Contraception Flashcards
What are the two mechanism of actions for contraceptions?
Inhibits viable sperm from coming into contact with mature ovum
Preventing fertilized ovum from successfully implanting in endometrium
What are the advantages and disadvantages of using male condoms? Are there any contraindications associated?
CI: Those allergic to latex or rubber
Advantages: STD protection
Disadvantage: High user failure rate; poor acceptance and potential breakage
What are the advantages and disadvantages of using female condoms? Are there any contraindications associated with its use?
CI: Allergy to polyurethane, and history of toxic shock syndrome
Advantages: STD protection, inserted ahead of time
Disadvantages: Poor acceptance to ring hanging out of vagina, high user failure rate
What are the advantages and disadvantages of using cervical caps and diaphragm with spermicide? Are there any contraindications associated with its use?
CI: Allergic to latex or rubber, recurrent UTI, History of TSS, Abnormal gynecological anatomy
Advantages: Low cost and reusable
Disadvantages: High user failure rate, less protection against STI, Increased risk of UTI and cervical irritation
What is the mechanism of action of progestins in contraceptions?
Thicken cervical mucus to prevent sperm penetration, slow tubal motility: delaying sperm transport and inducing endometrial atrophy: preventing fertilized egg from reaching endometrium
Also blocks LH surge and thus prevents ovulation
What is the mechanism of action in adding estrogen to COC?
Suppress FSH release and preventing ovulation
Stabilize endometrium lining to provide cycle control
When is a low dose of estrogen preferred?
Adolescents
Underweight
Age > 35 years
Peri-menopausal
Few side effects
When is a high dose of estrogen preferred ?
Obesity
Weight > 70.5kg
Early-mid cycle breakthrough bleeding
Tendency to be non-adherent
When is 4th generation progestins preferred?
Acne, oily skin and hirustism
What are some advantages and disadvantages of using drosperinone?
Advantages: Anti-mineralcorticoid, Anti-androgenic action, Reduced water retention, Decreases acne
Disadvantages: Hyperkalemia, thromboembolism, bone loss
Why is cyproterone not recommended for monotherapy in COC?
Increased risk of thromboembolism
When should I consider increasing dose of progestins?
Late cycle breakthrough bleeding
Painful menstrual cramping
What are the types of COC? Describe how they are different
Monophasic: Contains same amount of estrogen and progesterone
- less confusing, less complicated miss dosed instructions
Multiphasic: Contains variable amount of estrogen and progesterone
- Lesser progestin overall thus lesser side effects
Conventional COC: Contains 21 day active pills and 7 days placebo OR 24 active pill and 4 days placebo
- Including active pills help decrease hormone fluctuations and side effects
Extended cycle COC: 84 active pills and 7 day placebo
- Convenient and lesser periods
How can a dose be initiated? Is backup contraception then needed for each type of initiation?
First day of menses; no need for backup contraception
Sunday start (allow weekend free menstrual period); require backup contraception for at least 7 days
Quick start; require backup contraceptive for at least 7 days and until next menstrual period
List out the non-contraceptive benefits of taking COC.
Relief from menstrual related problems
Improve menstrual regularity
Acne
Decrease ovarian cyst, ectopic pregnancy, pelvic inflammatory disease, endometriosis, uterine fibroids and benign breast disease
Decrease risk of endometrial and ovarian cancer
PCOS
Iron deficient anemia
Premenstrual dysphoric disorder
What are the factors to consider before choosing a COC for patient?
Hormonal content required
Convenience
Adherence
Tendency for oily skin, acne, hirsutism
Medical conditions such as premenstrual syndrome, dysmenorrhea
Early/late bleeding
Cramping
How regular menses is
What are the 3 major adverse effects of taking COC?
Breast cancer
Venous thromboembolism
Ischemic heart disease and myocardial infarction
If patient highlights breast cancer history, when should I avoid prescribing COC?
Age more than 40y
Family history / risk of breast cancer
Current / recent history of breast cancer within 5 years
How does estrogen lead to an increased risk of VTE?
Increase hepatic production of factor VII, X and fibrinogen of coagulation cascade
What are some risk factors associated with increase VTE risk?
Age more than 35 years old
Smoking
Obesity
Family history of VTE
Immobilization
Cancer
What can I consider doing for those with increased VTE risk?
Lower dose of estrogen with older progestin
Use progestin only contraceptives
Use barrier method
What are some risk factors of ischemic stroke or myocardial infarction to highlight for those on COC?
Age
Hypertension
Migraine headache with aura
Obesity
Dyslipidemia
Smoking
Prothrombotic mutation
Which risk factors is of utmost importance in preventing ischemic stroke / MI? What can I do instead?
Migraine headache with aura
Can consider progestin only methods or barrier contraceptives
What are the absolute contraindications where COC use should be avoided?
