- increase in basal temp means ovulation has occured - abstenence for 5-10 d around ovulation - Track mucus: abundant, thin, wand watery - Measure for LH levels in urine

- Even low dose EE increases BP - Use ok in women

CHCs increase and decrease risk of migraines - Prodromal aura --> stroke risk Women subject to migraines should not use CHCs If migraines develop, D/c immediately Progestin only may be substituted

Contraception Flashcards by Brent Sokola

Rhythm method

increase in basal temp means ovulation has occured
abstenence for 5-10 d around ovulation
Track mucus: abundant, thin, wand watery
Measure for LH levels in urine

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Is a Gyneclogical exam recommended before CHC prescription given?

No, but Med history and BP measurement needed

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How is ovulation inhibited?

Progestins block LH surge

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Which progestin is available as a contraceptive patch?

Norelgestromin

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Other effects of progestins

Thicken cervical mucus, induce endometrial atrophy

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Most common Estrogen in CHCs?

Dose?

Ethinyl Estradiol (EE)
20-25 ug

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Estrogens function in CHC

Suppress FSH, prevent LH surge

- Stabilize endometrium

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Which hormone provides most of the effect in CHC?

the progestins
Mimics pregnancy (Corpus luteum secretes progesterone to prevent 2nd ovulation)

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Non-contraceptive benefits of CHC`

Decreased menstrual problems (cramps, pain, irregularity), Acne
Decreased risk of ovarian andometriial cancers, ovarian cysts, Pelvic inflammatory disease

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CHC ADRs; Estrogen excess

Nausea, breast tenderness, HA, Fluid Retention**

- Treat by decreasing estrogen dose, using progestin only, or IUD

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CHC ADRs; Estrogen deficiency

Midcycle breakthrough bleeding
Vasomotor symptoms (hot flashes), anxiety, decreased libido
Amenorrhea
Treated by increasing estrogen dose

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CHC ADRs; Progestin Excess

Increased appetite, weight gain, bloating
Acne, oily skin, hirsutisim
Depression, fatigue, irritability
Treat by decreasing progestin dose or use less androgenic progestin

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CHC ADRs; Progestin deficiency

Dysmenorrhea, late cycle breakthrough bleeding/spotting

- Treat by increasing progestin dose, use extended cycle or continuous regimen, or progestin-only, or IUD contraception

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CHC risks and age

low dose (

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CHC and smokers

Women over 35 and smokers are advised against COCs

-Progestin-only methods

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Use of CHC in perimenopausal women

Helps increase bone mineral density and helps with vaso motor symptoms (hot flashes)

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CHCs and HTN

Even low dose EE increases BP

- Use ok in women

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CHC and Dyslipidemias

-Progestins decrease HDL; increase LDL
-Estrogens decrease LDL; increase HDL
–>CHC usually no effect lipid profile
–>if controlled, can use CHC
Else (LDL>160 mg/dL) no use

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What is theCVD risk with CHCs in dyslipidemia

Thrombosis, not atherosclerosis

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Diabetes and CHCs

In healthy pt:
Most have no affect on insulin or HbA1c
Noincreased risk of TIIDM
**Women with DM should not use CHCs

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CHCs and migraines

CHCs increase and decrease risk of migraines

Prodromal aura –> stroke risk
*Women subject to migraines should not use CHCs
*If migraines develop, D/c immediately

***Progestin only may be substituted

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CHCs and Breast Cancer

No association

OK in benign breast disease, and family history of BC

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CHCs and thromboembolism

Estrogens increase hepatic production of clotting factors

-> risk of DVT & PE
-> Less risk than occurs in pregnancy, but still risk

**contraindicated in women with Hx of thromboembolic events

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Which CHC has least risk of thromboembolic event

Levonorgestrel less than desorgestrel

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CHCs and obesity risks

- Obese pt increased risk for contraceptive failure | - Increased risk of VTE

CHCs and obesity | Preferred therapy

Depot MPA or Levonorgestrel IUD preffered

CHCs and Lupus

should be avoided in pt with SLE + anti-phospholipid antibodies or vascular complications **Use progestin only contraceptives

Which progestin has anti-aldosterone effects? | What is that effect

Drospirenone | Less bloating/weight gain

3rd/4th gen progestins

Dropirenone, Deogestrel, norgestimate

What warning must be on Drospirenone (Yasmin, Yaz, Beyaz, Safyral) box?

