Contraception Flashcards
1
Q
Why is contraception used? Failure rate of not using contraception?
A
- prevent unintended pregnancies
- space pregnancies
- prevent pregnancy when it is dangerous or life threatening to the mother (valvular heart disease, ischemic heart disease, SLE, sickle cell disease, severe liver disease, thrombogenic mutations)
- failure rate of not using contraception: 85%
2
Q
How many pregnancies in US in 2006 were unintended? How many were terminated?
A
- 49% of 6.7 mill pregnancies unintended (80% of pregnancies in 19Yo and younger and 28% in married couples)
- 43% of unintended pregnancies in 2006 were terminated
3
Q
Reproductive life span of women and men?
A
- women: about 40 years of potential fertility, from menarche: avg age 12.5 to natural menopause avg age 51.5
approx half of avg US woman’s life span of 81.2 yrs - men: around 10-12 yo until death as long as vas deferens intact and able to ejaculate
4
Q
When is emergency contracpetion used?
A
- use of drugs to prevent pregnancy for women w/in 120 hrs of:
unprotected intercourse (includes sexual assault), failure of another method of contraception - consider at any time of menstrual cycle: higher probability of conception is 1-2 days b/f ovulation
5
Q
Emergency contraception in US?
A
- plan B: levonorgestrel 0.75 mg 2 pills to be taken 12 hrs apart, can be taken up to 24 hrs apart
- plan B one step or next choice one dose and other branded generics: single levonorgestrel 150 mg pill
- ella: ulipristal 30 mg - single dose, need Rx
- Yuzpe method: formulated using variety of combo oral contraceptives to achieve ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg, 2 doses in 12 hrs
- copper IUD: most effective but off label
6
Q
Access to oral hormonal EC (levonorgestrel)? Any prereqs, CIs? Cost?
A
- no need for pregnancy test or exam
- no medical CI
- access: approved for OTC availability for anyone of childbearing age
previously under 17 required a Rx, and some package inserts may state for 17 or older - cost: $40-50
7
Q
SEs of EC - levonorgestrel?
A
- N 24% and V 9% (higher with use of combined OCPs or Yuzpe method)
- irregular bleeding the month after tx
- less common: dizziness, fatigue, HA, breast tenderness
- no deaths or serious complications
- effective up to 120 hrs after event but take ASAP
8
Q
Prereq of admin of ulipristal or Cu IUD?
A
- pregnancy should be excluded b/f admin
- CIs and precautions exist for ulipristal and IUD
9
Q
Efficacy of EC?
A
- pooled data est at least 74% of expected pregnancies prevented
- Cu IUD: failure rate less than 1%
- ulipristal: failure rate 1.4%
- levonorgestrel: failure rate 2-3% (effectiveness may be less in overwt and obese woman)
10
Q
EC MOA?
A
- oral methods: inhibiting or delaying ovulation
- levonorgestrel is ineffective after ovulation has occurred
- Cu IUD: interfering with fertilization or tubal transport, preventing implantation by altering endometrial receptivity (less hospitable enviro for fertilization)
- use of oral hormonal EC doesn’t interrupt a pregnancy and has no adverse effects on pregnancy or fetus
11
Q
EC counseling for your pt?
A
- obtain pregnancy test if no menses 3-4 wks after EC
- discuss risk of pregnancy and STIs with unprotected sex
- encourage pt to start a regular contraceptive method or review correct use of current one
- EC is a back up, not a primary contraceptive method
12
Q
What are considerations for choosing a contraceptive method?
A
- efficacy (failure rate)
- safety (risks with consideration of health hx)
- SEs (to include effect on menses)
- convenience (correct use and access to care)
- cost
- personal lifestyle and pattern of sexual activity
- reversibility
13
Q
What are goals for teaching pts about contraception?
A
- dispel misconceptions
- review major SEs and risks, particularly as relate to her health hx
- compare options to maximize choice appropriate to lifestyle and ability to use correctly
- educate on proper use
- distinguish b/t contraception and protection from STIs
- encourage pts to talk about birth control issues with partner
- pt’s personal needs change over time, so helpful for pt to be aware of all options
- discuss EC with all pts
14
Q
Categories of contraception?
