Contraception Flashcards
What are basic methods of contraception
Periodic abstinence
Barriers (condoms, diaphragms, cervical caps, sponges)
Spermicides
Hormonal
What can alter the efficacy of condoms (male or female)
Decrease barrier: mineral oil based formulas, lotions, lubricants
Should you use condoms with spermicide
No longer recommended- no added protection against pregnancy or STD’s
Increase vulnerability to HIV
What are absolute contraindications of Diaphragms with spermicide
Allergy to latex
Recurrent UTI
Hx of TSS (bc they increase the incidence of UTI and TSS)
How do you use a diaphragm with spermicide
insert up to 6 hours before sex
MUST leave in place for 6 hours after intercourse
Do not leave in longer than 24 hours (TSS risk)
If you have sex again, leave diaphragm in, but also use a condom
What are absolute CI of a cervical cap
Hx of TSS
Abnormal PAP (can cause dysplasia)
allergic to spermicide
How do you use a carvicle cap
Same as a diaphragm with spermicide!
Only difference is cervical cap you can wear up to 48 hours before risk of TSS
Do cervical caps and diaphragms protect against STDs
NO!!
Not against STD or HIV- so if you are concerned, use a condom as well
How do you use a sponge
Moisten with water and insert 6 hours before sex
Provides protection for 24 hours
Leave in for 6 hours after intercourse
Do not leave in >24-30 hours
What are the different hormonal contraceptives in order from least to most efficacious
Combined hormonal contraceptives Hormonal transdermal patch Hormonal transvaginal ring Depo-Provera Copper IUD Levonorgestrel IUD Progestin only implant
What is cool about the progestin only implant
It is more effective than a tubal ligation or vasectomy
What is the temperature method good for
Retrospectively telling you when you ovulated- but you can’t use it to predict when you will ovulate (temp shoots high after ovulation)
The HPO axis has
negative feedback! (GnRH, FSH/LH, estrogen/progesterone)
The major pathways in adrenocortical hormone biosynthesis lead you to
production/release of estradiol
What are the aromatase inhibitors
Arimidex
Aromasin
Femara
-they decrease the level of estrogen in women with estrogen dependent cancer
Why do new OCP have lower levels of hormones
Because older high dose formulas were found to be associated with vascular and embolic events, cancer, and significant ADE
What is the MOA of combined hormonal contraceptives
prevent conception prior to fertilization
-Progestin provides most of the contraceptive effect
How does progestin prevent conception
thicken cervical mucus (sperm cant penetrate)
slow tubal motility
induce endometrial atrophy
block LH surge= no ovulation
How does estrogen prevent conception
suppress FSH= helps block LH surge= block ovulation
stabilize endometrial lining
provide cycle control
thicken cervical mucus
What 3 synthetic estrogens are available in the US
Ethinyl estradiol
Mestranol (prodrug- has to be converted by liver to ethinyl estradiol to be active)
Estradiol valerate
-Most COC have estrogen doses at 20-50 mcg of EE
Are progestins all the same
No- differ in respect to inherent estrogenic, antiestrogenic, and androgenic effects
Androgenic activity depends on these 2 variables
presence of sex hormone binding globulin
androgen:progesterone activity
(if SHBG decreases, free testosterone rises, more prominent androgen ADE)
What are the 4 generations of progestins
- well tolerated. low dose= more breakthrough bleeding (Norethindrone)
- long 1/2 life. more androgens (hirsutism/acne/lipids). better libido (Levonorgestrel)
- same activity as 2nd gen, less androgen effects (Desogestrel)
- anti-androgen (drospirenone)
How do you take progestin only pills
SAME time every day (3 hour window, max)
If >3 hours late, use another form of contraception
less effective than CHC BUT can be used post-partum
What are negative aspects of progestin only pills
40% of women still ovulate
Higher risk ectopic pregnancy
May cause irregular and unpredictable bleeding
Contraindications to progestin only pills are
Gastric bypass
ischemic heart disease
Rifampin therapy
What is great about monophasic OCPs
can string them together to avoid periods all together (normal to have some breakthrough bleeding)
Cheapest option
92% effective
Caution when using OCPs in women
>35 smoker HTN Dyslipidemia DM Migraines breast cancer thromboembolism obesity SLE
What does the CDC say about using CHC in smokers
If <35: level 2 (green)
If >35 and <15x day: level 3 (pink)
If >35 and >15x day: level 4 (red)
What does the CDC say about postpartum women using CHC
<21 days: level 4 (red)
21-42 days w/ VTE RF: level 3 (pink)
21-42 days w/o VTE RF: level 2 (green)
>42 days: level 1 (green)
What does the CDC say about using IUD in postpartum women
<10 min after delivering placenta: level 2
10 min after placenta-4 wks PP: level 2
>4 weeks: level 1
Puerperal sepsis: level 4
What hormones can you co-administer for added benefits
Caziant or Cyclessa: estrogen to prevent HA during menses
Tilia Fe or Tei-legest Fe (iron)
PEARLS for CHC
Encourage patients to use condoms to prevent STDs
Extensive history and safety concerns with using high dose estrogen
How much estrogen is ideal in different populations
No existing med conditions: 35 mcg or less of EE/ 0.5mg Norethindrone (1 gen)
Teens, Underweight, >35, perimenopausal: 20-25 mcg EE
Non-adherence: 35+mcg
Oily skin, acne, hirstism: low androgenic dose
What OCP are preferred to start on
