Contraception Flashcards
1
Q
What are the Canadian rates of birth in 2023?
A
10.1 births per 1000
-SK: 11.9 births per 1000 (2022)
2
Q
What is the average maternal age at first birth?
A
~30 years
3
Q
What is the percentage of pregnancies that are unplanned?
A
40-60%
->180,700 per year
-~50% of unintended pregnancies end in abortion
-approximately 1/3 of individuals have had at least one induced abortion
4
Q
What are the 5 hormones involved in the menstrual cycle?
A
GnRH (gonadotropin releasing hormone)
FSH (follicle stimulating hormone)
estrogen (predominantly estradiol)
LH (luteinizing hormone)
progesterone
5
Q
What is the role of GnRH in the menstrual cycle?
A
stimulates pituitary to release FSH and LH
6
Q
What is the role of FSH in the menstrual cycle?
A
stimulates maturation of follicles in ovaries
7
Q
What is the role of estrogen in the menstrual cycle?
A
stimulates thickening of endometrium (uterine lining)
suppresses FSH (negative feedback)
signals LH
8
Q
What is the role of LH in the menstrual cycle?
A
triggers ovulation
9
Q
What is the role of progesterone in the menstrual cycle?
A
produced by the corpus luteum (mass of cells resulting from the ruptured follicle when the ovum is released)
makes the endometrium favourable for implantation
signals the hypothalamus and pituitary to stop FSH and LH production (negative feedback)
10
Q
What is the average cycle length?
A
average is 28 days (range 21-40 days)
11
Q
What is day 1 of the cycle?
A
first day of period (menses)
12
Q
Describe the follicular phase.
A
day 1:
-first day of period
days 1-4:
-increases in FSH (follicle grows/develops)
days 5-7:
-one follicle becomes dominant
-starts producing estrogen (estradiol)
–>stops menstrual flow
–>stimulates thickening of endometrial lining
–>increased production of thin, watery cervical mucus
13
Q
What does consistently high estrogen levels cause?
A
stimulates the pituitary to release a mid-cycle surge of LH
LH=follicle maturation and triggers ovulation
14
Q
When does ovulation occur?
A
~28-32 hours after LH surge
typically around day 14 of a regular cycle
15
Q
Describe the luteal phase.
A
14 days long
released ovum travels through fallopian tubes to the uterus
if no implantation:
-corpus luteum deteriorates and stops producing progesterone
if implantation occurs:
-corpus luteum continues to produce progesterone but that function is ultimately taken over by the placenta
16
Q
What is the corpus luteum?
A
“left over” follicle
produces androgens, estrogen, and progesterone
progesterone provides negative feedback to stop FSH and LH production
maintains endometrial lining
17
Q
Describe the transition back from the luteal phase to the follicular phase.
A
as progesterone levels decrease
-endometrial lining is shed (menstruation)
-low progesterone and estrogen levels stimulate release of GnRH
18
Q
What are the four methods of contraception?
A
hormonal
barrier
permanent
natural family planning
19
Q
What are the two components of hormonal contraceptives?
A
estrogen
progestins
20
Q
What are the two forms of estrogen that can be in hormonal contraceptives?
A
ethinyl estradiol (EE)
-synthetic form of estradiol
-most common form
estetrol
-plant source
21
Q
What are progestins structurally similar to?
A
testosterone
-androgenic effects (acne, oily skin, hirsutism)
22
Q
Which progestins are anti-androgenic?
A
cyproterone acetate (Diane-35)
drosperinone
23
Q
What is the MOA of hormonal contraceptives?
A
estrogen and progestin provide negative feedback which inhibits ovulation
estrogen:
-suppresses release of FSH
progestin:
-suppresses release of LH and FSH
-thickens cervical mucus (impedes sperm transport)
-changes endometrial lining (not hospitable for implantation)
24
Q
What are the routes of administration for hormonal contraception?
A
oral (the Pill)
injectable
transdermal
intravaginal
intrauterine (hormonal and non-hormonal options)
implantable
25
List the routes of administration available for the following categories of hormonal contraception.
-combined
-progestin only
-long acting reversible contraception (LARC)
combined:
-pill
-patch
-ring
progestin-only:
-pill
-injection
long-acting reversible contraception (LARC)
-IUS/IUD
-implant
26
True or false: the types/doses of estrogen and progestin are identical in between products
false
it varies
27
Describe cyclic dosing of COC.
