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Pharmacology > Contraception > Flashcards

Contraception Flashcards

1
Q

Physiology of the Normal Menstrual Cycle

A
  • is regulated by positive and negative feedback in the hypothalamic-pituitary-ovarian axis
  • gonadotropin-releasing hormone (GnRH) pulses regulate follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which in turn, regulate the secretion of estrogen and progesterone from the ovary
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2
Q

Four Phases of the Menstrual Cycle

A
  1. Follicular
  2. Ovulatory
  3. Luteal
  4. Menstrual
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3
Q

Follicular Phase

A
  • first phase of menstrual cycle
  • FSH stimulates several follicles to develop
  • the dominant follicle synthesizes enough estradiol to create negative feedback and decrease FSH levels
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4
Q

Ovulatory Phase

A
  • second phase of the menstrual cycle
  • estradiol levels peak and exert positive feedback to induce an LH surge, which facilitates release of the mature ovum
  • estrogen promotes proliferation of the endometrium and development of progesterone receptors in the endometrium
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5
Q

Luteal Phase

A
  • third phase of the menstrual cycle
  • progesterone prevents new follicle development as well as differentiation of the endometrium
  • if no pregnancy, the corpus luteum degenerates, leading to menstrual bleeding
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6
Q

Estrogen

A
  • has positive effects on bone mass, increases serum triglycerides, and improves ratio of high-density lipoprotein to low-density lipoprotein
  • stimulates coagulation and fibrinolytic pathways
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7
Q

Progesterone

A
  • increases body temperature and insulin levels
  • may depress the CNS
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8
Q

Estrogen Contraceptives

A
  1. Ethynyl estradiol
  2. Mestranol
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9
Q

Examples of 1st Generation Progesterones

A
  1. Norethindrone
  2. Norethindrone acetate
  3. Ethynodiol diacetate
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10
Q

Examples of 2nd Generation Progesterones

A
  1. Norgestrel
  2. Levonorgestrel
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11
Q

Examples of 3rd Generation Progesterones

A
  1. Desogestrel
  2. Norgestimate
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12
Q

Examples of 4th Generation Progesterones

A
  1. Spironolactone derivative: drospirenone
  2. 19-nortestosterone derivative: dienogest
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13
Q

Mechanisms of Pregnancy Prevention

A
  • progestins are primarily responsible for the contraceptive effect
  • progestins exhibit a negative effect in the hypothalamic-pituitary-ovarian axis
  • progestins cause atrophy of the endometrium, preventing implantation
  • the estrogen component improves efficacy by suppressing FSH release
  • estrogen provides cycle control
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14
Q

Goals of Contraceptive Treatment

A
  • use the safest, best-tolerated, and most effective method that the patient desires
  • safety
  • tolerance
  • effectiveness
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15
Q

Fine Tune Contraceptive Drug Selection Based on

A
  1. menstrual pattern
  2. side-effect profile
  3. patient’s desire for discretion
  4. timing of subsequent pregnancy
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16
Q

Contraceptive Drug Selection: Cost

A
  • retail cost of OC (oral contraception) is $30 to $100 per cycle
  • generic OC is available on $4 retail lists
  • intrauterine device (IUD) or implant: upfront cost is expensive, but may have lower overall cost
17
Q

Non-contraceptive Benefits

A
  • decreased dysmenorrhea, menstrual irregularities, and menstrual blood loss
  • lessening of acne and hirsutism
  • fewer ovarian cysts
  • significantly reduced endometrial and ovarian cancer risk
  • lower incidence of benign breast conditions, such as fibrocystic changes and fibroadenoma
  • reduced risk of hospitalization for gonorrheal pelvic inflammatory disease
  • suppression of endometriosis in women who do not currently desire pregnancy
18
Q

