contraception Flashcards
what other uses do contraception have?
Prevent pregnancy
Prevention of STDs (w/ condoms)
Improvements in menstrual cycle regularity (w/ hormonal contraceptives)
Improvements in certain health conditions (with oral contraceptives [OCs])
Management of perimenopause
Methods of contraception?
periodic abstinence, barrier tecniques, spermicides, spermicides-implanted barrier technique, hormonal contraception
what are spermicides?
contain nonoxynol-9, are chemical surfactants that destroy sperm cell walls and act as barriers that prevent sperm from entering the cervical os
what is a Spermicides-implanted barrier technique?
vaginal contraceptive sponge contains 1 g of the spermicide nonoxynol-9
what is preferable: mineral oil based vaginal drugs formulations OR water-soluble lubricants?
water soluble!
Mineral oil-based vaginal drug formulations (ie, Cleocin, Premarin, and Monistat), lotions, or lubricants can decrease the barrier strength of latex
Why are condoms w/spermicides no longer recommended?
bc they provide no additional protection against pregnancy or STDs and may increase vulnerability to HIV
contraindications to female condoms (prelubricated)
Allergy to polyurethane
History of TSS
Advantages/disadvantages to male condoms
A: inexpensive, STD protection including HIV
D: High user failure rate (only 1x use)
Poor acceptance,
Possibility of breakage
Efficacy decreased by oil-based lubricants,
Possible allergic reactions to latex in either partner
Advantages/disadvantages to female condoms
A: Can be inserted just before intercourse or ahead of time
STD protection, including HIV
Not to be simultaneously with condoms
D: High user failure rate than male condoms (only 1x use),
Dislike ring hanging outside vagina,
Cumbersome
contraindications to diaphragm w/spermicide
Allergy to latex, rubber, or spermicide
Recurrent UTIs
History of TSS
Abn gynecologic anatomy
Adv/disadvantages to diaphragm w/spermicide
A: Low cost
Decreased incidence of cervical neoplasia
Some protection against STDs
D: High user failure rate,
Decreased efficacy with increased frequency of intercourse+,
Increased incidence of vaginal yeast UTIs, TSS#,
Efficacy decreased by oil-based lubricants
Cervical irritation
diaphragm w/spermicide can be inserted when? and left in how long?
6 hrs before and 6 hrs afterward but leaving in 24hrs NOT recommended d/t TSS
cervical cap (FemCap) contraindications (nonhormonal contraception)
Allergy to spermicide
History of TSS
Abnormal gynecologic anatomy
Abnormal papanicolaou smear
Adv/disadvanages to
A: Low cost
Latex-free,
Some protection against STDs,
FemCap reusable for up to 2 years
D: High user failure rate,
Decreased efficacy with parity, cannot be used during menses
how long can a cervical cap remain in place?
for multiple episodes of intercourse without adding more spermicide but should not be worn for more than 48 hours at a time to reduce the risk of TSS
what forms of contraception do NOT protect against STD’s like HIV
Diaphragms and cervical caps
contraindications to spermicides alone? (nonoxynol-9
Films, foams, gels, suppositories, sponges, and tablets)
allergy to spermicide
disadvantages to spermicides alone? (nonoxynol-9
Films, foams, gels, suppositories, sponges, and tablets)
High user failure rate, must be reapplied before each act of intercourse, may enhance HIV transmission, no protection against STDs, not promoted by WHO or CDC
contraindications to Sponge (Today)+
1gm nonoxynol-9?
Allergy to spermicide,
recurrent UTIs, history of TSS, Abnormal gynecologic anatomy
disadvantages to Sponge (Today)+
1gm nonoxynol-9?
High user failure rate, decreased efficacy with parity, Cannot be used during menses, No protection against STDs
Pt education for sponge use?
insert 6hrs before use, provides protection for 24hrs, leave in place at least 6hrs before removal but no longer than 24-30 d/t TSS
do NOT reuse
what are the most effective reversible family planning methods?
implants and IUDs
what are permanent means of sterilization?
hysterectomy, vasectomy
____ should always be used to reduce the risk of STI’s?
codoms
possible sxs in the early cycle?
irritability, depression, bleeding, lower abd. pain, N/D, libido changes, nose bleeds
possible sxs in the late cycle?
bloating, breast tenderness, wt. gain, eyes swollen, acne, dc, pain, constipation, swollen ankles
sxs of pregnancy*
secondary source of estrogen in men and women is where?
fat tissue
what hormone is MCly measured for nonpregnant women?
estrogen
what hormone is measured only during pregnancy
estradiol
what hormone may be measured in women who have gone through menopause?
estrone
hormonal contraceptives contain a combo of…
estrogen and progestin or a progestin alone
other hromonal contraceptives aside from oral forms?
