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PR3152 > Contraception > Flashcards

Contraception Flashcards

1
Q

What are the 2 forms of contraception

A
  1. Barrier method –> inhibiting viable sperm from coming into contact with a mature ovum
  2. Hormonal method –> preventing fertilized ovum from successfully implanting into the endometrium
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2
Q

What are the 4 barrier contraceptives available?

A
  1. Condoms (male)
  2. Condoms (female)
  3. Diaphragm with spermicide
  4. Cervical cap
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3
Q

Which contraceptives are useful for preventing STI transmission?

A

Condoms (male and female)

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4
Q

What are the limitations of barrier contraceptives?

A

High user failure rate

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5
Q

Benefits brought about by hormonal contraceptives

A
  1. Prevention of pregnancy
  2. Improvements in menstrual cycle regularity
  3. Management of perimenopause
  4. Management of PCOS
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6
Q

What is the MOA of progestin in COC?

A
  1. Thicken cervical mucus to prevent sperm penetration -> delaying sperm transport
  2. Induce endometrial atrophy (maintain thickness of endometrial and prevent it from growing)
  3. Stabilize the endometrial lining
  4. Provide cycle control
  5. Inhibit LH release –> prevents ovulation
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7
Q

What are the estrogen agents available?

A
  1. Ethinyl estradiol
  2. Estradiol valerate
  3. Esterol
  4. Mestranol
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8
Q

What is the main side effect of progestins?

A
  1. Androgenic side effects (ie. acne, oily skin, hirsutism) (associated with Gen1-3 progestins)
  2. Episodes of unpredictable spotting and bleeding (increases with increasing dose)
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9
Q

What is the MOA of Ethinyl estradiol?

A
  1. Synthetic estrogen
  2. Estrogen receptor agonist
  3. Inhibit FSH release from anterior pituitary –> suppress the development of ovarian follicle (prevent ovulation)
  4. Make endometrium unsuitable for implantation of the ovum
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10
Q

ADR of EE?

A
  1. breast tenderness
  2. Headahce
  3. Fluid retention (bloating)
  4. Nausea/ Vomiting or dizziness
  5. Weight gain
  6. Liver damage
  7. VTE
  8. MI/ stroke
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11
Q

ADR of EE?

A
  1. breast tenderness
  2. Headache
  3. Fluid retention (bloating)
  4. Nausea
  5. Dizziness
  6. Weight gain
  7. VTE
  8. MI/ stroke
  9. Liver damage
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12
Q

Factors favoring lower dose of EE?

A
  1. Adolescence
  2. underweight (< 50kg)
  3. Age >35 yo
  4. Peri-menopausal
  5. Fewer side effects
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13
Q

Factors favoring higher dose of EE?

A
  1. Obesity or weight >70.5 kg
  2. Early to mid-cycle breakthrough bleeding/ spotting
  3. Tendency to be non-compliant
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14
Q

List all the progestin agents by their Generation

A

Gen1: Norethindrone, Ethynodiol diacetate, Norgestrel, Norethindrone acetate
Gen2: Levonorgestrel
Gen3: Norgestimate, Desogestrel
Gen4: Drosperinone, Cyproterone

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15
Q

What are the features of Drosperinone (gen 4)?

A
  1. Analogue of spironolactone
  2. Anti-mineralocorticoid + some anti-androgenic action
  3. Less water retention and acne
  4. Can cause hyperkalemia, thromboembolism (VTE), and bone loss
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16
Q

What are the features of Cyproterone?

A
  1. Anti-androgenic + Anti-gonadotrophic
  2. Primary indication is to treat excessive androgen-related conditions
  3. Should not be used solely for contraception
  4. High risk for thromboembolism (VTE)
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17
Q

When there is early-mid-cycle breakthrough bleeding, what do you adjust in the COC?

A

Increase estrogen concentration

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18
Q

When there is late-cycle breakthrough bleeding and painful menstrual cramps, what do you adjust in the COC?

A

Increase progestin concentration

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19
Q

Advantages of monophasic COC

A
  1. Less confusing
  2. Less complicated miss-dosed instructions
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20
Q

Advantages of multiphasic COC

A
  1. Tend to have lower progestin –> less androgenic s/es
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21
Q

How many active and placebo pills are in conventional COC

A

21 days active pill + 7 days placebo (pill-free interval)
- Newer formulations has 24 active pills + 4 days placebo

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22
Q

Benefit of shorter pill-free interval?

