Contraception Flashcards
What are the 2 proven MoA of conception for birth control?
- Suppression of ovulation
- Thickening of cervical mucous
What are other possible MoA of conception for Birth control pills NOT proven?
- slowing tubal motility
- endometrial atrophy
- local endometrial edema
What are the 4 general contraception mechanisms?
1) prevent sperm from entering
2) prevent ovum from entering area of fertilization
3) prevent implantation
4) fertility awareness
1) What is the only estrogen used in all hormonal contraceptives?
2) What is it’s pro-drug?
3) Where is it converted from pro-drug to drug?
1) ethinyl estradiol
2) mestranol
3) liver
How do the different forms COCs (mono-, bi-, tri-) differ from one another?
- estrogen : progestin
- which progestin is used
- how many phases
What does the estrogen component of COCs do?
- provides regulation of the menstrual cycle
What is the primary reason for failure in COCs?
- missed pills
- stop taking pills and not starting another form of BC
What are the advantages to COCs?
- rapid reversibility –> return of ovul after 2 wks
- decreased dysmenorrhea
- reduced PMS Sx
- reduction of PMDD
What are the symptoms that you MUST have at least one of for PMDD diagnosis?
- marked depressed mood
- anxiety or tension
- swing in emotion
- pronounced anger or irritability
What are the general health benefits for COCs?
1) ↓ endometrial cancer risk
- 1 yr = 40% ↓, 10 yr = 80%
- protection continues 20 yrs after Rx d/c
2) ↓ ovarian cancer risk
3) ↓ benign breast dz risk (controversial)
4) improvement in acne (r/t ↓ in testosterone)
5) plugs them into the healthcare system
What are the disadvantages to COCs?
- daily admin
- prescription required in most states
- no STI protection
Which part of the birth control pill is mainly for contraceptive action
progestin
What factors put women at risk for MI?
- older, higher doses of estrogen
- other MI risks
- smoking
What are the FDA Complications listed for COC
RISK of VTE ie. HTN, DM, hx of VTE etc. Cancers ie abnormal vaginal bleeding Liver disease ... jaundice, hepatic ademona allergy to pregnancy...
What factors put women at risk for stroke?
- smoking >10 cig/day
- Age > 35
- Uncontrolled HTN
COC Quick start method
start day of visit other contraception x 7 days menses delayed till placebo *OFF LABEL but WHO Recommends improved compliance NO known effect of COC on Pregnancy
What factors put women at risk for VTE?
- older, higher dose estrogen pills
- obesity (BMI > 30)
- Hx of VTE, immobilization
- Age
COC Sunday Start
- 1st pill on 1st Sunday after period
**If period on Mon/Tues use backup for 7 days
Limitation will run out of pills on a Sat. limits access to pharmacy..
Benefit period free weekend.
Broad spectrum antibiotic cause for decrease (Not Proven)
theoretical reduction in systemic levels due to change in gut bacteria that strip conjugation from estradiol allowing re-absorption
actual effect of antibiotics on COC
some affect liver metabolism reducing amount of conjugated form available
For smokers, don’t uses COCs if:
- > 35 and >15 cig/day
- > 40 and any regular smoking
How to start COCs in smokers?
- Start with 20 mcg EE
- Use backup for 2-3 mo d/t enzyme inducer effect and already low dose
- ↑ EE if breakthrough bleeding occurs
When to start COC in postpartum women?
Delay until 3-4 weeks postpartum d/t hypercoagulability and thrombo. risk
How to manage COC in breastfeeding women?
- inform that COC may affect QUALITY of milk and ↓ nutrition content
- Do not use if breastfeeding is ONLY source of nutrition
- Ok to use if using both bottle/breast
missed pills Simplified approach Overkill method if unprotected sex in last 5 days
use EC at once
take 2 COC the next day then continue as directed
use a condom for 7 days
missed pills Simplified method no unprotected sex X 5D
2 COC then continue use
Condoms x 7D
Side effects of COC
spotting or bleeding before completing, after withdrawal, mid cycle.