Current breast cancer or recent breast cancer within 5 years
History of DVT / PE or acute DVT or patients with preexisting DVT and are on anticoagulant therapy
Major surgery with prolonged immobilization
< 21 days postpartum
Thrombogenic mutations
Migraine with aura
SBP > 160mmHg and DBP > 100 mmHg
HTN with vascular diseases
Current or history of ischemic heart disease
Cardiomyopathy
Smoking more than 15 sticks a day and age more than 35 years old
History of cerebrovascular disease
List the minor adverse events that can occur
Breakthrough bleeding, acne, bloating, nausea and vomiting, headache, menstrual cramps and breast tenderness or weight gain
How should I counsel patients on their experience for minor adverse effects?
To persevere COC use for 2-3 months before changing product unless patient is experiencing serioud adverse effects
What can I do to help with breakthrough bleeding? HINT consider when is breakthrough bleeding occurring.
Early / mid cycle bleeding: Increase estrogen content
Late cycle bleeding: Increase progestin
What can I do for acne upon taking COC?
Change to less androgenic progestin and consider increase estrogen
If patient is on progestin only pills, consider changing to COC
What can I do for patients who complain of bloating upon taking COC?
Decrease estrogen and consider changing to drospirenone (4th gen progestin)
What can I do for patients who complain of nausea and vomiting upon taking COC?
Decrease estrogen and take pills at night.
Change to progestin only products
What to do if patient complains of headache for their COC?
Exclude migraine with aura
Use extended cycle / continuous cycle
What to do if patient complains of getting menstrual cramps after taking COC?
Increase progestin content or change to extended cycle/continuous
What to do if patient complains of breast tenderness or weight gain after taking COC?
Keep estrogen and progestin as low as possible
What are the 3 drug drug interactions to consider for COC? What is the mode of action?
Rifampicin: Alter gut flora, alter metabolism and cause lesser active drug
Anticonvulsants: decreases free serum concentration of estrogen and progesterone
HIV Antiretrovirals: act as protease inhibitors
What is the inter relationship of COC and drug drug interactions?
Lower the dose of hormones, increased risk of interaction compromising efficacy
What can you advice patients who take Rifampicin and are planning to start on OCS?
Take backup contraceptives for at least 7 days
What should I enquire if patient complains of a missed dose?
How long ago the missed dose was
If patient missed one dose less than 48h ago, what can she do?
Take missed dose immeadiately and continue rest of the pack. DO NOT need backup contraceptives
IF patient missed 2 or more consecutive doses, what can she do?
Take missed dose immediately and discard the other missed doses
Finish the rest of the pack
Take backup contraceptives for at least a week.
If patient missed her COC dose on the last week of cycle, what can she do?
Finish remaining active pills in current pack and skip hormone free interval
Start new pack and use backup contraceptives for at least 7 days
What are other options to consider beside COC and barrier protective method?
Progesterone only pills
Transdermal contraceptives
Vaginal ring
Progestin injection
IUD
Subdermal progestin
What are some indications for progesterone only pills?
Breastfeeding
Intolerant to estrogen
Conditions that preclude estrogen
What are some contraindications for progesterone only pills?
Current or recurrent history of breast cancer
Poor adherence
Is back up contraception needed for progesterone only pills? What should I consider before initiating?
Consider when is patient starting on pills. If starting within 5 days of menses, no need backup contraception. If starting on other days, need back up contraception for 2 days.
If dose of POP is later than 3 hours, what do I advice the patient?
Back up contraception for 2 days
What is the dose of transdermal contraception?
Once weekly for 3 weeks followed by patch free week.
What is the dose for vaginal ring? Is product placement important here?
Use for 3 weeks and discard
Product placement not as important since drug absorption is what matters
Why are vaginal rings and transdermal contraceptives not recommended?
Increased exposure to VTE
What are the potential issues of using progestin injections?
Delayed return of fertility
Variable breakthrough bleeding
Weight gain and short term bone loss
Need to avoid older women and those with osteoporosis risk factors
Is progestin injection a long term solution? Why?
No
Requires evaluation for more than 2 years use
What is the mode of action for IUD?
Inhibit sperm migration
Damage ovum
Damage and disrupt transport of fertilized ovum
List the contraindications associated with IUD
Pregnancy
Current STI
Undiagnosed vaginal bleeding
Malignancy of GI
Uterine abnormalities
Uterine fibroids
What is the difference between progestin IUD and copper IUD?
Menstrual frequency: Progestin IUD has decreased menstrual flow while copper IUD has heavier bleeding
Concomitant conditions:
Progestin IUD preferred for those with concomitant menorrhagia while copper IUD preferred for those with concomitant amenorrhea
Duration of use:
Progestin IUD use for 5 years while copper IUD for 10 years
Mode of action: Progestin IUD causes endometrial suppression and mucus thickening
Copper IUD can be used as emergency contraceptive
What are the advantages and disadvantages of long acting reversible contraception?
Advantages: Effects are reversible
Disadvantages: Invasive
What is a subdermal progestin implant and what are the adverse drug reactions associated?
Single 4cm implant containing progestin that can cause irregular bleeding pattern as an adverse drug reactions.