COC originally developed to mimic 28-day cycle
21 days of API + 7 days placebo
24 days of API + 4 days HFI
24 days of API + 2 days EE + 2 days HFI
*monophasic, biphasic, or triphasic*
28
What are the 3 phasic formulations for COC dosing?
monophasic: fixed levels of EE and progestin
biphasic: fixed EE levels; increased progestin in 2nd phase
triphasic: fixed or variable EE levels; increased progestin in all 3 phases
*different colours of pills for different strengths*
29
What is the idea of multiphasic products?
attempt to imitate the normal menstrual cycle-higher proportion of progestin to EE in second half of cycle
*no difference in efficacy, bleeding patterns, or adverse effects*
30
What is extended dosing of COC?
>1 "cycle" of active pills then HFI
84 days of API + 7 days EE (10mcg) or HFI
31
What is continuous dosing of COC?
can use any product (<50mcg EE) for continuous dosing (oral, transdermal, vaginal)
-even multiphasic products
32
True or false: there is no difference in efficacy or short-term adverse effects between cyclic and extended/continuous dosing
true
33
When is it most effective to start the pill?
most effective if started on day 1 (first day of period) and taken daily at the same time daily
34
What should be done if someone did not start the pill on day 1?
use back-up birth control method for first 7 days
*takes 7 days of continuous pill to use to suppress ovulation*
35
Describe the efficacy of COC.
perfect use: <0.3% failure rate
-one pill OD exactly 24hrs apart
typical use: 3-8% failure rate
-forgetting to take pill or taking it late (>24hrs apart)
-starting pack late
36
What are the adverse effects that are common in first 3 months of starting the pill?
breakthrough bleeding:
-check adherence
-if lasts >6months look for other causes (STIs)
breast tenderness:
-if lasts longer than first 3 months, look for other causes
nausea
37
What are some possible remedies for breakthrough bleeding, breast tenderness, and nausea from COC?
BTB:
-change to pill with higher estrogen/progestin (depending when BTB occurs in cycle)
breast tenderness:
-change to pill with less estrogen
nausea:
-take HS or with food
-change to pill with less estrogen
38
What are other adverse effects of COC? (other than the ones that are common in the first 3 months)
weight gain
-some notice increased appetite in first month, but overall little or minimal weight gain
headache or migraine
-can be hormone-related (can either increase or decrease with use)
mood changes-depression?
-some evidence for an association
acne
-can worsen initially but usually improves with long-term use
-continued problem? change to pill with less androgenic activity
39
What are the potential benefits of COC?
simple and effective birth control
improves menstrual symptoms and regularity
-reduces dysmenorrhea and ovulation pain
-reduces PMS symptoms
decreases incidence of:
-endometriosis
-endometrial cancers
-ovarian cancer
-ovarian cysts
-osteoporosis (increased bone density)
-acne and hirsutism
40
What are the risks of COC?
contraceptive failure:
-especially if missed pills with <20mcg estrogen
VTE:
-risk is 2-3x higher than in non-users
-risk increases with age, smoking, higher estrogen doses
-controversy whether drospirenone increases risk
MI and stroke (arterial thrombosis):
-increased risk associated with estrogen >50mcg/d, age >35, smoking, HTN, CVD risk factors
breast cancer:
-suggested there is an increased risk of 1.3x
-risk may return to baseline within 10yrs of DC
cervical cancer:
-suggested increase risk of 1.5x with >5yrs use
41
What are the early danger signs of COC?
ACHES
-abdominal pain (severe)
-chest pain (severe) or SOB
-headaches (severe)
-eye problems (blurring, flashing, vision loss)
-severe leg pain (calf or thigh)
42
What are the 3 main types of potential drug interactions for COC?
drugs that reduce the enterohepatic circulation of oral contraceptives
drugs that induce the metabolism of oral contraceptives
drugs that have their metabolism altered by oral contraceptives
43
What are the drugs that reduce enterohepatic circulation of oral contraceptives?
antibiotics: ???s
-increased intestinal transport (diarrhea)
-decreased enterohepatic reabsorption of estrogen
-penicillins, cotrimoxazole, nitrofurantoin, metronidazole
44
What is the management of the antibiotic-COC drug interaction?
no interactions: no restrictions to use
*except rifampin*
45
What are the drugs that induce metabolism of COC?
