Contraception Flashcards
Female reproductive cycle review
28 days; 2 phases-
Day 1= first day of menseS
Two phases:
FOLLICULAR
D 1-14
Anterior pituitary releases FSH which causes eggs to begin to mature
(Usually 5-7 eggs maturing but only 1 or 2 dominant follicles)
» follicles secrete estrogen which PROMOTES GROWTH OF UTERINE LINING» when estrogen levels reach a certain point LH is secreted from anterior pituitary, finalizing follicle development and OVULATION OCCURS!
LUTEAL PHASE
D 14-28 (ovulation until menses)
Site of ovulation becomes Corpus Luteum and secretes progesterone for an impending pregnancy until placenta could take over (ie about 10 weeks)
If no fertilization, there is a loss of feedback and CL DEGRADES
» lack of progesterone»_space; shedding of uterine lining
Types of hormonal contraception
1. OCPs- COCs (combined oral contraceptives) Monophasic Biphasic Triphasic -progestin only "mini pill" 2. IUD (mirena) 3. Other progestin-only implants (Depo Provera, Implnanon)
Oral contraceptives: combined OC’s almost always contAin ethinyl estradiol (EE), and a progestin.
EE is always the same but the difference in progestins…
…is the androgen in activity
Aka: how much does it behave like testosterone
More androgenic= more acne, bloating, hirsuitism
Newer progestins have less androgenic activity
OC’s: How do they work?
- combined estrogen / progestin work to suppress release of FSH and LH; without ovulation pregnancy cannot occur
1. Estrogen: suppresses LH AND FSH/speed ovum transport, decreasing fertilization time
2. progestin: in its ovulation by suppressing release of LH, THICKEN CERVICAL MUCUS (ie barrier), and creates a more hostile environment for implantation
OC’s 4 types and main points on each
- Monophasic : 1 level of hormone for cycle
- Biphasic: 2 combos of estrogen/ progestin
- Triphasic: 3 “ “ “” “”
Tripahsic: Has many different forms, either progestin or estrogen may increase or stay same
Progestin only: constant level of progestin
estrogen is almost always EE, but the type of progestin changes
Progestins are all derivatives of testosterone-
Either an estrane or a gonane does not describe pharmacological activity
Exception = drosperinone. A derivative of aldosterone.
OC’s - how to pick one, how to dose
*start with low dose» lowest risk side effects
(Low dose pills have 18-25 mcg EE, normal pills have 30-50 mcg)
**triphasic mimics normal cycle, so good place to start
Low dose pill better for:
History of common migraines (no aura) Uterine fibroids HX heavy menses HTN FIbrocystic blasts
If pt weighs more than 160#, how to dose:
Need pill with higher amounts estrogen and progesterone
If triphasic causes untoward side effects like mood swings, try…
Monophasic for extended cycle regimens:
Menses q 3 mo
84 days of EE/progestin
(seasonique, seasonale,Lybrel)
Are hormones variable in mono, bi and tri phasic? y / n
Hormones are viable with these preparations**
There are generations of progestins. The third gen, gonane, “Desogestrel/ Norgestimate,” is….
Least adrenergic; increased risk for blood clots
Progestin only pills are good choices for:
- Breastfeeding women( estrogen can decrease supply but not likely progestin)
- Women with HX blood clots
- HX of classical migraines
Some items to emphasize with Progestin only pills:
- *must be taken same time every day- no room for error. If miss pill, use back up pill
- there are no placebo pills
- most women have irregular spotting but no menses
- amenorrhea common
Some name of progestin- only:
Norethidrone (Micronor, Camila, Errin, Jovlivette)
norgestrel (overette)
How to start OC’s: quick start
Quick start=
Patient starts that day regardless of cycle
Needs back up method until next menses
Higher risk for breakthrough bleeding first month
How to start OC’s: First Day Start
Pt starts first pill first day of next cycle
No back up method needed (good for someone unlikely to use back up method)
How to start OC’s: Sunday start
pt starts first Sunday after period starts
Need back up birth control for 7 days
OC’s
Follow up, pt counseling
Follow up in 3 months after start
Ask about side effects and breakthrough bleeding
Note- side effects decrease with use
Encourage pt to try for at least one month in order to choose better pill if need be
OC’s
breakthrough bleeding
For BB early in cycle day 1-10 or no mense during placebo week» need more estrogen support
For BB later in cycle day 10-21» need more, or a different type of progestin
Risks of OC’s
- Increased migraine severity
- Increased risk CVA
- Headaches
- Blood clots
- HTN
- Mood changes
- Gallbladder disease
- Acne
- Bloating
- Hair loss / hirsuitism
Benefits of OC’s
Overall very safe
Decreased menstrual bleeding so decreased risk anemia
Decreased cramping
Predictable cycle
Contraindications of OC’s
- HX CV ischemia - MI, CVA
- A fib
- Heart failure
- Previous blood clot
- Ovarian/ breast CA
- Smoker > 35 yo
- Pregnant
- Uncontrolled HTN
- Liver tumors / disease
- Undiagnosed vaginal bleeding
- HX classical migraine (I.e., with AURA)
Danger signs on OCS
A: abdominal pain ( hepatic/ gallbladder) C: chest pain (PE) H: H/a ( CVA) E: eye problems S: swelling in legs / aching in LE (DVT)
OC’s and CA RISK
Overall decrease risk (ovarian, endometrial) but NOT GIVING TO PTS with CA
40-80% less risk ovarian ca than with nonusers
Protective benefit most clear with monophasics
50-60% less risk endometrial cancer
* risk also decreases with increased length of use
Protective benefit continues 20years after last use
* slight increased risk cervical cancer
**ocs not clearly linked to increased risk breast cancer!
Breast cancer Dx in OC’s users tended to be less advanced more localized