Monophasic
What can women with dysmenorrhea, menstrual migraines, or severe PMS benefit from
extended cycle regimens (eliminate/reduce # of periods per year)
ADE of CHC are
N/v tender breasts weight gain acne, oily skin depression, fatigue MC**breakthrough bleeding Vaginal irriation (ring) application site rxn (transdermal)
What Sx should make you immediately d/c CHC
ACHES! Abdominal pain Chest pain Headaches Eye problems Severe leg pain
VERY serious ADE of CHC that should make you stop immediately include
vision loss, proptosis, diplopia unilateral numb, weak, tingle hemoptysis slurred speech severe ttp, swelling, or palpable cord on leg hepatic mass
These ADE of CHC require evaluation but don’t emergently d/c
no menses spotting breast mass RUQ pain midepigastric pain Migraine galactorrhea jaundice depression pruritis uterus increase in size
When would you need to adjust estrogen/progestin content
if breakthrough bleeding occurs past 6 months
When should you start the pill
typically on first sunday after menstrual cycle begins (weekend free periods)
can also do quickstart and start today
-either way, use another method of contraception for first 7 days (for whole first cycle to be even safer)
What happens if you get pregnant while on OCP
nothing! no adverse effects to fetus because they’re just hormones
simply stop taking the pill once you find out
What factors are concerning about using CHC postpartum
if mom is hypercoagulable (effects of lactation)
in first 21 days, risk for VTE is higher
if you absolutely need contraception, use progesterone only
if breastfeeding: avoid for first 24 days if you have RF, 30 days everyone else
No restriction after 42 days
How can you adjust hormones to counteract certain ADE
minimize risk of DVT: low dose estrogen
min. nausea, breast ttp, vascular HA: low estrogen dose
min. spotting/bleeding: high dose estrogen/progestin
min androgen effects: 3 gen progestin
avoid dyslipidemia: 3 gen progestin
What are long acting reversible contraceptives
Nexplanon (etonorgestrel)
Mirena, Liletta, Kyleena, Skyla: levonorgestrel (2 gen)
Paragard (copper IUD)
What contraceptive is first line for teens
LARC aka IUD’s
Skyla is smaller and good for teens or women with a smaller uterus
DO NOT use LARC if
anatomic abnormalities Hx breast, cervical, or endometrial cancer PID post-abortion postpartum pregnant pelvic TB STD unexplained vaginal bleeding
What is Mirena
5 year IUD that reduces bleeding, can shrink fibroids, and reduce endometriosis
99% effective 7 days after insertion
How long is Skyla good for
3 years
What is ParaGard
10 year copper IUD that can be off label for emergency contraception
Great for women >35 and a smoker
99% effective immediately
but, causes more menstrual bleeding
Contraindications to ParaGard are
SLE w/ thrombocytopenia
Wilson’s disease (in theory) 2/2 copper
What is Nexplanon
single rod good for 3 years
may cause irregular bleeding patterns but 99% effective
Contraindications to Nexplanon are
cirrhosis
ischemic heart disease
ADE of using Levonorgestrel IUD are
irregular menses insertion complications expulsion PID -must council on STD prevention!
What is Depo-Provera
birth control shot good for those w/ sickle cell dz, older smokers, or seizure pts
97% effective BUT can cause:
weight gain, irregular menses, bone loss (reverses after stopping shot)- hirsutism, acne, depression
If worried about bone loss, stop depo-provera at
2 years
Contraindications of depo-provera
current breast cancer
If giving depo-provera, consider these things
cirrhosis breast cancer in last 5 years DM with microvascular dz CVD uncontrolled HTN SLE unexplained vaginal bleeding women close to menopause (less time to reverse osteoporosis)
What is OrthoEvra
one patch, good for 3 weeks and remove for the 4th week- do NOT wear over breasts
+/- nausea if placed on abdomen
92% effective
Contraindications to usinf OrthoEvra
high risk VTE
skin condition
obesity
What is NuvaRing
intravaginal ring placed in for 3 weeks, out for 1 (35 days of meds in each)- use tampon applicator to help place
Can decrease frequency of BV
92% effective
Contraindications to NuvaRing are
intact hymen
-if it falls out, rinse and re-insert
If you switch, how long do you need to overlap
pill-to-pill: none pill-to-ring: none pill-to-patch: 1 day pill-to-implant: 4 days pill-to-copper IUD: 5 days pill-to-shot: 1 week pill-to-hormone: 1 week
Common ADE of emergency contraceptives are
n/v (less if using progesterone only) irregular bleeding (menses onset 1 week early)
What do you NO need to do after using emergency contraception
screen for pregnancy! if already pregnant, it will not harm the fetus
How does emergency contraception work
High dose progesterone that creates an environment not conducive to fetus implantation or stops/delays ovulation- BUT- not harmful to a fetus
Must take within 72 hours of unprotected intercourse- the earlier, the less chance of pregnancy
What are the emergency contraceptives
Plan B one step next choice one dose Next choice Levonorgestrel generic -available OTC in US now!
What is Ulipristal
Selective progesterone receptor modulator- delays ovulation
Rx only as single dose (30mg) taken w/in 5 days (120 hrs) of unprotected intercourse
MOA of Ulipristal depends on
timing of administration relative to menstrual cycle
Future contraceptive is
microchip! remote controlled contraception
very similar to an implant, but it is said to last 16 years