CYP450 3A4 inducers
-anticonvulsants (carbamazepine, phenytoin)
-rifampin
-herbals (STJ wort)
46
What is the management of the interaction between COC and drugs that induce its metabolism?
use product with higher estrogen levels (>30ug EE)
use extended dosing (skip HFIs)
*use alternative to interacting drug or other method of birth control*
47
Which drugs have their metabolism altered by oral contraceptives?
lamotrigine
-significantly reduced levels by induction of lamotrigine glucuronidation
48
What is the management of the oral contraceptive-lamotrigine interaction?
use alternative to interacting drug or other method of birth control
49
What are the contraindications to COC?
thromboembolic disease (current or past VTE)
HTN (>160/100mmHg)
ischemic heart disease/stroke
known or suspected breast cancer
migraine with aura
severe/active liver disease
post-partum (wait 3-6wks post-partum bc increased risk of VTE)
smokers (>15cigs/d) over 35 years old
50
What is the dosing of the transdermal patch (Evra)?
0.6mg EE + 6mg norelgestromin
-average daily release of 35ug EE + 200ug norelgestromin
51
Describe the efficacy of the transdermal patch.
perfect use:
-failure rate=0.3-0.7%
typical use:
-failure use=8%
52
Describe administration options of the transdermal patch.
apply patch on day 1 (no back-up method needed)
apply first Sunday (back-up method x 7d)
53
How long should one transdermal patch be left on?
1 patch applied weekly x 3 weeks
then no patch for 1 week (HFI)
54
Where can the transdermal patch be applied?
upper arm
buttocks
lower abdomen
upper torso
*good adhesive, <2% fall off*
55
What are the adverse effects of the transdermal patch?
similar to oral contraceptives
local skin irritation (20%)
can have increased spotting in first 2 cycles
56
When would transdermal patches be less effective and have increased risk of clots?
weighing >90kg
57
What are the drug interactions for the transdermal patch?
similar to COC
58
What is the Nuvaring?
flexible, non-latex vaginal ring
EE 15ug + 120ug etonorgestrel released daily
59
Describe the efficacy of intravaginal contraception.
perfect use:
-failure rate=0.3-0.8%
typical use:
-failure rate=8%
60
Describe administration of the Nuvaring.
insert (anywhere in the vagina) between days 1-5
-backup birth control for 7 days if not day 1
leave in for 3 weeks, remove for 1 week (HFI)
61
When is expulsion a concern for the Nuvaring?
if out for >3hrs
*expulsion rate is ~4%*
62
What is something to always ask if someone missed a dose of a contraceptive?
unprotected sex in last 5 days?
63
What are the adverse effects of intravaginal contraception?
similar to COC
vaginitis (5-13%)
foreign body sensation/discomfort
problems during sex (can have sex with it)
64
What are the drug interactions of intravaginal contraception?
similar to COC
65
How should the Nuvaring be stored?
store in fridge at pharmacy
stable x 4 months at room temperature (put exp date on box for patient)
66
What are the two options for progestin-only pills?
norethindrone
drospirenone
67
What is the dosing of norethindrone?
35mcg daily (no HFI)
68
What is the dosing for drospirenone?
4mg OD x 24 days then 4 placebo pills
69
What is the MOA of norethindrone?
alters cervical mucus and endometrium
in 50-60% of women can alter ovulation (suppress FSH/LH) and cause amenorrhea (no menstruation)
70
What is the indication for norethindrone?
estrogen contraindicated
-history/risk of blood clots
-smokers >35yrs old
-obese
-migraine
breastfeeding (wont decrease milk supply)
71
What is the MOA of drospirenone?
primarily suppresses ovulation
72
What is the indication for drospirenone?
estrogen contraindicated
-history/risk of blood clots
-smoker >35yrs old
-obese
-migraine
breastfeeding (wont decrease milk supply)
73
Describe administration of norethindrone.
start on day 1 (up to day 5) and take OD continuously (no HFI)
back-up method required for 2 days
MUST take at same time every day (within 3 hours)
-effect on cervical mucus only lasts ~24hrs
-missed pill (>3hrs)=back up method x 48hrs
74
Describe the efficacy of norethindrone.
perfect use:
-failure rate=0.5%
typical use:
-failure rate=5-10%
75
Describe administration of drospirenone.
