm with spermicides, cervical cap ; some protection
Non hormonal method Can’t be given in recurrent UTI
Diaphragm with spermicides, sponge
*diaphragm increase incidence of vaginal yeast
Non hormonal method that Can’t be used in menses
Cervical cap, sponge
Menstrual cycle length
21-40 days.
Median 28
Spermicides are?
Nonoxynol-9 , chemical surfactant that destroy sperm cell wall and act as a barrier
2- no protection against STDs, and when used more than 2 times daily may increase the risk of hiv due to vaginal epithelium distruption
Which barriers Needs prescription
Doesn’t need prescription
Diaphragm, cap need prescription to decide size
Cap is available in 3 sizes
***diaphragm and cap are reusable can be used more than once
- sponge is available in one size and doesn’t need prescription, for one time use and should be discarded after removal
- condoms doesn’t need prescription
Time before,after and can be kept up to?
Diaphragm 6before, 6 after , shouldn’t be kept for longer than 24 hours
Cup 6 before , 6 after (must), shouldn’t be kept for longer than 48 hours
Sponge 6 before, 6 after, shouldn’t be kept for longer than 24-30 hours
Monophasic vs multiphasic vs extended cycle tablets
Monophasic; same amounts of estrogen and progestin for 21 days followed by 7 days free interval
Multiphasic; variable amounts of estrogen and progestin for 21 days followed by 7 days free interval
Extended cycle tablets; pills taken for 84 days followed by 7days free interval or estrogen only pills
Mini pills (pop)
- Must be taken every day at the same time for 28 days , if delayed more than 3 hrs: backup method for 48 hrs
- May not prevent ovulation ; higher risk of ectopic pregnancy
- associated with irregular and unpredictable menstrual bleeding
Emergency contraceptive is?
Ulipristal acetate
Space between emergency contraceptives and hormonal contraceptives at least 5 days to get the maximum effect of both
Initial dose, formulation of CHC
35 mcg ethinyl estradiol + progestin based on pt characteristics
Early side effects of OC are?
Nausea, bloating, breakthrough bleeding usually improve by the 3rd cycle
*Most common side effect; irregular bleeding
- Early breakthrough bleeding is typically due to insufficient estrogen
- Late breakthrough bleeding is due to insufficient progestin
- nausea due to; estrogenic effect
- skin breakouts may occur due to androgenic effects
Serious side effect and should dc CHC after consulting health care provider;
Serious warning signs; abdominal pain, chest pain, headache, eye problems, severe leg pain
Eye=> Loss of vision , proptosis,diplopia
Hemoptysis: pulmonary embolism
Slurring speech, unilateral numbness=> hemorrhage,stroke
DMPA side effects
Menstrual irregularities, Weight gain, acne,hirsutism,depression, decreased bone density. (Androgenic side effects)
Improve after ? 6months bcz its long acting depot
Pelvic inflammatory disease is an adverse effect of?
IUD (INTRAUTERINE DEVICE )
Other side effect is menstrual irregularities (spotting, amenorrhea) and is treated with NSAIDs
Antibiotics and OCS
Rifampin reduce the efficacy of OCs thus when using rifampin back up method should be used for 7-28 days after use of rifampin
Other AB has the potential to do this too but still not proved
- if rifampin or AB is used for more than 2 months; consider other contraception method as DMPA or IUD ( avoid oral )
Anticonvulsants and OCS
Some anticonvulsants (phenobarbital, phenytoin, carbamazepine) induce the metabolism of estrogen and progestin; we should consider DMPA or larc IUD ^implants is contravesal
Use of OCS with Lamotrigine; reduce effectiveness of lamotrigine and worsens seizures
Contraindications for CHC
Hypertension (diagnosed or bp>160/100)
<21 days postpartum
History or risk of thromboembolism/ DVT/PE
IHD, cardiac disease
Smoker >15 cig and age>35
Breast cancer
Liver cancer
Severe decompensated Liver disease (acute)
Major surgery with prolonged immobilization
Migraine with aura
Organ transplant
Antiretrovirals and OCS
Protease inhibitors and OCs both can affect the levels of each other
Drospirenone and hyperkalemia
Drospireneone is a spironolactone derivative which has anti mineralocorticoid activity; potassium sparing
So caution should be warranted in pts who take meds that increase k or cyp3A4 inhibitors or pts with hx of hyperkalemia
Missed doses of CHC
*if one tablet; take as soon as possible and cont regimen
But If in the beginning of cycle (1st week) free interval >7days Emergency, start pack ASAP, use backup for 7 consecutive days
*if 2 tabs are missed; in week1&2 take one tab ASAP and discard the other missed and then cont the regimen as it is ( take 2 tabs on same day and discard the other missed and cont regimen) and use backup method until 7 pills are taken consecutively and use emergency
*If 2 tabs were missed in the 3rd week; finish the active tabs and start a new pack directly with no hormone free interval
Add backup method for 7 days
No emergency
*if 3 or more pills ; take 1 pill immediately , use emergency, use back up for 7 days, discard missed, cont package , start new package immediately no hormone free period
Vomiting and diarrhea
If occurs for less than 48 hrs no need for redosing
If persists more than 48 hrs and in the last week cont regimen and start new pack immediately with no hormone free interval and use backup method for 7 consecutive days after V&D subsides.