Headaches evaluate for HTN
Weight change. Insufficient data
usually go away after 3rd cycle
Yasmin
- Drosperinone +EE
- Drosperinone has antimineralcorticoid activity = K sparing diuretic
Yas
like Yasmin but 4 placebo = shorter periods
Missing 1-2 active pills (>30 mcg EE)
- take 1 active pill ASAP and take 1 pill for day
* *consider EC if missed in 1st week and unprotected sex
Missing 3+ pills during week 1-2 (>30 mcg EE)
- take 1 active pill ASAP and take 1 pill for day
- use back-up until 7 active pills taken in a row
Missing 3+ pills during week 3
- finish active pills and throw away placebo
- start new pack next day without using placebo
COC S/E - Unsched Vag Bleeding (UVB) Key Points
- By 3rd pack UVB should cease for most women
- Avoid switching to new BC before 3 month period
COC S/E - UVB Mgmt Issues
- ↑ [progestin] i.e. switch to TP COC if spot/bleeding occurs before completing active pills
- ↑ [EE] and ↓ [progestin] if cont spotting/bleeding after withdrawal bleeding
COC S/E - Headache concerns
- Eval for HTN if new onset, worsening, and other S/Sx of TIA/CVA
- *HA d/t S/E usually gone by 3rd cycle and switching COCs won’t help**
What ↑ risk of hyperK on Yas?
- chronic NSAID
- concurrent spironolactone use
- ACEi/ARBs
- K suppl/salt sub
1) How Seasonique and LoSeasonique different from Seasonale?
2) What are the benefits
3) What is effect of extended cycle COCs on cancer risk?
1) Both have no placebo, Seasonale has 84 active + 7 placebo
2) shorter and lighter periods
3) showed no ↑ in cancer risk or no ↑ presence of pre-cancerous cells
1) What Rx causes atrophic endometrium?
2) What was its proposed benefit?
3) How was it hypothesized to cause this?
4) What actually happened?
1) Lybrel (1st approv for cont use)
2) No periods
3) Thought to reduce bleeding and CA risk b/c nothing to slough off, shown safe and effective
4) After 6 mos, approx half of women still had irreg spotting/bleeding**
1) What is NuvaRing
2) How is it used?
1) Soft flexible ring w/ 120 mcg prog and 15 mcg EE
- Similar [EE] d/t no first pass effect
2) Use like monophasic COC, just don’t put it in your mouth (21 days in, 7 days out)
Advantages of NuvaRing?
- easy to use
- slow and steady hormone release
- rapid effect, rapid reverse
Disadvantages of NuvaRing?
- Same VTE risk as COCs
- Ring expulsion spits out like ping pong ball.
- Foreign body sensation
How is ring expulsion managed with NuvaRing?
< 3 hrs = rinse, reinsert
> 3 hrs in week 1-2 = reinsert, back-up 7 days, EC if unprotected sex
> 3 hrs in week 3 = discard, new ring right away, back-up for 7 days
Don’t take out during sex, keep it in for target practice turns into a Cock ring…
How to start NuvaRing?
1) Insert 1st day (0)of period –> no contra back-up
2) Insert 1-5 days of period –> back up for 7 days
3) Insert on day of MD visit –> back up for 7 days
How is Annovera different from NuvaRing?
Annovera can be reused 13 times like a condom. whereas a new NuvaRing needed each cycle
How are transdermal patches used?
- A new patch placed each week
- *Make sure old patch is removed** shouldn’t look like a checkerboard on back.
- Can be placed on abd, butt, upper torso (no boobs), upper-outer arm (where skin is more uniform)
Advantages and disadvantages of patches?
Adv:
- weekly application and rapidly reversible
Disadv:
- ↑↑ risk of MI/CVA/VTE d/t higher [systemic]
- skin rxn
- breast sx: engorgement(< why is that a disadvantage?)/painful that’s more common vs COC
How to start patches?
- 1st day of period –> no back-up req’d
- 1st Sunday after period –> back-up for 7 days
How to manage lost/loose patches?
- < 24 hr = re-adhere w/ pressure (no adhesives)
- *if no seal –> replace**
- > 24 hr / unknown = new patch cycle, back-up x7 days, and offer EC if unprotected
- *Change days are different**
- if site rxn occurs –> rotate sites, not on same site
How is POPs different from COC?
