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GYN > Contraception > Flashcards

Contraception Flashcards

1
Q

What does USMEC stand for?

A

U.S. Medical Eligibility Criteria for Contraceptive Use

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2
Q

What does each of the 4 category of USMEC mean?

A

The USMEC category 1 indicates that there are no restrictions to use of the contraceptive. Category 2 indicates that the benefits of the contraceptive outweigh the risks and the patient still can use the method, although in certain situations there may be a need for additional follow-up. Category 3 means that the risks of the contraceptive generally outweigh the benefits. Nevertheless, the method still may be used if nothing else is available or acceptable to the patient and she has been counseled about the potential risks. The patient may require close follow-up to ensure that continued use is safe. Category 4 conveys that the method is contraindicated and should not be used

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3
Q

What percentage of sexually active women become pregnant within 1 year if they are not using contraceptives?

A

85%

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4
Q

Why does estrogen containing OCP increase risk for VTE?

A

The estrogenic component of combined hormonal contraceptives increases hepatic production of serum globulins involved in coagulation (including factor VII, factor X, and fibrinogen) and increases the risk of venous thromboembolism (VTE) in users. Although all combined hormonal contraceptives cause an increased risk of VTE

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5
Q

How much more dangerous is pregnancy compared to using OCP while you are already at risk for VTE?

A

2 times!

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6
Q

For a women w/ h/o VTE, can she use combined OCP?

A

Yes, it depends.

For women with a prior VTE, the risk of a recurrent VTE depends on whether the initial thrombosis was associated with a risk factor that is permanent (eg, factor V Leiden) or reversible (eg, surgery). Therefore, a combined hormonal contraceptive candidate with a history of a single episode of VTE that occurred years earlier and was associated with a nonrecurring risk factor (eg, after immobilization because of a motor vehicle accident) may not currently be at increased risk of a recurrent VTE, and a combined hormonal contraceptive may be considered if no other method is available or desired (USMEC category 3).

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7
Q

How far in advance should you stop OCP if you are about to undergo surgical (including gynecologic) procedures?

A

Don’t have to stop for all surgeries.
The normalization of clotting factors associated with stopping combined contraceptives is not observed unless discontinuation happens 4–6 weeks before major surgery.

Use of combined hormonal contraceptives is contraindicated in patients undergoing major surgery with anticipated prolonged immobilization (USMEC category 4). Otherwise, if patients are expected to be ambulatory postoperatively, there is no reason to stop combined hormonal contraception (USMEC category 2).

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8
Q

Compare combined hormonal contraceptive patch and ring appears similar to that with combined OCs in terms of it’s risk of VTE.

A

Although the data are conflicting, the risk of VTE associated with the combined hormonal contraceptive patch and ring appears similar to that with combined OCs

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9
Q

Does decreasing the dose of ethinyl estradiol make a difference in terms of decreasing VTE risk?

A

Reductions in ethinyl estradiol dose from 50 micrograms to less than 50 micrograms were associated with decreased risk of VTE, but not to much lower level.

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10
Q

Does using newer generation formulations of progestins make a difference in VTE risk?
What’s older older formulations of progestins? What’s newer formulations of progestins?

A

No! The risk of VTE associated with combined hormonal contraceptives formulated with desogestrel, drospirenone, and etonogestrel is similar to the risk associated with use of methods formulated with older progestins

Older formulations of progestins (levonorgestrel and norethindrone) 
Newer progestins (desogestrel and drospirenone in oral contraception and etonogestrel in the vaginal ring)
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11
Q

In women with a history of or at risk of VTE, myocardial infarction, or stroke, what USMEC category do Progestin-only pills, the contraceptive implant, or an LNG-IUD belong to?

What about DMPA?

A

2

The USMEC allows the use of DMPA in women at risk of VTE (USMEC category 2).

The hypoestrogenic effect and increased total cholesterol levels seen in DMPA users 40 41 result in concern that the risk might outweigh benefit of DMPA use in women with a personal history of ischemic heart disease or stroke (USMEC category 3).

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12
Q

What are some familial thrombophilias? What does this matter?

Can these women use combined hormonal contraceptives? What can they use?

A

Women with thrombophilic syndromes, including factor V Leiden mutation, prothrombin G20210A mutation, protein C, protein S, or antithrombin deficiency have an increased risk of VTE during combined hormonal contraceptive use.