If in first week: consider emergency
OCS and return to fertility
The average delay in ovulation occurs after 1-2 weeks of dc the OCS
Woman > 35 and CHC
CHC shouldn’t be given to woman > 35 and has migraine with aura, smoking, uncontrolled HTN, dm with vascular disease
Hypertension and CHC
CHC increase bp by 6-8 mmHg regardless of Estrogen dosage
And its associated with increased risk for mi and stroke
- low dose CHC is acceptable in women <35 and well controlled HTn
-if bp >160/100 CHC is contraindicated
-in women with bp 140-159/90-99 risk outweigh benefit
-if pt is taking ACE-i,ARBs, aldosterone antagonist => avoid giving Drospirenone as it causes hyperkalemia
Dyslipidemia and CHC
Progestin worsen lipid profile by increasing LDL and reducing HDL
Estrogen has beneficial effect by removing LDL BUT It may increase TGs
This happens in high doses.
It’s acceptable to use CHC in women with dyslipidemia as the single CV risk factor
Diabetes and CHC
Carbohydrate metabolism is affected by high doses of progestin, while nowadays formulations contain low progestin so no problem to use them in women with dm but non smoker,<35, no vascular disease.
- women with dm and vascular disease (nephro, neuro,retinopathy or any other vascular disease) shouldn’t use CHC
- Women with diabetes for more than 20 years duration also shouldn’t use CHC
Migraine and CHC
- nonmigrainous headaches and migraine without aura can use CHC
- While CHC shouldn’t be used in pts with migraine with aura at any age due to increased risk of strokes.
Breast cancer
—Women with benign breast ca or family history of breast CA can use CHC (not ci)
—Women with current or past history of breast CA history shouldn’t use CHC
Thromboembolism and CHC
Estrogen increase hepatic production if factor vii,x , fibrinogen in the coagulation state thus increase the risk of thromboembolic events, this risk is increased in women with hypercoagulable states; deficiency in; protein c, s, factor v , antithrombin 3 , also in immobility, surgery,pregnancy, obesity, malignancy.
—Pregnancy has higher risk for VTE compared to the use of CHC!