A
- hormonal
- IUD
- barrier
- permanent
15
Q
Why is there contraception failure?
A
- inappropriate use
- failure to use (influence of cost and access)
- failure of method (correct use failure rate)
16
Q
Typical use failure rate of hormonal methods?
A
- oral pills: 9%
- transdermal patch: 9%
- injections: 6%
- IUD less than 1%
- subdermal implants less than 1%
- intravaginal ring 9%
17
Q
OCP - MOA: estrogen?
A
- suppression of GnRH (hypothalamus) - inhibits the midcycle surge of gonadotropin LH - prevents ovulation, suppresses FSH secretion which prevents ovarian folliculogenesis
- stabilizes endometrium to minimize breakthrough bleeding - low dose (20, 30 or 35 mcg) or high dose (50 mcg)
18
Q
OCP- MOA: progestin?
A
- (a 19-nortestosterone or drospirenone):
suppresses LH secretion and therefore, suppresses ovulation (less potent than estradiol) - thickens cervical mucus which inhibits sperm migration
- creates an atrophic endometrium unfavorable to implantation
- impairs normal tubal motility/peristalsis
19
Q
Older progestin effects? Newer progestin effects?
A
- older: more androgenic - norethindrone, norethindrone acetate, levonorgestrel
these lower HDL cholesterol - newer: less androgenic effects - norgestimate, desogestrel, drospirenone, less effect on carbs and lipid metabolism, more effective at reducing acne and hirsutism, possible increase risk of thromboembolism
20
Q
Diff generations of progestins?
A
- 1st gen: norethindrone (acetate), ethynodiol diacetate
- 2nd gen: levonorgestrel and dl-Norgestrel (higher androgenic but more effective than 3rd in countering thrombotic effects of estrogen)
- 3rd gen: desogestrel - may have increased risk of VTE
- unclassified: drospirenone (yasmin and yaz) less androgenic but risk of VTE up to 3x compared to levonorgestrel
21
Q
What are advantages of new progestins?
A
- higher HDL and lower LDL
- higher SHBG - result: decreased free testosteron levels and estrogen effects
- greater affinity to progesterone binding sites
- reduced amenorrhea
22
Q
Non-contraceptive uses of OCPs?
A
- endometriosis: reduce pelvic pain
- tx for acne and hirsutism
- tx for heavy, painful or irregula periods
- reduce occurrence of recurrent ovarian cysts
- PCOS (acne, hirsutism, unopposed estrogen influence to endometrium)
- PMS/PMDD
- decreased risk of ovarian cancer
- decreased risk of ovarian cancer**
- decrease menstrual migraine (with continuous or extended cycle)
23
Q
Why would higher dose estrogen pills be rx?
A
- 50 mcg
- b/c of spotting or absence of withdrawl bleeding that can’t be managed on lower dose
- tx other problems:
AUB
reduce recurrent ovarian cysts
historically higher dose estrogen BCPs used for acne b/f less androgenic progestins available
24
Q
Diff types of OCP preps?
A
- monophasic
- multiphasic (biphasic or triphasic) - changes in E and P throughout month
- extended cycle: withdrawal flow q 12 wks
- POP or mini pill
25
Q
Diff OCP cycles?
A
- 21 days on, 7 days off (most formulations)
- 24 days on, 4 days off (drospirenone containing forms)
- 84 days on, 7 days off - extended cycle - seasonale, introvale (estradiol and levonorgestrel)
- seasonique and Loseasonique take on 91 day cycle, but intead of placebo 10 mcg of ethinyl estradiol taken for 7 days - use in pts with endometriosis, PMDD, or women who prefer less menses
26
Q
Typical choices for pill formulations depends on?
A
- typically start with monophasic in younger or less compliant pt but generally it doesn’t matter much
- perimenopausal women are usually started on lower estradiol pill
- androgenic influence of progestin may be taken into consideration
- breastfeeding women: POP
- ift they have used a formulation in past that’s worked - be reluctant to mess with success!
27
Q
Before beginning an OC what should be done? Diff methods for starting? F/U?