Use of combined hormonal contraceptives is contraindicated in women with known familial thrombophilias (USMEC category 4)

Progestin-only methods and LNG-IUDs are acceptable alternatives for individuals with known thrombogenic mutations (USMEC category 2).

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13
Q

Do patients with systemic lupus erythematosus (SLE) have an increased risk of arterial thrombosis or venous thrombosis?

What can increased the risk of thromboembolism even more?

A

Both.

Risk of thromboembolism is further increased by the presence of persistently positive antiphospholipid antibodies

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14
Q

What are the different antiphospholipid antibodies?

A

lupus anticoagulant, anticardiolipin antibody, and anti-β2-glycoprotein antibody

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15
Q

There is an estimated 50-fold increased risk of WHAT in SLE women?

A

myocardial infarction

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16
Q

What USMEC category is combined hormonal contraception for women with SLE and positive antiphospholipid antibodies?

A

USMEC category 4

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17
Q

What USMEC category is combined hormonal contraception for women with SLE without antiphospholipid antibodies?

A

category 2 in the absence of other cardiovascular disease risk factors (eg, older age, smoking, hypertension, diabetes, and hypercholesterolemia)

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18
Q

Does combined hormonal contraceptives worsen SLE disease activity in women with inactive or stable active disease?

A

No

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19
Q

Can you use progestin-only methods, including LNG-IUDs, for women w/ SLE?

A

category 3 for SLE patients with antiphospholipid antibodies

category 2 for SLE patients without antiphospholipid antibodies

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20
Q

Be cautious with starting WHAT on women w/ SLE complicated by severe thrombocytopenia?

A

DMPA, because of concerns for menstrual bleeding with severe thrombocytopenia that may be worsened by the irregular bleeding with the initiation of DMPA

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21
Q

What USMEC category is LNG-IUD in for women w/ SLE on immunosuppressant medications?

A

USMEC category 2

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22
Q

8 major risk Factors for Venous Thromboembolism in Users of Combined Hormonal Contraceptives

A

Smoking and age 35 years or older

Less than 21 days after giving birth or 21–42 days after giving birth with other risk factors (eg, age 35 years or older, previous venous thromboembolism, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, body mass index of 30 or greater, postpartum hemorrhage, postcesarean delivery, preeclampsia, or smoking)

Major surgery with prolonged immobilization

History of deep vein thrombosis or pulmonary embolism

Hereditary thrombophilia (including antiphospholipid syndrome)

Inflammatory bowel disease with active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, or fluid depletion

Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies

Superficial venous thrombosis (acute or history)

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23
Q

Combined hormonal contraceptives is USMEC category 4 during the first ? days after giving birth

A

21

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24
Q

Beyond ? days, women without VTE risk factors can use combined hormonal contraceptives regardless of breastfeeding status.

A

?

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25
Q

When doe the VTE risk factors return to baseline in the postpartum period?

A

12 weeks

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26
Q

How soon should you place immediate postpartum IUD?

A

Within 10min

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27
Q

What are some contraindications for immediate postpartum IUD?

A

A peripartum course complicated by chorioamnionitis, postpartum endometritis, or sepsis makes IUD insertion contraindicated until evaluation by a clinician at the postpartum visit (USMEC category 4)

28
Q

What does progestin affect lactogenesis? If you can’t wait to start POP, how soon?

A

There is a theoretical concern, nevertheless, that initiation of progestin methods immediately after giving birth could preempt lactogenesis given that progesterone withdrawal after delivery of the placenta is thought to be the trigger to prolactin secretion.

At least give it 48–72 hours postpartum, till after the onset of lactogenesis

29
Q

How soon can women ovulate after birth, breast feeding and not breast feeding?

A

Most nonbreastfeeding women will not ovulate until 6 weeks postpartum, however, some women may experience ovulation as early as 3 weeks postpartum.

Pregnancy risk is decreased for 6 months at most in exclusively breastfeeding women who do not use formula supplementation and who, therefore, meet criteria for the lactational amenorrhea method of contraception.

30
Q

Healthy, nonsmoking women without specific risk factors for cardiovascular disease can continue combined hormonal contraception until age ?

A

50-55

USMEC category 2

However, because age is an independent risk factor for cardiovascular disease and thromboembolism, caution should be used if women have additional risk factors such as smoking, obesity, diabetes, hypertension, or migraine headaches with aura (USMEC category 3–4)

31
Q

What’s the estimated sterility rate for 40yo, 45yo, 50yo?