-newer gen of progestin (desogestrel,norgetimate, Drospirenone ) have higher risk for thrombosis due to increased anti androgenic effect (behave like estrogen which is responsible for thrombosis risk)
—Consider pop, low dose estrogen with older gen progestin, or barriers in women with risk for thrombosis
-pts with history of thromboembolism, or pts with major surgeries and prolonged immobilization are contraindicated to use CHC
Obesity and CHC
Obese women has higher metabolic rate thus more metabolism to the hormones plus more adipose tissue thus more sequestering for the hormones: resulting in reducing the efficacy of OCS! &higher failure rate
- in addition obese women are at increased risk for thrombosis
IUD, Implants, DMPA, pop are considered safe in obese women
—benefit of using CHC generally outweigh risk
— Pop is more appropriate for obese women >35
*** copper IUD is considered the most reliable Emergency contraception method in obese women
Postpartum and CHC
In the first 21 days: Ci, give pop
Breastfeeding and there is no risk for VTE; avoid for 30 days
Breastfeeding and there is risk for VTE: avoid for 42 days postpartum
Not breastfeeding; and there is risk for VTE; avoid for 42 days
Not breastfeeding and no risk for vte; avoid in first 21 days postpartum
**After 42 days postpartum: no restrictions on use of CHCs
Consider giving pop in the first 21 days postpartum
SLE and CHC
OCS with less than 50 mcg EE don’t increase the risk of flare among women with stable SLE without antiphospholipid/ anti cardiolipin antibodies
—CHC should be avoided in pts with SLE and antiphospholipid antibodies or vascular complications and risk outweigh benefit in using pop in these pts
Use IUD in these pts
In pts with SLE without antiphospholipd antibodies; we can use either pop or IUD or CHC with EE<50
—-SLE pts with severe thrombocytopenia should avoid DMPA and copper iud
Injectable progestins ; DMPA
Administered every 3months in first 5 days of cycle
If given on 1-7 days of cycle no need for backup
Other wise back up method for 7 days is needed
IM 150mg/ml in the gluteal or deltoid muscle and SC 104 mg in the abdomen or thigh
SHOULD BE REPEATED EVERY 3 months (12 weeks)
If dose was delayed for more than 13 weeks in IM and 14 weeks for the SC:
Pregnancy test is needed to exclude pregnancy
DMPA and postpartum
Women who are not breastfeeding can receive DMPA immediately postpartum
DMPA and return to fertility
Return to fertility may be delayed after dc when using DMPA compared to OCs, so it’s not recommended in women who desire to be pregnant in the near future
Delay is about 10 months minimum
Adverse effect of DMPA
Menstrual irregularities: spotting, prolonged bleeding, amenorrhea
NSAIDs or short course of COC (if no ci) may be Beneficial
Other AE is WEIGHT GAIN
Not ci in obese woman but not preferred and other risk factors should be Evaluated
- Short term bone loss in younger women due to
Lower ovarian estrogen bcz of suppressed Gnrh
So shouldn’t be used for more than 2 years unless there is no other adequate methods.
DMPA and corticosteroids
It’s not recommended to use DMPA with Women on long term Cs due to high risk of fractures
DMPA routine screening /monitoring
Bone mineral density (fractures)
Monitor weight gain and BMI
Menstrual cycle disturbances
at 3 month follow up
LARC is?
hormonal & non hormonal long acting reversible contraceptives ; IUD, Implants
No difference between typical/ perfect use because they don’t require effort/ adherence from the pt
Sub dermal progestin implant
Etonogestrel (nexplanon, implanon)
1- primary MOA is to suppress ovulation
2. It thicken mucous and cause atrophy for the endometrium
-efficacy is reduced in obese women >130% of the IBW
- if inserted in day1-5 no need for backup otherwise use backup for 7 days
-fertility returns after 30 days of removing the implant
-the major side effect is menstrual irregularities (use NSAIDs for 5-7 days is recommended or if no ci use estrogen for 10-20 days )
Pts on etonorgestrel implant should be monitored annually for menstrual cycle disturbances, local inflammation, or infection at the implant site, acne, Breast tenderness, headache, hair loss
Anti seizure medications, enzyme inducers and contraception
In patients who are taking enzyme inducers (phenytoin, carbamazepine, rifampin);
We should either
switch to DMPA Or IUD
Or add non hormonal method to the progestin implant due to risk of decreased efficacy of progestin.