Contraceptive Drug Interactions

A
  • TB drugs
  • antiepileptic drugs
  • St. John’s Wort
19
Q

Contraceptive Drug Adverse Reactions

A
  • venous thromboembolism risk increases three to five times with OC use
  • cholestatic jaundice
  • benign hepatic neoplasms
  • myocardial infarction
  • stroke
  • neurological migraines
20
Q

Traditional OC Regimen

A
  • 21 days active drug + 7 days inactive tablets with withdrawal bleed during inactive tablets
21
Q

Extended Cycle OC Regimen

A
  • 84 days of active drug, then 7 days off
  • withdrawal bleed once every 3 months
22
Q

Monophasic

A
  • same dose of estrogen and progestin for full cycle
23
Q

Biphasic

A
  • vary the dose of progestin
24
Q

Triphasic

A
  • vary the dose of estrogen, progestin, or both
25
Q

OC First Day Start

A
  • pills started on first day of menstrual cycle
  • no backup method needed
26
Q

OC Sunday Start

A
  • first pill taken on the Sunday following the start of menses
  • back method for first 7 days
  • menses only occur during the week
27
Q

OC Quick or “Same Day” Start

A
  • first pill taken on the day of the office visit
  • back up method needed for the first 7 days
28
Q

OC Patient Education

A
  • what to do if doses are missed
  • 50% of women discontinue because of the side effects
29
Q

Contraceptive Topical Patch

A
  • Ortho Evra patch: releases 20 mcg of estrogen and 150 mcg of norelgestromin
  • patch applied weekly for 3 weeks, then 1 week off
  • start on first day of menses (can start other days if back up method is used)
  • ADRs similar to OC ADRs
  • Increased failure rate in women weighing more than 198lb
30
Q

Vaginal Ring

A
  • NuvaRing is a soft, flexible plastic ring that releases 15 mcg of estrogen and 120 mcg of etonogestrol daily
  • ring is placed in the vagina, left in place for 3 weeks, and then is left off for 1 week
  • better cycle control and decreased breakthrough bleeding are achieved compared with OC
  • systemic exposure to estrogen is lower
31
Q

Progestin Only Pills

A
  • these are used when estrogen is contraindicated
  • contraceptive effect is through thickening of cervical mucus and prevention of sperm penetration
  • users have to be diligent about taking dose daily at the same time (if a pill is taken even a few hours late, back up is recommended for the next 48 hours)
  • ADRs: changing bleeding patterns and breast tenderness are common
32
Q

Injectable Progestins

A
  • depot medroxyprogesterone acetate (Depo-Provera) is a long-acting, injectable progestin-only contraceptive
  • one injection is effective in suppressing ovulation for 12-13 weeks
33
Q

Advantages of Injectable Progestins

A
  • once every 12 week dosing
  • effective
34
Q

Disadvantages of Injectable Progestins

A
  • spotting, followed by amenorrhea
  • weight gain
  • depression
  • black box warning: decreased bone density with longer-term use
35
Q

Mirena IUD

A
  • releases 20 mcg of levonorgestrel daily
  • can be left in place for 5 years
  • only small levels of systemic circulating hormone and minimal systemic side effects
  • changes in menstrual bleeding, amenorrhea
36
Q

Implanon

A
  • an implantable rod that contains 68 mg of etonogestrel
  • provides contraception for up to 3 years
37
Q

Emergency Contraception

A
  • should be implemented as soon as possible (less than 72 hours) after unprotected intercourse
  • may be initiated up to 120 hours after
38
Q

Methods of Emergency Contraception

A
  • Combined OCs
  • Progestin only (Plan B and Next Choice)
  • Copper IUD
39
Q

Monitoring

A
  • routine female screening
    + history
    + breast and pelvic examinations
    + Papanicolaou (“Pap”) test and sexually transmitted infection testing
    + blood pressure
  • physical examination, breast examination, pelvic examination, and PAP testing not required for contraception prescription
  • BP and ADRs monitored at 3 months, then annually

Pharmacology (6 decks)

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