start on day 1 and take OD continuously (24/4)
back-up method required for 7 days
76
Describe the efficacy of drospirenone.
perfect use:
-failure rate=0.5%
typical use:
-failure rate=5-10%
77
What are the adverse effects of progestin-only pills?
irregular bleeding (more so in first months)
headache
bloating
acne
breast tenderness
potential to increase K
78
What are the contraindications for progestin-only pills?
liver disease
breast cancer
drug interactions similar to COC
79
What is the available injectable contraception?
progestin injection (Depo-Provera)
-150mg medroxyprogesterone acetate
80
What is the MOA of Depo-Provera?
prevents ovulation by suppressing LH/FSH surge
increases viscosity of cervical mucus
potentially alters endometrial lining to make it inhospitable to implantation
81
Describe the efficacy of Depo-Provera.
perfect use:
-failure rate=0.3%
typical use:
-failure rate-=3-7%
82
Describe administration of Depo-Provera.
given IM q 12 weeks
-maximum effectiveness of <13 weeks
if injected on day 1-5: no back-up method
if injected after day 5: back-up method x 3-4wks
83
What should you do if you miss a dose of Depo-Provera?
if given in >14th week, do pregnancy test, EC prn, back-up method for contraception
84
What are the adverse effects of injectable contraception?
unpredictable bleeding in first months (gets better with time)
hormonal associations: acne, headaches, nausea, decreased libido, breast tenderness
weight gain (<2kg)
may decrease BMD (esp in first 2 yrs)
delayed return to fertility (avg 9 months)
85
What are the benefits of injectable contraception?
no estrogen (option for smokers, migraine)
few DI
amenorrhea (~60% at 12 months)
less adherence issues
86
What are the contraindications/precautions/risks to injectable contraception?
breast cancer
uncontrolled HTN/stroke/IHD
liver disease
87
What was the first IUD available?
Dalkon Shield
-prongs to keep in place made it painful to insert and removed, and string wicked bacteria into uterus
88
How often should a copper IUD be replaced?
q 3-10 yrs (product dependent)
89
What is the MOA of copper IUDs?
copper is released and produces an inflammatory reaction that is toxic to sperm, makes sperm transport difficult and possibly prevents implantation
90
What is the effectiveness of a copper IUD?
failure rate=0.6%
91
Which progestin is in hormonal IUDs?
levonorgestrel
92
What are the two hormonal IUDs available?
Mirena
-replace q 5 yrs
-initially delivers 20mcg/d to 10mcg/d
Kyleena
-replace q 5 yrs
-initially delivers 17.5mcg/d to 9mcg/d
93
What is the MOA of hormonal IUDs?
thickens cervical mucus to prevent sperm transport and permeability
alters endometrial lining to prevent implantation
can suppress ovulation in some individuals
94
What is the effectiveness of hormonal IUDs?
failure rate=0.2%
expulsion can occur (~6%/5yrs)
95
Describe administration of IUDs.
T-shaped piece of plastic with a copper wire or drug reservoir inserted by clinician into the uterus
*best if inserted on last few days of period*
96
What are the adverse effects of IUDs?
increased bleeding and cramping in first few months, but usually subsides
very rare for perforations
pelvic inflammatory disease
97
What are the contraindications to IUDs?
pregnancy
breast, cervical, endometrial cancer
STI or pelvic infection within 3 months
98
What is the product available as implantable contraception?
progestin-only (Nexplanon)
-etonogestrel 68mcg-up to 70mcg delivered daily
-lasts up to 3 yrs
99
What is the MOA of implantable contraception?
inhibits ovulation
changes cervical mucus
100
What is the effectiveness of implantable contraception?
>99% effective
101
Describe administration of implantable contraception.
inserted directly under the skin of the inner side of non-dominant upper arm
insert day 1-5 of cycle
should be able to feel it
102
What are the adverse effects of implantable contraception?
bleeding irregularities
headache
weight increase
breast pain
103
What are the contraindications to implantable contraception?
pregnancy
breast cancer
104
What are the barrier methods for contraception?
condoms
-decrease risk of pregnancy and STIs
diaphragms
-reusable, dome-shaped cap that covers cervix
-requires initial fitting by a clinician
sponges
-impregnated with spermicidal agents
cervical cap
-small than a diaphragm, fits over cervix
-requires initial fitting by a clinician
spermicides
-nonoxynol-9 (surfactant that destroys cell wall of sperm)
105
What are the types of condoms available?