Increased risk of VTE

Progestin only pills

-Less effective -irregular bleeding -Must be taken at same time every day 40% of women still ovulate

COC first line

low dose

COC choice for adolescents, underweight, women over 35, perimenopausal

Very low dose. 20-25 ug EE

COC choice for women >160 lbs

35-50 ug EE. Do not exceed 50 ug

Progestin-only candidates

-Migraines with aura -Thromboembolic diseases -SLE -Women >35 y with: +smoker +obseity +HTN

``` Transdermal patch (Ortho Evra) Contents ```

Ethinyl Estradiol + norelgestromin

Transderm effectivenes

Equally effective as COCs, but higher failure rate in women >189 lbs

Transdermal EE exposure

- 60% higher: avoids first pass metabolism | - possible thromboembolic risk

``` Vaginal rings (Nuvaring) Contents ```

EE + Etonogestrel

Vaginal rings effectiveness

Equally effective as COCs | Lower systemic dose of estrogen

Vaginal rings use

Inserted and worn for 3 weeks

Depo-Provera (injectable progestin) | Dose/drug/route(s)

150 mg medroxyprogesteron acetate (DMPA) IM (also SC)

Depo-provera | duration *efficacy

3 months, 97% actual efficacy

Depo cessation

prolonged delay to fertility (10-18 months)

Depo risk

DMPA suppresses estradiol production, risk of decreased bone mineral density

Implanton sub dermal progestin implant | Drug, duration, effectiveness

etonorgestrel 3 years 97%

Implanon complaints

irregular menstrual bleeding and spotting

Implanon and BMD

No decrease in BMD

Implanon and removal

rapid return to fertility

Intra uteron deices Types MOA

``` Copper ions (paragard) or levonorgestrel (Mirena, skyla, liletta) Reduce sperm mobility or interfere with implantation ```

Intra uterine device effectiveness

99&

Paragaurd Duration ADRs

10 years Increase blood flow by 35% Increased dysmenorrhea

Mirena Duration dose

5 years10 | ug pregestin/d with low systemic absorption

Mirena ADRs

reduces menstrual blood flow but increases spotting in first year. Amenorrhea 20% first year 60% fifth

IUDs general ADR | and removal

- May increase pelvic inflammatory disease | - Fertility returns immediately after

What is the most widely used reversible contraception?

IUD

``` Emergency Contraception (Plan B) Contents ```

1.5 mg levonorgestrel | Taken 1 dose or two split doses q12h

Plan B MOA

Prevent ovulation, sperm motility | DO NOT EFFECT IMPLANTATION (if ovulation has already occurred: you're screwed

Plan B use

should be taken within 72 h of intercourse (max 5d)

Plan B adverse effects

Nausea | May induce withdrawal bleeding

Plan be availability

Available behind the counter to patients of lll ages

Yuzpe regimen

COCs for emergency contraception | 100 ug EE + 0.5 mg levonorgestrel; repeate after 12 h

Anti-progestins | Eg,

Ulipristal (ella) | Mifepristone

Anti-progestin | MOA

- Block ovulation, impare endometrial proliferation - Effective up until day of LH surge - Longer acting than levonorgestrel

Anti-progestins use by

Must be within 5 days of coitus

Which EC is considered embrotoxic?

Anti-progestins

Anti-progestin availability

Rx Only

Anti-progestin contraindications and ADRs

- Metabolized by CYP3A4 - Contraindicated in severe liver disease - Minimal ADR: abdominal pain

Copper IUD (paragaurd) EC Use by Effectiveness

up to 5 d post coitus | most effective EC 99%