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PHAR 253 > Contraception > Flashcards

Contraception Flashcards

1
Q

what % of pregnancies are unplanned?

A

40-60%
~50% of unplanned pregnancies end in abortion

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2
Q

what is GnRH and what does it do?

A

gonadotropin-releasing hormone stimulates pituitary to release FSH and LH from hypothalamus

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3
Q

what is FSH and what does it do?

A

follicle stimulating hormone stimulates maturation of follicles in ovaries

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4
Q

what does estrogen do?

A

stimulates thickening of the endometrium (uterine lining)
suppresses FSH (negative feedback)
signals LH

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5
Q

what is LH and what does it do?

A

luteinizing hormone triggers ovulation

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6
Q

what does progesterone do?

A

makes the endometrium favorable for implantation
signals the hypothalamus and pituitary to stop FSH and LH production (negative feedback)

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7
Q

where is progesterone produced?

A

the corpus luteum

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8
Q

what is the follicular phase?

A

days 1-7
day 1: first day of period
days 1-4: increase FSH (follicle grows)
days 5-7: one follicle becomes dominant, starts producing estrogen, stops menstrual flow, stimulates thickening of endometrial lining

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9
Q

when does ovulation occur?

A

~28-32 hours after the LH surge
typically around day 14 or a regular cycle

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10
Q

what is the luteal phase?

A

*14 days long
released ovum travels through fallopian tubes to the uterus
“left over” follicle becomes corpus luteum
- produces estrogen and progesterone
- provides negative feedback to stop FSH and LH production
- maintains endometrial lining

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11
Q

what happens if there is no implantation?

A

corpus luteum deteriorates and stops producing progesterone

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12
Q

what happens if implantation occurs?

A

corpus luteum continues to produce progesterone.. but that function is taken over by the placenta

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13
Q

when does the luteal phase switch to follicular phase?

A

as progesterone levels decrease and endometrial lining is shed (menstruation)

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14
Q

what stimulates the release of GnRH?

A

low levels of progesterone and estrogen

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15
Q

what is the difference between efficacy and effectiveness?

A

efficacy = how well something works in an ideal situation
effectiveness = how it happens in real life (drops about 10% usually)

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16
Q

what are the different contraception methods?

A

hormonal
barrier
permanent
natural family planning

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17
Q

what are the components of hormonal contraceptives?

A

estrogen - ethinyl estradiol (EE)
progestins - numerous options

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18
Q

what is the MOA of hormonal contraceptives?

A

estrogen and progestin provide negative feedback which inhibits ovulation

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19
Q

what is estrogens role in HC?

A

suppresses release of FSH

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20
Q

what is progestins role in HC?

A

suppresses release of LH and FSH
thickens cervical mucus
changes endometrial lining (the difference from progesterone)

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21
Q

what are the administration forms of HC?

A

oral(the pill)
injectable
transdermal
intravaginal
intrauterine
implantable

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22
Q

what are the categories of HC?

A

combined
progestin-only
long-acting reversible contraception (LARC)

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23
Q

what are the combined HC?

A

pill
patch
ring

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24
Q

what are the progestin-only HC?

A

pill
injection

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25
Q

what are the LARC HC?

A

IUD/IUS
implant

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26
Q

what are the 3 phasic formulations?

A

monophasic
biphasic
triphasic

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27
Q

what is monophasic?

A

fixed levels of EE and progestin

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28
Q

what is biphasic?

A

fixed EE levels
increase progestin in 2nd phase

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29
Q

what is triphasic?

A

fixed or variable EE levels
increase progestin in all 3 phases

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30
Q

what is extended dosing?

A

> 1 cycle of active pills the HFI

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31
Q

what is continuous dosing?

A

uninterrupted, no HFI
might be better to use monophasic (same level of hormone)

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32
Q

why do extended or continuous dosing?

A

less risk of ovulation
highest risk of ovulation when you miss the first pill in a pack
less “periods” - less period pain

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33
Q

when should the combined OC pill be started?

A

most effective if started on day 1 of period
can start on the first sunday after period starts (to avoid weekend period)
but can also start any day of the cycle

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34
Q

what do you need to do if not starting the combined OC pill on day 1?

A

use backup birth control for first 7 days

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35
Q

what is the efficacy of combined OC pill?