latex
polyurethane
-compatible with oil-based lubricants and is more sensitive but greater risk for breakage
lambskin
-doesnt protect against STIs
106
Describe the efficacy of condoms.
external condom:
-perfect use=failure rate of 3%
-typical use=failure rate of 14%
internal condoms
-perfect use=failure rate of 5%
-typical use=failure rate of 20%
107
What are the methods of permanent contraception?
tubal ligation: occlusion of the fallopian tubes
-failure rate=0.5% after 1yr, 1.8% after 10yrs
vasectomy: occlusion of the vas deferens
-failure rate=0.2% after 1yr, 2.2% after 10yrs
108
What is natural family planning?
no contraceptive devices or chemicals
revolves around timing of ovulation
109
Describe the basal body temperature method of contraception.
take temp first thing in AM (at same time q day)
increase of at least 0.2C above baseline temperature indicates ovulation has occurred
after 3 consecutive days of increased temp, fertile period considered over
doesnt predict beginning of fertile period therefore limit to only having sex after 3 consecutive days
110
Describe the billings method of contraception.
identify fertile period by recognizing change in consistency and volume of cervical mucus
-changes around time of ovulation
-cervical mucus becomes clearer, slippery, and more elastic as ovulation nears
-after ovulation, mucus becomes more viscous and less volume
111
Describe the calendar method of contraception.
chart menstrual cycle over 6-12 cycles
determine fertile period
-subtract 21 from length of shortest cycle
(fertility begins)
-subtract 10 from length of longest cycle (fertility ends)
doesnt account for factors that influence timing of ovulation (stress, illness, etc)
112
Describe the lactational amenorrhea method of contraception.
physiological infertility from breastfeeding caused by hormonal suppression of ovulation
98% effective IF:
-exclusively breastfeeding
-baby <6 months old
-period hasnt resumed
113
What is emergency contraception?
any form of birth control used after intercourse but before implantation
womans last chance to prevent a pregnancy
114
Why are pharmacists involved in the prescribing of emergency contraception?
most accessible HCP
highly respected drug experts
physical exam not required, but provider assessment prior to EC is beneficial
increased EC access will decrease unwanted pregnancies and abortions
115
What is fertilization?
process of combining sperm with the ovum
116
How does pregnancy begin?
implantation of fertilized ovum (implantation occurs ~6-14 days after fertilization)
117
What is contraception?
prevention of pregnancy
118
What is medical termination?
disruption of implanted pregnancy and induction of uterine contractions
119
What are the indications for emergency contraception?
patient is of reproductive age
patient does not want to get pregnant
patient has had unprotected sex within the past 120 hours
-LNG: approved for up to 72hrs, some efficacy up to 120hrs
-UPA: approved for up to 120hrs
-Cu-IUD: up to 7 days (maybe longer)
120
When is the risk of pregnancy greatest?
5 days before ovulation to 1 day after
*it is difficult to determine with certainty the womens cycle, thus EC should be offered regardless of the cycle day on which UPI occurred*
121
What are the options for emergency contraception?
oral:
-ulipristal acetate (Ella)
-levonorgestrel (Plan B)
-combination OCP (Yuzpe method)
device
-copper IUD
122
Describe the copper IUD as a method of emergency contraception.
must be inserted by a physician
effective up to 7 days after unprotected intercourse (maybe longer?)
123
What is the MOA of the copper IUD for emergency contraception?
induces sterile inflammatory reaction in uterus, by-products of inflammation and Cu is toxic to sperm and egg
may prevent implantation
124
Describe ulipristal acetate (UPA) as a method of emergency contraception.
1 tablet (30mg) stat
selective progesterone receptor modulator
effective up to 5 days after unprotected sex
-does not seem to decrease over time
125
What is the MOA of UPA?
prevents or delays ovulation
-must be given before or during the peak of the LH surge
126
Describe levonorgestrel as a method of emergency contraception.
1 tablet (1.5mg) stat
more effective the earlier it is taken
-decreased effect when used 72-120hrs after
127
What is the MOA of levonorgestrel?
delays ovulation
-must be given BEFORE the peak of LH surge
-may inhibit sperm/ova travel
128
What are the adverse effects of oral emergency contraception?
nausea
vomiting
cramps
fatigue
headache
breast tenderness
*side effects more pronounced with Yuzpe method due to high levels of estrogen*
129
Which oral emergency contraceptive is excreted into breastmilk?