A
  1. Reduce hormone fluctuations between cycles –> less side effects
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23
Q

How many active pills and placebo are in extended-cycle COC?

A

84 days active + 7 days placebo –> less periods
- Continuous COC has no placebo

24
Q

What are the different methods for initiating COC and what to take note of?

A
  1. First day method: Start on first day of menstrual cycle –> no backup contraceptions required
  2. Sunday start method: Start on first Sunday of menstrual cycle –> require backup contraceptive for 7 days
  3. Quick start method: Start ASAP –> require 7 days backup contraceptive or more (until next cycle)
25
Q

Factors in selecting COC?

A
  1. Hormonal content required
  2. Convenience
  3. Adherence level
  4. Tendency for acne, oily skin, or hirsutism
  5. Medical conditions (eg. premenstrual syndrome, dysmenorrhea)
26
Q

Non-contraceptive benefits of COC

A
  1. Relief from menstrual related problems
  2. Improvement in menstrual regularity
  3. Better for acne
  4. Premenstrual dysphoric disorder (PMDD - severe PMS)
  5. Iron-deficient anemia
  6. PCOS
  7. Reduced risk for ovarian and endometrial cancers
  8. Reduced risk of ovarian cysts, ectopic pregnancy, pelvic inflammatory diseases, endometriosis, uterine fibroids, benign breast disease
27
Q

Major side effects associated with COC?

A
  1. Breast cancer
  2. Venous Thromboembolism (VTE)
  3. Ischemic stroke/ MI
28
Q

Risk factors for breast cancer when on COC

A
  1. Duration on COC (after discontinuation, risk return to normal)
  2. Age >40 yo (avoid)
  3. Family Hx/ risk factors for breast cancer
  4. Current/ recent PMH of breast cancer (within 5 years)
29
Q

Which agent in COC are responsible for increasing VTE risk?

A
  1. Estrogen: Increase hepatic production of factor VII, factor X, and fibrinogen –> increase coagulation
  2. Newer generation progestin (Desogestrel, Drosperinone, Cyproterone)
30
Q

Risk factors for VTE

A
  1. > 35 yo
  2. Obesity
  3. Smoker
  4. Family Hx of VTE
  5. Immobilization
  6. Cancer
31
Q

Alternative contraceptives if patient is at risk of VTE?

A
  1. Low dose estrogen with older generation progestins
  2. Progestin-only contraceptives
  3. Barrier method
32
Q

Which component in COC is responsible for the increased risk of MI/ ischemic stroke?

A

Estrogen > progestin

33
Q

Which risk factor of MI/ ischemic stroke is an absolute contraindication for COC?

A

Migraine with aura (opt for progestin-only or barrier contraceptives)

34
Q

Risk factors of MI/ ischemic stroke that requires low-dose estrogen/ progestin-only/ barrier contraceptives

A
  1. Age
  2. HTN
  3. Obesity
  4. Dyslipidemia
  5. Smoking
  6. Prothrombotic mutations
35
Q

Absolute contraindications for COC

A
  1. Current breast cancer/ Recent Hx of breast cancer (within 5 years)
  2. Hx of Deep vein thrombosis/ pulmonary embolism, acute DVT/ PE and patients with DVT/ PE while on anticoagulant therapy
  3. Major surgery with prolonged immobilization (increased risk for VTE)
  4. <21 days postpartum
  5. Thrombogenic mutations
  6. Migraine with aura
  7. Severe HTN (SBP >160mmHg or DBP >100mmHg)
  8. HTN with vascular disease
  9. Current/ Hx of ischemic heart disease
  10. Cardiomyopathy
  11. Smoking ≥15 sticks/day AND age ≥35 yo
  12. Hx of cerebrovascular disease
36
Q

Common adverse effects of COC use and management

A
  1. Breakthrough bleeding: If early/ mid cycle, increase estrogen; If late cycle, increase progestin
  2. Acne: Change to less androgenic progestin
  3. Bloating: Decrease estrogen/ change to progestin with mild diuretic effect (ie. Drosperinone)
  4. N/V: Reduce estrogen/ take pills at night
  5. Headache: Usually occurs in pill-free interval, switch to extended-cycle COC or continuous COC
  6. Menstrual cramps: Increase progestin/ switch to extended-cycle or continuous COC
  7. Breast tenderness/ Weight gain: Reduce estrogen and progestin
37
Q