A
- minimal screen: careful medical hx and BP and BMI
- 3 methods for starting:
1. quick start: start day Rx regardless of day of cycle once pregnancy ruled out
2. sunday start: start 1st sunday after period begins
3. start 1st day of menses - with quick start or sunday start, must use backup method for 7 days after starting pill
- a POP should be started in first 5 days of menses
- good idea to rx 3-4 months and have woman return to check BP, confirm taking correctly and eval SEs
28
Q
What education should you give to pt b/f they start OCPs?
A
- when to start pill
- impt of taking it same time q day esp POP (taken in 3 hr window)
- if miss 1 pill take ASAP, contraceptive benefit not compromised
- if 2 pills missed - double up for 2 days, use back up method for rest of cycle
- high risk time for conception if next pill cycle not started on time (already had 7 pill free days)
- may have nausea for first couple days - can take with food
- ask pt to notify with increasinly severe or frequent HAs, SOB or chest pain or swelling of extremity
- menses generally shorter, lighter and with less cramping
29
Q
What is Ortho-Evra? Downside of this?
A
- contraceptive patch
- changed q 7 days for 3 wks and then 1 wk off for menses
- delivers constant level of 20 mcg ethinyl estradiol and 150 mcg of norelgestromin daily
- resultant serum levels of EE 66% higher than 35 mcg oral pill. In 2008, FDA revised labeling to state possible higher risk of thromboembolism
30
Q
How does the nuvaring work?
A
- delivers 15 mcg estradiol and 120 mcg estonogestrel daily for 3 wks intravaginally
- remove for 1 wk then insert new one
- if it falls out or needs to be removed - rinsse with cold or warm (not hot) water and reinsert w/in 3 hrs
31
Q
What are absolute CIs for estrogen contraception?
A
- hx of thromboembolic event or stroke or known thrombogenic mutation (factor V leiden)
- known CVD, cardiomyopathy, BP 160/100 or greater, complicated valvular heart disease
- SLE with + antiphospholipid abs
- women 35 or older who smoke
- migraines with aura
- women 35 or older with migraines
- hx of cholestatic jaundice with pill use
- hepatic carcinoma or benign adenoma, any active liver disease or severe cirrhosis
- current breast cancer
- first 21 days postpartum (increased risk of clotting)
- Undx AUB
32
Q
Careful consideration b/f use of estrogen?
A
- HTN (younger than 35, nonsmoker, eval cumulative RFs for CAD/stroke)
- anticonvulsant therapy
- migraines w/o aura (younger than 35, eval cumulative RFs for CAD/stroke)
- diabetes (eval cumulative RFs for CAD/stroke)
- hx of bari surgery with malabsorptive procedure like Roux en Y (possible decreased efficacy with oral pills)
- psychotic depression
- UC (may increase with years of use)
- obese, older than 35
33
Q
Efficacy of hormonal pills, patch and ring?
A
failure rates:
- theoretical/correct use: less than 1%
- typical use: 9%
34
Q
HC SEs?
A
- nausea/bloating
- breast tenderness
- spotting/break through bleeding (BTB): MC (10-30% in first 3 months)
- amenorrhea (about 5% after several yrs, more common with 20 mcg estradiol pill) - goal with extended or cont. delivery
- fatigue
- HA: may occur in early cycles and generally improve with subsequent cycles
- depression/moodiness
- decreased libido
- **low dose doesn’t cause wt gain
35
Q
How common is BTB as HC SE?
A
- MC SE
- independent of progestin
- can add extra estrogen or switch to more estrogenic progestin
36
Q
Tx of amenorrhea if not desired?
A
- try prep with more estrogen
37
Q
Estrogen - adverse effects of excess or deficiency?
A
- excess: N/V bloating/edema HTN migraine breast tenderness decreased libido wt gain heavy menstrual flow leukorrhea - deficiency: early cycle spotting/BTB amenorrhea vaginal dryness
38
Q
Progestin - adverse effects of excess or deficiency?
A
- excess: acne increased appetite/wt gain fatigue HTN depression hirsutism vaginal yeast infections - deficiency: late BTB amenorrhea heavy menstrual flow