UPA
-express and discard milk for one week after use
130
Which oral emergency contraceptive is preferred if use is due to missed hormonal contraception?
LNG
-progestin may block UPA from working
131
How long must a woman wait to restart hormonal contraception after using UPA?
5 days (allows progesterone receptors to clear)
-use back-up birth control until 7 consecutive days of use
132
True or false: UPA and LNG are effective if unprotected sex occurs after EC
false
only works for one particular event
133
What is the preferred BMI for each of the emergency contraception options?
LNG: less effective if BMI >25
UPA: preferred if BMI 25-30
Cu-IUD: preferred if BMI >30
134
Do enzyme inducers decrease efficacy of oral emergency contraception?
not a CI to using oral EC
-some suggest increasing the LNG dose (3mg) if used with enzyme inducers
135
Describe how hormonal contraception should be restarted after emergency contraception.
LNG: same or next day
-back up contraception x 7 days
UPA: 5 days after dose
-back up contraception for 5 days after UPA + first 7 days of OC restart
Cu-IUD: start hormonal contraception 7 days before removal, or use back up contraception for first 7 days (or keep Cu-IUD)
136
True or false: pregnancy or abortion generally places women at significantly greater medical risks than would the brief use of the hormones in EC
true
137
What are the absolute contraindications to oral emergency contraception?
pregnancy
allergy to product components
138
What are the absolute contraindications to the Cu-IUD for emergency contraception?
pregnancy
unexplained vaginal/uterine bleeding
copper allergy
active pelvic infection
139
What are the drugs in Mifegymiso?
mifepristone 200mg
misoprostol 800mg (4x200mg)
140
How should Mifegymiso be taken?
misoprostol taken 24-48hrs after mifepristone
misoprostol by buccal route (30mins then swallow remaining fragments with water)
141
What does mifepristone do?
progesterone receptor modulator
-termination of pregnancy up to 63 days
142
What is the issue with emergency contraception?
no protection against STIs
STIs should be discussed with patients at risk and physician referrals should be made if the potential for transmission exists
143
What is the age of consent in Canada?
16 years
-can consent if 14 or 15 if partner isnt >5yrs older and not in a position of authority, trust, or dependency
-can consent if 12 or 13 if partner isnt >2yrs older and not in a position of authority, trust or dependency
minor=<18 yrs
144
Is the legal age of majority (18) relevant in consent for medical treatment?
no
*an individual who is able to understand the nature and anticipated effect of the proposed treatment, the alternatives and the consequences of no treatment is competent to give valid consent*
145
What is the role of pharmacists in helping women who have been sexually assaulted?
providing EC if appropriate
providing patient education
referring to other HCPs
referring to other agencies if appropriate
*referrals to the police or sexual assault crisis centre should be made only at the discretion of the individual*
146
What is something that pharmacists are required to do by law in the context of sexual assault?
report the assault of a minor
147
What are the requirements of a pharmacist when prescribing EC/HC?
competency
proper environment (accessible, confidential, private)
appropriate content (education, follow-up and/or referral when necessary)
148
What is the verdict surrounding moral/religious beliefs as a pharmacist in the context of contraception?
unethical for pharmacist to promote their moral or religious beliefs
MUST refer patients to a pre-arranged alternative that doesn't compromise products efficacy due to delay
149
True or false: emergency contraception can be prescribed in advance
true
LNG is OTC
can prescribe UPA just in case
150
How should emergency contraception be provided?
*ideally* supplied directly to a patient who makes a request for it
no restriction on OTC sale of LNG to partners, UPA is prescribed so patient only
151
What should be determined when prescribing for emergency contraception?
date of last menstrual period (LMP)
time since unprotected sex
did an additional unprotected sexual encounter occur since LMP
that the individual wants EC
152
What should be determined when prescribing for hormonal contraception?
patient is at least 12 years old
medical history (risk factors/CI)
medication history
do they want to become pregnant in next year?
153
How can nausea be minimized with oral emergency contraception?
take with food or pre-medicate with Gravol
154
What should be the next course of action if a woman vomits after using oral emergency contraception?
repeat doses that are vomited within 2 hrs (LNG) or 3hrs (UPA) of taking
155
How do we know that emergency contraception worked?
woman should get period within ~21 days