IUD Types, MOA, duration, contraindications
1Copper para grad , 4 levonorgestrel (Mireya,liletta, skyla, kyleena)
MOA : inhibition of sperm migration, damaging ovum
Plus in progestin containing IUD: there is endometrium suppression and thickening of cervical mucous
Copper last for 10 years while the progestin last for 5 years except for skyla for 3 years
CI; stds, pelvic inflammatory disease, pregnancy, abnormal vaginal bleeding, inflammationsurerine anomalies
Women with current stds should dela6 IUD insertion while If STDS developed when IUD is already in place (STDs occurred after insertion) : keep iud in its place and treat std
IUD and blood flow
Copper iud is associated with increased menstrual blood flow and dysmenorrhea
While levonorgestrel iud reduce menstrual blood loss overtime and some pts develop amenorrhea
but with levonorgestrel iud there is increased spotting in the first 6 months (counsel the pt about that)
Emergency contraception
First line
1.Progestin only formulations
Levonorgestrel 1.5 mg tab for one dose or 0.75 mg 2 tabs
2.progesterone receptor modulators;
Ulipristal acetate (Ella)
Available by prescription only single dose of 30 mg taken within 5 days (120 hrs) of unprotected intercourse
3.Others; copper iud, high dose COC
after intercourse, implantation of fertilized egg takes 5 days
So take levonorgestrel containing Ec within 72 hrs of unprotected intercourse ( the earlier the better)
They may be effective for up to 5 days but if the woman can access ulipristal or copper IUD it’s better (after 72 hrs)
Common side effects: N &V , irregular bleeding
Irregular bleeding occur in all EC methods and usually 1 weak before or after the expected time
Ulipristal (Ella)
Is not recommended in breast feeding
Can be used as EC for up to 5 days after unprotected intercourse
Need prescription
30 mg single dose
May interfere with ongoing hormonal contraception so caution should be taken in the same cycle of using Ulipristal; use a reliable barrier method
Even if woman on a Regular hormonal contraceptives
—women should avoid starting hormonal contraceptive method for at least 5 days after Ulipristal use; this may alter the efficacy of both Ulipristal and hormonal contraceptive
Obesity and emergency contraception
data demonstrated that there might be a decreased efficacy of levonorgestrel in women > 75 kg but still controversial
In general It’s better to use copper IUD
Pregnancy termination drugs
Misoprostol, mifepristone, methotrexate
With misoprostol being used in comb with one of the above or alone
Mifepristone MOA;
1-progesterone receptor blocker, ( progesterone is needed to maintain corpus luteam during pregnancy)
2- soften the cervix and increase prostaglandins synthesis in which stimulate the contractions
Monitor ddi with enzyme inducers p/ inhibitors
2– misoprostol MOA
Is prostaglandins e1 analog (soften cerivx and induce contractions) found as oral, vaginal,but Al, sublingual
3- methotrexate MOA
Is an immunomodulator inhibit dihydrofolate reductSe and inhibit dna synthesis thus affecting rapidly growing cells in the placenta and cause abortion
Abortion regimens; mifepristone 600mg on day 1 - misoprostol 400 mcg after 48 hrs (most common and FDA approved )
Misoprostol-methotrexate or misoprostol alone
Follicular phase
Fisrt 4 days: FSH rise and allow for small group of follicles for continued growth
At day 5-7 one follicle becomes dominant
Dominant follicle keep secreting estradiol
increasing amounts of estradiol;
- inhibit the gnrh and thus FSH and thus other follicles die
- Estradiol stops the menstrual flow form the previous cycle
- Start to prepare the endometrium to receive the ovum by thickening the endometrium lining of uterus and thinning of the watery cervical mucus so the spermicides can pass through
FSH-> aromatase enzyme
Aromatase enzyme —> convert androgen into estrogen.
Ovulation
When estradiol levels remain elevated for a sustained period of time it stimulates the release of LH from the anterior pituitary
Lh helps in the final stage maturation Of follicle to become an COC yet
Estradiol peak 24-36 hrs before ovulation
Lh peak 10-16 hrs before ovulation
Lh surge occur 28-32 hrs before follicle rupture
Then ovulation occurs => oocyte is released into Fallopian tube into the endometrium
Luteum phase
The remnant of follicle become s corpus luteum which synthesize androgen, estrogen and progesterone
Progesterone helps maintain the endometrial lining and inhibit the Gnrh preventing development of new follicles
In pregnancy Hcg prevent regression of corpus luteum and stimulate a sustained production of estrogen and progesterone, until the placenta is able to do this role
If no fertilization=> corpus degenerate , estrogen and progesterone levels fall thus endometrium shedding and menstruation
Then at day 4 of menstru cycle FSH level rises and new follicles are stimulated again…
Pop
Must be taken at the same time daily for 28 days
If > 3 hrs late; backup methods should be used for 48 hrs
Pop may not inhibit ovulation so higher risk for ectopic pregnancy