Counselling points for patient complaining about mild side effects associated with COC

A
  1. Adverse effects tend to occur during early COC use, may improve by 3rd-4th cycle after adjusting to hormone levels
  2. Persevere on COC for 2-3 months before considering a change
38
Q

DDI with COC

A
  1. Rifampin: Antibiotic that can alter gut flora –> alter metabolism –> less active drug; use backup contraceptive for 7 days after discontinuing rifampin
  2. Anticonvulsants (eg. phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine, lamotrigine): Reduces free serum concentrations of both estrogen and progestin
  3. HIV antiretrovirals (eg. Ritonavir, Darunavir): Reduces both effectiveness of COC and antiretroviral
39
Q

Counseling for missed dose of COC

A
  • If one dose is missed (<48hrs since a pill should have been taken), take the missed dose immediately and continue with the rest as usual
  • If ≥2 consecutive doses are missed (>48hrs), take the missed dose immediately and discard the rest of the missed dose –> continue the rest as usual and have backup contraceptive for 7 days
  • If pills were missed during the last week of hormonal tablets (eg. day 15-21), finish the remaining active pills in the current pack, skip the hormone-free interval and start a new pack the next day, backup contraceptive for 7 days
40
Q

Advantages of Progestin-only pills (POP)

A
  1. Good for breast-feeding (avoid estrogen while breastfeeding), intolerant to estrogen, conditions that preclude estrogen
  2. Continuous pills (28 days pills)
41
Q

Counselling points for initiating Progestin-only pills (Norethisterone)

A
  1. Start within 5 days of menstrual cycle/ bleeding –> no backup contraceptive required
  2. Start any other day –> require backup contraceptive for 2 days
42
Q

Counselling for missed dose of Progestin-only pill

A

If late dose by >3 hours, back-up contraceptive for 2 days is required

43
Q

What are the components in transdermal contraceptives

A

Both estrogen and progestin

44
Q

Limitations of transdermal contraceptive

A
  1. Not as effective in patients >90 kg
  2. Continuous exposure to estrogen can increase risk of VTE
45
Q

Limitation of transdermal rings

A

Continuous exposure to estrogen can increase risk of VTE

46
Q

Frequency of progestin injections

A

IM injection every 12 weeks (3 months)

47
Q

Limitation of progestin injection

A
  1. Return to fertility might be delayed
  2. Breakthrough bleeding especially in the first 9 months
  3. 50% of patients become amenorrhea after 12 months
  4. Regular doctor’s visit
48
Q

Notable adverse effects of progestin injections

A
  1. Weight gain
  2. Short term bone loss –> reduced bone mineral density (Black Box Warning)
49
Q

When to avoid progestin injections

A
  1. Older women
  2. Osteoporosis risk factors (especially long-term steroids) –> risk of bone loss
50
Q

List the 2 long acting reversible contraception (LARC) available

A
  1. Intrauterine device (IUD)
  2. Subdermal progestin implants
51
Q

MOA of IUD

A
  1. Inhibition of sperm migration
  2. Damage ovum
  3. Damage/ disrupt transport of fertilized ovum
  4. (if with progestin) Endometrial suppression and thickening of cervical mucus
52
Q

Contraindication of IUD

A
  1. Pregnant
  2. Current STI
  3. Undiagnosed vaginal bleeding
  4. Malignancy of genital tract
  5. Uterine anomalies of uterine fibroids
53
Q

Risk associated with IUD

A
  1. Uterine perforation
  2. Expulsion
  3. Pelvic inflammation
54
Q

Uses for Levonorgestrel IUD

A
  1. To decrease menstrual flow
  2. Ideally used if concomitant menorrhagia
  3. Inserted for 5 years
  4. Side effects include: spotting and amenorrhea
55
Q

Use for Copper IUD

A
  1. Used for heavier menses/ bleeding
  2. Ideally used if concomitant amenorrhea
  3. Inserted for 10 years
  4. Can be used as emergency contraception

PR3152 (7 decks)

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