A

perfect use: <0.3% failure rate
typical use: 3-8% failure rate

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36
Q

adverse effects of combined OC common in first 3 months

A

breakthrough bleeding
breast tenderness
nausea

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37
Q

adverse effects of combined OC

A

weight gain
headache or migraine
mood changes
acne - can initially worsen but improve with long term use

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38
Q

benefits of combined OC

A

simple and effective birth control
improve menstrual symptoms and regularity
decreases incidence of endometriosis, endometrial cancers, ovarian cancers, ovarian cysts, osteoporosis, acne and hirsutism

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39
Q

risks of combined OC

A

contraceptive failure
venous thromboembolism (VTE)
MI and stroke (arterial thrombosis)
breast cancer
cervical cancer

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40
Q

what are the early danger signs of combined OC?

A

A - abdominal pain (severe)
C - chest pain (severe) and SOB
H - headaches (severe)
E - eye problems (blurring, flashing, vision loss)
S - severe leg pain (calf or thigh)

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41
Q

what drug interactions do combined OC have?

A
  • drugs that reduce enterohepatic circulation of oral contraceptives
    CYP450 3A4 inducers(anticonvulsants, anti-infectives, st johns wort) - drugs that induce the metabolism or oral contraceptives
    Lamotrigine - drugs that have their metabolism altered by oral contraceptives
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42
Q

when are combined OC contraindicated?

A

thromboembolic disease
hypertension (>160/100)
ischemic heart disease / stroke
known or suspected breast cancer
migraine with aura
severe / active liver disease
post-partum - wait at least 3-6 weeks
smokers over 35 years old

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43
Q

what is in the transdermal patch (Evra)?

A

0.6mg ethinyl estradiol + 6.0mg norelgestromin

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44
Q

what is the efficacy of the transdermal patch?

A

perfect use: failure rate = 0.3-0.7%
typical use: failure rate = 8%

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45
Q

where should the patch be applied?

A

upper arm
butt
lower abdomen
upper torso

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46
Q

adverse effects of the patch

A

similar to OC
local skin irritation
can have increased spotting in first 2 cycles
less effective and increase risk of clots if weighing >90kg

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47
Q

drug interactions of the patch

A

similar to combined OC

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48
Q

what is the intravaginal contraceptive and what is in it?

A

flexible, non-latex vaginal ring(Nuvaring)
- EE 15mcg + 120mcg etonogestrel released daily

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49
Q

what is the efficacy of the ring?

A

perfect use: failure rate = 0.3-0.8%
typical use: failure rate = 8%

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50
Q

administration for nuvaring

A

insert into vagina
leave in for 3 weeks, remove for 1 week (HFI)

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51
Q

how long can you remove the ring for?

A

less then 3 hours

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52
Q

adverse effects of the ring

A

similar to combined OC
vaginitis
foreign body sensation / discomfort
problems during sex

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53
Q

what are the drug interaction for the ring?

A

similar to combined OC

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54
Q

how does the nuvaring need to be stored?

A

store in fridge at pharmacy
stable at room temp for 4 months

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55
Q

how long can you use the ring for before replacing it?

A

until expiry
and there is one on in the states that you can use for 1 year

56
Q

what is in the progestin-only pill (“mini-pill”)?

A

norethindrone or drospirenone

57
Q

what is movisse and jencycla and how is it taken?

A

norethindrone 35mcg daily (no HFI)

58
Q

what is slynd and how is it taken?

A

drospirenone 4mg QD x 24 days then 4 placebo pills

59
Q

what is the MOA of norethindrone?

A

alters cervical mucous and endometrium
can alter ovulation in 50-60% of women (suppresses FSH/LH)

60
Q

what is the MOA of drospirenone?

A

primarily suppresses ovulation

61
Q

when is the progestin-only pill indicated?

A

if estrogen is contraindicated
- history/risk of blood clot
- smoker >35
- obese
- migraine
breastfeeding - won’t decrease milk supply

62
Q

what is the efficacy of the progestin-only pill?

A

perfect use: failure rate = 0.5%
typical use: failure rate = 5-10%

63
Q

administration for norethindrone

A

start on day 1 and take QD continuously
back up method required for 2 days
MUST take at same time every day (within 3 hours)

64
Q

administration for drospirenone

A

start on day 1 take QD continuously (24/4)
back up method required for 7 days

65
Q

adverse effects of progestin-only pill

A

irregular bleeding (more so in first months)
headache
bloating
acne
breast tenderness

66
Q

when is the progestin-only pill contraindicated?

