Contraception Flashcards
Which progestin has anti-androgenic SEs?
Drospirenone (4th gen)
Benefits of Drospirenone (4th gen)?
ADEs? (3)
Anti-mineralocorticoid and anti-androgenic.
Causes less water retention and less acne, oily skin and hirsutism (androgenic SEs)
ADEs: hyperkalemia, thromboembolism, bone loss
3 main ADEs of COCs?
- Breast CA
- VTE
- Ischemic stroke, MI
Contraindications for COCs with regards to breast CA? (3)
- Age > 40 y/o
- Family history/ risk factors of breast CA
- Current/ recent hx of breast CA within 5 years
Contraindications for COCs with regards to VTE? (6)
- Hx of DVT/ PE, acute DVT/ PE, and pts with DVT/ PE and on anticoagulant therapy
- Major surgery with prolonged immobilization
- < 21 days postpartum + other risk factors
- < 6 weeks postpartum if breastfeeding
- Thrombogenic mutations
- SLE with APLA (antiphospholipid antibody syndrome)
Explain the role of estrogens and progestins in causing the SE of VTE
Estrogens ↑ hepatic production of factor VII, factor X and fibrinogen of coagulation cascade
New generation progestins (Drosperinone, Cyproterone, Desogestrel) ↑ protein C resistance
For a pt at risk of VTE, what contraceptive methods do we suggest?
- Low dose EE + older progestins
- Progestin-only pill
- Barrier methods
Explain the role of COCs in causing ischemic stroke/ MI- does it happen more with estrogen or progestin?
What are the risk factors?
More with estrogen
Risk factors:
- Age
- HTN
- *Migraine headache with aura
- Obesity
- Dyslipidemia
- Smoking
- Prothrombic mutations
Contraindications for use of COCs with regards to ischemic stroke/ MI? (8) (MSHCCSHD)
- Migraine with aura ⚠️ (AVOID estrogen completely, use progestin-only or barrier methods)
- SBP > 160 mmHg / DBP > 100 mmHg
- HTN with vascular disease
- Current/ hx of ischemic heart disease
- Cardiomyopathy
- Smoking ≥ 15 sticks/day AND age ≥ 35 y/o
- Hx of cerebrovascular disease
- Diabetes > 20 yrs or with complications
For a pt at risk of ischemic stroke/ MI, what contraceptive methods do we suggest?
- Low dose estrogen
- Progestin-only pill
- Barrier methods
We can initiate a COC on 3 different dates:
1) First day of menstrual cycle
2) First sunday after menstrual cycle begins
3) Quick start- NOW
Elaborate on the need for backup contraceptives for each of the options + advantage of the 2nd option
1) First day of menstrual cycle: no backup contraceptive required
2) First sunday after menstrual cycle begins: backup contraceptive required for at least 7 days.
Advantage: May provide weekends free of menstrual periods
3) Quick start- NOW: backup contraceptive required for at least 7 days and potentially until next cycle begins
What is the suggested action for ADEs:
1) Breakthrough bleeding
2) Acne
3) Bloating
1) Breakthrough bleeding:
if early-mid phase: ↑ estrogen
if late phase: ↑ progestin
2) Acne
switch to less androgenic progestin
if on POP, consider switching to COC
can ↑ estrogen
3) Bloating
↓ estrogen
change to progestin with mild diuretic effect (Drospirenone)
What is the suggested action for ADEs:
4) N/V
5) Headache
6) Menstrual cramps
7) Breast tenderness/ weight gain
4) N/V
↓ estrogen
take pills at night/ change to POP
5) Headache
Exclude migraine with aura first
Usually occurs in pill-free week → switch to extended cycle/ continuous/ shorter pill-free interval
6) Menstrual cramps
↑ progestin/ switch to extended cycle or continuous
7) Breast tenderness
Keep both estrogen/ progestin as low as possible
What medications have DDI with COCs? (3) (HAR)
How do they affect COCs?