A

17% at age 40, 55% by age 45, and 92% by age 50

32
Q

What are some positive effects of combined hormonal contraceptives for perimenopausal women?

A

Positive effect on bone mineral density, abnormal uterine bleeding (AUB), a reduction in vasomotor symptoms, reduced risk of endometrial cancer and ovarian cancer, which is of particular importance to older women of reproductive age and those at increased risk of these types of cancer

33
Q

What USMEC category does DMPA belongs to for who are older than 45 years without other risk factors for cardiovascular disease?

A

2

In older women who have been using DMPA long term, it is unknown if bone mineral density levels return to baseline before entering menopause

34
Q

Are the efficacy for different weight class the same with combined hormonal pill, patch, or ring?

A

the overall risk of unintended pregnancy in women who used the combined hormonal pill, patch, or ring was not significantly different across BMI categories

35
Q

What does weight make a difference in oral contraceptions?

A

Pharmacokinetic studies show that, compared with normal weight women, women with obesity require twice as long to reach steady state therapeutic levels of contraceptive steroids when starting the pill or after the hormone-free interval because of changes in clearance

36
Q

What USMEC category is combined hormonal contraceptives in for women with obesity?

A

USMEC category 2 because obesity and use of combined hormonal contraceptives represent independent risk factors for VTE

37
Q

Is the efficacy of LNG-IUD affected by weight?

A

ecause all LNG-IUDs work locally on the uterus and do not rely on systemic drug levels, their efficacy is not affected by BMI

38
Q

Roux-en-Y gastric bypas, oral contraception?

A

USMEC category 3

Women who undergo bariatric surgery that may compromise the absorption of oral medications (Roux-en-Y gastric bypass or biliopancreatic diversion) should not use oral contraception (combined hormonal or progestin-only) because efficacy may be impaired (USMEC category 3)

39
Q

Biliopancreatic diversion, oral contraception?

A

USMEC category 3

Women who undergo bariatric surgery that may compromise the absorption of oral medications (Roux-en-Y gastric bypass or biliopancreatic diversion) should not use oral contraception (combined hormonal or progestin-only) because efficacy may be impaired (USMEC category 3)

40
Q

Oral contraception for restrictive types of bariatric surgery?

A

USMEC category 1

41
Q

List examples of restrictive types of bariatric surgery?

A

vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy

42
Q

Do SSRI or SNRI affect hormonal contraception?

Do depression worsen with hormonal contraception?

A

No.

No.

Women with depressive disorders can use all methods of hormonal contraception (USMEC category 1) because depressive symptoms do not appear to worsen with use of any method of hormonal contraception, including DMPA. Combined hormonal contraceptives use does not modify the effectiveness of fluoxetine. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors do not appear to interact with the metabolism of hormonal contraceptives.

43
Q

what USMEC category for St. John’s wort with combined hormonal contraception, progestin-only pills, and the etonogestrel implant?

A

USMEC category 2

44
Q

Which is more common: migraine without aura or migraines with aura?

A

Migraine without aura is the most common subtype of migraine, accounting for 75% of cases

45
Q

What’s aura?

A

Aura is the complex of neurologic symptoms, usually visual, that occurs usually before the headache. Aura lasts 5–60 minutes and can present as zigzag lines spreading across the visual field, or sensory symptoms, such as pins and needles, speech disturbances, or motor weakness

46
Q

What USMEC category for progestin-only method in women with migraines with or without aura?

A

USMEC category 1

47
Q

What USMEC category for combined hormonal contraceptives in women with migraines without aura and no risk for stroke?

A

USMEC category 2

48
Q

What USMEC category for estrogen-containing contraceptives in women with migraines with aura?

A

USMEC category 4

49
Q

What USMEC category for these BP:

  1. BP below 140/90 mm Hg
  2. systolic 140–159 mm Hg or diastolic 90–99 mm Hg
  3. systolic 160 mm Hg or greater or diastolic 100 mg Hg or greater or with vascular disease
A
  1. any hormonal contraceptive method
  2. USMEC category 3 w/ combined hormonal contraceptives
  3. USMEC category 4 w/ combined hormonal contraceptives

When multiple risk factors exist, combined hormonal contraception may increase a patient’s cardiovascular disease risk to an unacceptable level (USMEC categories 3 and 4)

50
Q

Use of combined hormonal contraceptives in women w/ HTN increase what risk? by how many folds?