A

liver disease
breast cancer
drug interactions similar to combined OC

67
Q

what is in the progestin injection?

A

150mg medroxyprogesterone acetate

68
Q

what is the MOA of the injection?

A

prevents ovulation by suppressing LH/FSH surge
increase viscosity of cervical mucous
potentially alters the endometrial lining to make it inhospitable to implantation

69
Q

efficacy of the injection

A

perfect use: failure rate = 0.3%
typical use: failure rate = 3-7%
- due to delayed or missed dose

70
Q

administration for injection

A

given IM q 12 weeks
no backup method required if injected on day 1-5
if injected after day 5 use backup method for 3-4 weeks

71
Q

what do do for missed dose of injection

A

if given >14 weeks do pregnancy test, EC prn, backup method for contraception

72
Q

adverse effects of injection

A

unpredictable bleeding in first months
acne, headaches, nausea, decreased libido, breast tenderness
weight gain (<2kg)
may decrease bone mineral density
delayed return to fertility (average 9 months)

73
Q

benefits of injection

A

no estrogen
few drug interactions
amenorrhea (~60% at 12 months)
less adherence issues

74
Q

contraindications of injection

A

breast cancer
uncontrolled hypertension
stroke / IHD
liver disease

75
Q

what was the first IUD?

A

the dalkon shield in 1950

76
Q

MOA of copper IUD

A

copper is released and produces an inflammatory reaction that is toxic to sperm, makes sperm transport difficult and possibly prevents implantation

77
Q

when does the copper IUD need to be replaced?

A

every 3-10 years (product dependent)

78
Q

efficacy of copper IUD

A

failure rate = 0.6%

79
Q

what is in a hormonal IUD (IUS)?

A

levonorgestrel

80
Q

how much drug does the mirena deliver?

A

20mcg/day initially.. to 10mcg/day

81
Q

how much drug does the kyleena deliver?

A

17.5mcg/day initially.. to 9mcg/day

82
Q

what is the MOA of a hormonal IUD?

A
  • thickens cervical mucous to prevent sperm transport and permeability
  • alters endometrial lining to prevent implantation
  • can suppress ovulation in some individuals (some eventually develop amenorrhea)
83
Q

effectiveness of hormonal IUD

A

failure rate = 0.2%
expulsion can occur (~6%/5 years)

83
Q

when should a hormonal IUD be inserted?

A

best if inserted on last few days of period (within first 7 days of cycle)

84
Q

adverse effects of IUDs

A
  • increased bleeding and cramping in first few months, but usually subsides
  • very rare for preforations
  • pelvic inflammatory disease (~1%)
85
Q

contraindications of IUDs

A

pregnancy
breast, cervical, endometrial cancer
STI or pelvic infection within 3 months

86
Q

what is the implantable contraception?

A

progestin-only nexplanon

87
Q

what is in the nexplanon?

A

etonogestrel 68mg - up to 70mcg delivered daily

88
Q

how long does nexplanon last?

A

up to 3 years

89
Q

what is the MOA of nexplanon?

A

inhibits ovulation
changes cervical mucous

90
Q

effectiveness of nexplanon

A

> 99% effective

91
Q

when should nexplanon be inserted?

A

day 1-5 of cycle
- use backup for 7 days if after day 5

92
Q

adverse effects of nexplanon

A

bleeding irregularities
headache
weight increase
breast pain
may migrate in some cases

93
Q

contraindications of nexplanon

A

pregnancy
breast cancer

94
Q

what are the barrier methods?

A

condoms
diaphragms
sponges
cervical cap
spermicides

95
Q

efficacy of external condoms

A

perfect use: failure rate = 3%
typical use: failure rate = 14%

96
Q

efficacy of internal condoms

A

perfect use: failure rate = 5%
typical use: failure rate = 20%

97
Q

what is a diaphragm?

A

reusable, dome-shaped cap that covers the cervix
requires initial fitting by clinician

98
Q

what is a sponge?

A

impregnated with spermicidal agents

99
Q

what is a cervical cap?

A

smaller than a diaphragm - fits over cervix
requires initial fitting by a clinician

100
Q

what is spermicide?