- HIV antiretrovirals
- ↓ effectiveness of COC and antiretrovirals - Anticonvulsants
- ↓ serum free conc of estrogen and progestin - Rifampicin
- Alters gut flora → alters metabolism of COC → less active drug
- Use additional contraception until Rifampicin discontinued for at least 7 days
What are the actions to take when one dose of COC is missed (<48h)?
Take missed dose immediately
Continue rest as usual
What are the actions to take when 2 or more consecutive doses of COC missed (>48h)?
Is backup contraceptive required?
Take missed dose immediately, discard the rest of the missed doses
Continue rest as usual
Backup contraceptive for at least 1 week
What are the actions to take when COC doses are missed during the last week (day 15-21)?
Is backup contraceptive required?
- Finish remaining active pills in current pack
- Skip hormone-free interval
- Start new pack next day
Backup contraceptive for at least 1 week
What are the 2 types of POP?
- Continuous POP: norethinedrone/ levonorgestrel → 28 active pills
- Drospirenone → 24 active, 4 inactive
What are the instructions for starting a POP, any backup contraceptive required?
- Start within 5 days of menstrual cycle: no backup contraceptive required
- Any other day: backup contraceptive required for 2 days (7 days for drospirenone)
What do we do if we:
1) Late dose of N/L by >3h
2) Miss dose of Drospirenone by <24h
3) Miss dose of Drospirenone by ≥ 48h (≥ 2 pills missed)
1) Take missed dose and continue, backup for 2 days
2) Take missed dose and continue
3) Backup needed for 7 days
What can you say about hormonal transdermal patches and vaginal rings?
Continuous, higher exposure to estrogen ↑ risk of VTE
How often do we given progestin injections?
Every 12w, do not use for longer than 2y
SEs of progestin injections? (3)
What is one disadvantage?
- Variable breakthrough bleeding in first 9 months (MOST COMMON)
- Weight gain
- Short term bone loss (bone mineral density ↓)
Disadvantage:
Return to fertility might be delayed
Contraindications of progestin injections? (2)
- Older women
- Other osteoporosis risk factors (eg long term steroids)
SEs of LARC subdermal progestin implants (68mg etonogestrel)
- Spotting (34%)
- Prolonged bleeding (18%)
- Amenorrhea (22%)
Contraindications of IUDs? (6)
- Pregnant
- Current STI
- Undiagnosed vaginal bleeding
- Malignancy of genital tract
- Uterine anomalies
- Uterine fibroids
Compare Levonorgestrel IUD and Copper IUD
Levonorgestrel IUD:
- Menstrual flow DECREASED
-Typical spotting, amenorrhea
- Ideal if concomitant menorrhagia
- 5 years
Copper IUD:
- HEAVIER menses/ bleeding
- Ideal if concomitant amenorrhea
- 10 years
- Emergency contraception
3 types of emergency contraception?
Which are preferred for obese pts?
- Copper IUD (preferred for obese)
- Ella tablet (preferred for obese)
- Postinor 2 tablet
How do we use copper IUD for emergency contraception?
Insert within 5 days
How do we use Ella tablets for emergency contraception?
Can we still give it to pts already on progestin-containing OC?
Take 1 tablet ASAP or within 120h
Efficacy decreased if pt alr on progestin-containing OC, DO NOT give to pt within 5d of progestin-containing OC, or take progestin 5d later instead
How do we use Postinor 2 tablets for emergency contraception?
Take 2 tablets ASAP, preferably within 12h, not later than 72h
How is ethinyl estradiol metabolised? (liver) (process and by which enzyme)
What contributes to its longer t1/2?
- Phase I: hydroxylation by CYP3A4
- Phase II: conjugation with glucuronide and sulfation into hormonally inert ethinylestradiol glucuronides and ethinylestradiol sulfate
EE sulfate → enterohepatic recirculation to give longer t1/2 of ~13 - 27h
What do you know about progestin only pills/ injections and return to fertility?
Not desirable for women planning a pregnancy soon after cessation → ovulation suppression can sometimes persist for as long as 1.5 years
What must you take note of for the metabolism regarding progestin contraception?
Some norethindrone can be metabolized in liver to EE
Hence requires special attention of potential CV related complications (‼️VTE)