Transdermal patch
Vaginal contraceptive ring
Long-acting injectable
Implantable
Intrauterine contraceptives
older high dose formulations of hormonal contraceptives were assoc. w/
vascular, embolic vents, cancers, and significant SE’s
how do combined hormonal contraceptives (CHCs) work?
primarily before fertilization to prevent conception
_____ provide most of the contraceptive effect?
progestins
MOA of progestins?
*progestins block the LH surge therefore inhibiting ovulation
by thickening cervical mucus to prevent sperm penetration,
slowing tubal motility and delaying sperm transport,
inducing endometrial atrophy
MOA for estrogens
suppress FSH release from the pituitary, which may contribute to blocking the LH surge and preventing ovulation
primary role of estrogen in hormonal contraceptives is to stabilize the endometrial lining and provide cycle control
helps thicken cervical mucus
what are the 3 synthetic estrogens found in hormonal contraceptives?
- Ethinyl estradiol (EE)
- Mestranol:
must be converted by the liver to EE before it is pharmacologically active. Is 50% less potent than EE - Estradiol valerate
Most combined OCs, transdermal patch, and vaginal ring contain…
estrogen at doses of 20 to 50 mcg of EE
Mestranol is 50% less potent than…
EE
progestins differ w/respect to…
inherent estrogenic, antiestrogenic, and androgenic effects
androgenic activity is dep. upon variables:
- the presence of sex hormone (testosterone) binding globulin (SHBG-TBG)
- androgen:progesterone activity ratio
if the amnt of SHBG-TBG is decreased, free testosterone levels ___ and androgenic side effects are ____
increase
more prominent
1st generation progestin characteristics
well tolerated, but lower doses have more breakthrough bleeding
e.g. Norethindrone
2nd generation progestin characteristics
long half life (in implant/IUD), more androgenic activity- better for libido, worse for hirsutism/acne/lipids
e.g. Levonorgestrel
3rd generation progestin characteristics
same progestational activity with decreased androgenic activity
e.g. Desogestrel
4th generation progestin characteristics
anti-androgenic properties
e.g. Drospirenone
Progestin only must be taken…
at same time every day (3hr window)
if taken ___ hrs late, pts should use backup method of contraception for ___hrs
3
48
Minipills put you at higher risk for…
ectopic pregnancy
Minipills (progestin only) characteristics
may not block ovulation, used post-partum, less effective than combo OC’s,
minipills (progestin only)
assoc. w/irregular and unpredictable menstrual bleeding
contraindications w/minipills (progestin only)
gastric bypass, ischemic heart disease, Rifampin therapy
what is the cheapest contraceptive upfront?
Combined Oral Contraceptives (COC) or Combined Hormonal Contraceptives (CHC) or Oral Contraceptive Pill (OCP)
92% effective w/usual use
what does “stringing” packs of any brand COC, CHC, or OCP’s together mean?
skipping the placebo w/the BCP’s
what are some special considerations for using COC, CHC, or OCP’s?
Women older than 35 yrs, smoking, HTN
Dyslipidemia, DM
Migraine HA’s, breast CA, Thromboembolism, Obesity, Systemic Lupus Erythematosus
CHC practice pearls
Excessive/deficient amounts of estrogen and progestin are related to the MC ADE’s
Important concern regarding the use of CHCs is the lack of protection against STDs
Encourage patients to use condoms for prevention of STDs
Extensive history of safety concerns traditionally related to high dose estrogen tablets
what is the recommended dose for OC?
35mcg or less of EE and less than 0.5mg of norethindrone
Nonadherence to OCs increases risk of pregnancy which may be greater in women taking OCs containing…
less than 35mcg of EE
what pt population can take oral contraceptive?