A

the relative risk of acute myocardial infarction in women with hypertension is increased by a factor of 12

51
Q

Which one of these increase BP:

  1. Contemporary low-dose (35 micrograms or less) combined estrogen–progestin OCs
  2. progestin-only pills, DMPA, subdermal implant, or LNG-IUD methods
A

1.

Unlike other progestins, the use of DMPA in women with hypertension of systolic 160 mm Hg or greater or diastolic 100 mm Hg or greater is generally not advised because of the theoretical risk of unfavorable lipoprotein changes that could contribute to cardiovascular risk (USMEC category 3)

52
Q

All hormonal contraception are in what USMEC category for women with uncomplicated insulin or noninsulin dependent diabetes?

A

2

53
Q

what USMEC category for women with diabetes of more than 20 years of duration or evidence of microvascular disease (retinopathy, nephropathy, or neuropathy), using combined hormonal contraceptives?

A

USMEC category 3 or 4 depending on the severity of the condition

54
Q

what USMEC category for women with diabetes of more than 20 years of duration or evidence of microvascular disease (retinopathy, nephropathy, or neuropathy), using DMPA?

A

USMEC category 3

Because DMPA increases lipoprotein profiles favorable to atherosclerosis and these women might already have existing cardiovascular disease

55
Q

hormonal contraceptives for women with a family history of breast cancer?

A

Gynecologic care providers need not restrict use of any hormonal contraception in women with a family history of breast cancer (USMEC category 1) or women with identified mutations in breast cancer susceptibility genes (eg, BRCA1 and BRCA2) who have not personally been diagnosed with breast cancer

56
Q

USMEC category for combination estrogen–progestin or progestin-only contraception, including the LNG-IUD, and personal h/o cancer?

A

USMEC category 4 for current or recent breast cancer

Category 3 for no evidence of disease for 5 years or more

57
Q

USMEC category for use of combined hormonal or progestin-only contraception, including continuation of a previously placed LNG-IUD, for patient in whom cervical, endometrial, or ovarian cancer is diagnosed and while awaiting for surgery?

A

USMEC category 1 or 2

58
Q

USMEC category for any hormonal method of contraception, for women who have been treated for gestational trophoblastic disease with suction curettage, if hCG levels are falling or undetectable or if hCG levels are elevated but intrauterine disease is not evident or suspected

A

USMEC category 1 or 2

59
Q

USMEC category for IUD, for women with gestational trophoblastic disease for whom there is persistently elevated hCG levels or malignant disease when intrauterine disease is evident or suspected

A

USMEC category 4

60
Q

What antiepileptic is the only antiepileptic medication known to have its metabolism affected by estrogen-containing contraceptives?

A

Estrogen-containing contraceptives reduces lamotrigine serum levels with concomitant use. Therefore, dose adjustments of lamotrigine may be needed if hormonal contraceptives are used concomitantly and lamotrigine levels may increase during the hormone-free intervals.

61
Q

USMEC category for combined hormonal contraception or progestin-only pills and rifampin and liver-enzyme inducing antiepileptic and antiretroviral medications?

A

USMEC category 3

increased risk of contraceptive failure

62
Q

USMEC category for DMPA and LNG-IUDs and rifampin and liver-enzyme inducing antiepileptic and antiretroviral medications?

A

USMEC category 1

63
Q

Liver enzyme inducer Antiepileptic Drugs

A

Carbamazepine

Felbamate

Oxcarbazepine

Phenobarbital

Phenytoin

Primidone

Rufinamide

64
Q

List the only two antimycobacterial drugs that affect the metabolism of estrogen and progestin and have pharmacokinetic evidence of lower serum steroid levels, which may affect contraceptive efficacy

A

Rifampin and rifabutin, two antimycobacterial drugs in the rifamycin class

progestin-only pills (USMEC category 3)
the etonogestrel subdermal implant (USMEC category 2)
DMPA or the LNG-IUD (USMEC category 1)

65
Q

USMEC category for progestin-only methods for women taking anticoagulants

A

USMEC category 2

66
Q

USMEC category for combined contraceptives for women on therapeutic anticoagulation

A

USMEC category 3

GYN (4 decks)

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