A

nonoxynol-9
surfactant that destroys the cell wall of sperm (kills and immobilizes sperm)
used with sponges, diaphragms and cervical caps

101
Q

what are the forms of permanent contraception?

A

tubal ligation - occlusion of the fallopian tubes
vasectomy - occlusion of the vas deferens

102
Q

efficacy of tubal ligation

A

failure rate:
- 0.5% after 1 year
- 1.8% after 10 years

103
Q

efficacy of vasectomy

A

failure rate:
- 0.2% after 1 year
- 2.2% after 10 years

104
Q

what is natural family planning?

A

no contraceptive devices or chemicals
revolves around timing of ovulation

105
Q

failure rates of natural family planning

A

fertility awareness - up to 24%
coitus interruptus - up to 22%
abstinence - 0%

106
Q

natural family planning with basal body temp

A

take temp first thing in the morning (at the same time each day)
increase of at least 0.2C above baseline temp indicates ovulation has occurred
after 3 consecutive days of increased temp, fertile period considered over
doesn’t predict beginning of fertile period

107
Q

billings method for natural family planning

A

identify fertile period by recognizing change in consistency and volume of cervical mucous
- changes around ovulation
- becomes clearer, slippery and more elastic as ovulation nears
- after ovulation, mucous becomes more viscous and less volume

108
Q

calendar method for natural family planning

A

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)
*doesn’t account for factors that influence timing of ovulation

109
Q

lactational amenorrhea method

A

physiological infertility from breastfeeding caused by hormonal suppression of ovulation
98% effective if:
- exclusively breastfeeding
- baby <6months old
- period hasn’t resumed

110
Q

what is EC?

A

any form of birth control used after intercourse but before implantation
- last chance to prevent pregnancy

111
Q

what schedule is plan B?

A

3

112
Q

define fertilization

A

process of combining the sperm with the ovum

113
Q

define pregnancy

A

begins with implantation of fertilized ovum (implantation occurs ~6-14 days after fertilization)

114
Q

define contraception

A

prevention of pregnancy

115
Q

define medical termination

A

disruption of implanted pregnancy and induction of uterine contractions

116
Q

when is EC indicated?

A

patient is of reproductive age
patient does not want to get pregnant
patient has had unprotected sex within the past 120 hours (5 days)

117
Q

how long is plan b (LNG) approved for after unprotected sex?

A

up to 72 hours (3 days)

118
Q

how long is Ella(UPA) approved for after unprotected sex?

A

up to 120 hours

119
Q

how long is the copper IUD approved for after unprotected sex?

A

up to 7 days (maybe longer)

120
Q

when is the risk of pregnancy the greatest?

A

5 days before ovulation to 1 day after because sperm survive up to 5 days and egg survives 12-24 hours

121
Q

what are the EC options?

A

oral - ella, plan b, combination OCP
device - copper IUD

122
Q

what is the drug in ella?

A

ulipristal acetate 30mg (1 tab)

123
Q

what is the drug in plan b?

A

levonorgestrel 1.5mg

124
Q

how does the copper IUD work for EC?

A

the MOA induces sterile inflammatory reaction in uterus.
by products of inflammation and copper are toxic to sperm and egg
also may prevent implantation

125
Q

what is the MOA of ella?

A

prevents or delays ovulation
must be given before or during the peak of the LH surge

126
Q

what is the MOA of plan b?

A

delays ovulation
may inhibit sperm/ova travel
must be given before the peak if the LH surge

127
Q

which combined OC can be used for EC?

A

alesse - 5 pills/dose
triquilar - 4 pills/dose
min-ovral - 4 pills/dose

128
Q

adverse effects of EC

A

nausea
vomiting
cramps
fatigue
headache
breast tenderness

129
Q

how long after taking UPA(Ella) can you restart HC?

A

5 days

130
Q

what EC is preferred for use due to missed HC?

A

LNG (plan b)

131
Q

which EC is preferred in people with BMI 25-30?

A

UPA(ella)
copper IUD if BMI >30

132
Q

are there any contraindications to EC?

A

pregnancy or allergy to something in the EC

133
Q

what is in mifegymiso?

A

mifepristone 200mg - progesterone receptor modulator
misoprostol 800mg (4 x 200mg)

134
Q

what is mifegymiso?

A

terminates pregnancy of up to 63 days

PHAR 253 (8 decks)

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