Adolescents, underweight women (less than 50 kg [110 lb]), women older than 35 y/o, and those who are peri-menopausal
which is preferred: monophasic or multiphasic?
monophasic
Extended-cycle OCs either eliminate or reduce the number of menstrual cycles per year, leading to…
less premenstrual sxs, dysmenorrhea and menstrual migraines
Extended-cycle regimens may be beneficial for women with symptoms such as…
dysmenorrhea, severe premenstrual syndrome, or menstrual migraines
ADE’s of combined hormonal contraception?
Nausea/vomiting Breast tenderness Weight gain Acne, oily skin Depression, fatigue Breakthrough bleeding/spotting Application site reaction (transdermal) Vaginal irritation (vaginal ring)
when do you need to immediately discontinue CHC’s?
"ACHES" abdominal pain chest pain/SOB Headaches, CVA, or incr. BP Eye problems Severe leg pain (thromboembolic process)
unilateral numbn/weakness, hemoptysis, slurring speech, hepatic mass/TTP, slurring speech
OC ADE pearls
Many sxs occurring with early OC use: N, bloating, breathrough bleeding (okay for 2-3mo’s)
MC adverse effect = irregular bleeding
expect w/in first 6mo’s
if irregular bleeding persists longer than 6 mo’s –> the estrogen or progestin content may need to be adjusted
when to start OC’s
traditional is sunday but consider quick start (today)
instruct to still use backup contraceptive for 7 days
concerns for postpartum use of CHC’s?
Mother’s hypercoagulability and the effects on lactation
first 21d postpartum d/t risk of thrombosis
if required –> progestin-only
breastfeeding –> avoid for 42 days if VTE risk or 30d w/out RF’s
why would you select a product w/lower dose estrogen?
To minimize risk of thrombosis, nausea, breast TTP, vascular HA’s
why would you select a pill w/higher dosage of estrogen or a progestin w/great potency?
to minimize spotting or breakthrough bleeding
how can you minimize androgens effects?
use 3rd generation progestin, low-dose norethindrone or ethynodiol diacetate
how can you avoid dyslipidemia?
3rd generation progestin, low-dose norethindrone or ethynodiol diacetate
what is the 1st line for sexually active adolescents?
Long Acting Reversible Contraception (paraguard, nexplanon, mirena, liletta, kyleena)
contraceptive use unacceptable health risk factors:
Anatomic abnormalities History of breast, cervical or endometrial cancer (initiation vs continuation) PID Post abortion Postpartum Pregnancy Pelvic TB STDs Unexplained vaginal bleeding
Benefits of Mirena
approved for 5 yrs, reduces bleeding, shrinks fibroids and reduces endometriosis, 99% effect (7 days after administration)
how long is the paragard (copper T) approved for?
10yrs
contraindications for paragard?
SLE (with thrombocytopenia)
Wilson’s Disease
how long is a nexplanon approved for?
3 yrs
contraindications for nexplanon (implanon)
cirrhosis, ischemic heart disease
ADE’s for Levonorgestrel IUD
Menstrual irregularities
Insertion-related complications
Expulsion
Pelvic inflammatory disease
copper IUD effect on periods?
irregularities typically heavier
Depo-Provera can cause…
wt. gain and irregular menses even after stopping shot but bone losses do reverse
Depo-provera (DMPA) is good for which types of pt’s?
sickle cell, older smokers, seizures
contraindications for depo-provera?
Current breast cancer
DMPA ADE’s
Menstrual irregularities, Wt gain
Acne, Hirsutism, Depression, Decreased bone density
Transdermal patch use and pt education?
one patch per wk, 3 wks on and 1 wk off
do NOT wear over breasts
can cause N if placed over abd
contraindications for transdermal patch
higher risk for VTE, skin conditions, obesity
Vaginal ring pt. education and use?
3 weeks in/ 1 week out, 35 days of medication in each ring
Can use tampon applicator to help with insertion
Rinse and reinsert if comes out
contraindication w/vaginal ring?
intact hymen
common adverse effects for emergency contraception…
N/V, irregular bleeding
screening prior or after pregnancy not recommended
TorF: if pregnant an emergency contraceptive can cause harm to the fetus.
False. No harm.
Emergency contraceptives like Plan B one step or Next choice need to be taken w/in…
3 days or 72hrs
MOA for emergency contraception
is inhibiting or delaying ovulation
what is ulipristal (ella)?
Selective progesterone receptor modulator with mixed progesterone agonist and antagonist properties
emergency contraception (120hr window)