- NO VTE risk
- Progestin only at a lower dose (norethindrone)
- No placebos
- Less variability in spotting, breakthrough
Why do POP typically fail?
- Pills must be taken at the same time d/t lower progestin doses having shorter DoA
POP MoA
- Inhibited ovulation in variable portion of cycle
- Cervical mucus thickening
- *Reduced ovum transport**
- *Altered endometrium**
PO injection disadvantage (Depot)
slow recovery 50% @ 10 mo 90% @20 mo. RTClinic x3 Mo. Decrease in Bone Mineral Density. - WHO says reversible - FDA says may be not reversible and use - FDA says use > 2 yrs only if other methods inadeq
COC First Day Start
1) procedure
2) key points
1) 1st pill on 1st day of next period (ensures woman not preg)
2) No need for back-up method but ↑ chance of not starting correctly
Nexplanon advantage
no user maintenance
works for 3 years
0.05% effective
reversible in 6 weeks
Nexplanon disadvantages
impropper insertion bruising/pain
Clinician dependant
effective during first 5 days of bleed else Backup x7D
1) 4 situations where POP can be started immed w/ no back-up req’d
2) When to use back-up when starting POPs?
3) For how long?
1) Starting during 1st five days of period
- Btw 6 wks - 6 mos postpartum if fully breastfeeding and amenorrheic
- W/in first 21 d postpartum if not breastfeeding
- Day after stopping another hormonal method
2) When any other situation occurs that does not require back
3) 2 days
IUD advantages
effective, long lasting, cost effective
IUD Disadvantages
spotting cramping, spontaneous expulsion 2-10% x1 yr perforation a insertion string problems (missing may be perforation/expulsion) gets stuck in teeth
Condom types and key points
1) latex - stronger, less break and slip
2) synthetic - more breaks and slips vs latex
3) no std manufact, more porous –> ↑ risk of STI and preg
Spermicide formulations and timing
1) Gels, creams, and foams
- immediate use, used alone if thrill seeker
2) Suppositories/Tablets/Inserts
- “hold on a minute” x15
3) Film
- “hold on a minute”x15 and at the back near cervix
Spermicide disadvantages
- “hold on a minute”
- Pre-cuddling takes > 1-3 hours –> degredation
- Genitalia irritation
- Messy (and this is bad?)
makes your breath smell funny
important distinction for Novelty condoms
not FDA tested cannot claim to prevent pregnancy or STD
1) Progestin Only EC MoA
2) Indication and Key Point
1) Prevent ovulation and impair sperm transportation
2) Approved up to 72 hours after unprotected sex
* *Taking sooner = ↑ efficacy**
1) Progestin Only EC MoA
2) Indication and Key Point
1) Prevent ovulation and impair sperm transportation
2) Approved up to 72 hours after unprotected sex
* *Taking sooner = ↑ efficacy**
COC EC ADR’s
N/V headache, irregular bleeding breast engorgement
Ulipristal (Ella) 2 key points
1) 30 mg dose has same effectiveness for entire 120 hours
2) May be more effective vs POPs in BMI > 26
Copper-T IUD 2 key points
1) Inserted up to 5 days after unprotected sex
2) Most effective EC (~99%)
When is Copper-T IUD not recommended?
- Pelvic inflamm Dz
- Active gonorrhea
- Active chlamydia
What is Seasonale, Seasonique, LoSeasonique?
- COCs approved for extended cycles
What is Lybrel?
- First COC approved for continuous use
What is Xulane?
- Transdermal EE + progestin patch
What is the progestin-only injection?
depot medroxyprogesterone acetate
What are Implanon and Nexplanon?
Intradermal progestin-only impregnated implant
What are Mirena/Skyla/Liletta/Kyleena?
Levonorgestrel impregnated IUD
What is ParaGard?
Non-drug, copper-based IUD
What are Plan B One-Step, Next Choice One Dose, My Way, Take Action?
Progestin-only emergency contraceptives with single 1.5 mg levonorgestrel dose
What is Ella?
30 mg progesterone receptor modulator with mixed agonist/antagonist emergency contraceptive that has a uniform 120 hour efficacy
What is Copper-T IUD?
Copper-based emergency contraceptive IUD
