Contraception Flashcards
What happens in the follicular stage?
FSH stimulates several follicles to develop. The dominant follicle synthesizes enough estradiol to create negative feedback and decrease FSH levels
What happens in the ovulatory phase?
Estradiol levels peak and exert positive feedback to induce an LH surge, which facilitates the release of the mature ovum. Estrogen promotes proliferation of the endometrium and development of progesterone receptors in the endometrium.
What happens in the luteal phase?
Progesterone prevents new follicle development as well as differentiation of the endometrium. If no pregnancy occurs, the corpus luteum degenerates, leading to menstrual bleeding.
What hormone makes people feel better during menstruation?
estrogen- increases energy and feel good feeling
What hormone makes people feel bloated, low, and slow?
Progesterone
What percentage of pregnancies are unintended in the United States?
nearly half (45%)
What percentage of unintended pregnancies were paid for my medicaid?
2/3
What are the challenges for family planning?
few easy effective methods, low patient compliance and lack of knowledge, societal conflict about FP, clinical challenge, little time, tight budgets, risk taking behaviors
What do you need before prescribing contraception?
Medical history and blood pressure
What is not required prior to prescribing contraception?
pap smear, pelvic/breast exam, STI testing, hgb
Estrogen has positive effects on ?
bone mass, increases serum triglycerides, and improves HDL and LDL ratios
Estrogen stimulates which pathways
coagulation and fibrinolytic pathways
Progesterone increases ___ ____ and _____ ____
body temperature and insulin levels
Progesterone may depress the ?
Central nervous system
Estrogen is contraindicated with which types of migraines
migraines with aura
Progestins are primarily responsible for?
contraceptive effect
Progestins exhibit a ______ effect in the ______ _____ ____ axis
negative
hypothalamic-pituitary-ovarian axis
Progestins cause ____ of the endometrium, which ?
atrophy
prevents implantation
The ____ component improves efficacy by ______ ____ release
estrogen
suppressing FSH
Estrogen provides _____ ____
cycle control
What are the three goals of contraceptive treatment?
safety, tolerance, effectiveness
If a patient has a history of ____, do not use estrogen
clotting
Progesterone decreases the ____ _____ and may take a ____ to come back
endometrial lining; a year
Non-contraceptive benefits of OC
decreased dysmenorrhea, irregularities, and blood loss
fewer ovarian cysts
lower incidence of benign breast conditions
reduced hospitalizations for gonorrheal PID
endometriosis suppression
Contraception significantly reduces the chance of what cancer?
endometrial and ovarian
What is contraindicated in a family history of breast cancer?
estrogen
venous thrombo-embolism risk increases how much with OC use?
3-5 times
Adverse drug reactions with OC
cholestatic jaundice, benign hepatic neoplasms, myocardial infarction, stroke, neurological migraines
Estrogen contraindications
migraine with aura, uncontrolled hypertension, postpartum <3 weeks, history of DVT, SMOKING (over 35 and smoking >15 cigarettes/day)
Traditional dosing of OC
21 days active drug + 7 days inactive drug
Extended cycle dosing for OC
84 days of active drug then 7 days off
Withdrawal bleed
Once every 3 months
monophasic dosing
same dose of estrogen and progestin for full cycle
biphasic dosing
vary the dose of progestin, with an increase in the amount of progestin in the latter half of the active pills (these are rarely used today)
triphasic dosing
vary the dose of estrogen, progestin, or both (more popular today)
Is there a benefit to doing triphasic dosing? Why?
no benefit to triphasic dosing and you cannot do continuous dosing with this dosing as you are more likely to have break through bleeding
If a patient comes to the office for OC and has a negative hcg, when can they start the pill?
same day-but use a backup method for 2 weeks
If you are on OCP, can you still have withdrawal bleeding?
yes-at the end of the pack as there are still hormone adjustments
OC cycle is better controlled with which dosing?
30-35EE rather than 20mcg
Extended cycle dosing decreases what?
the days of bloating and menstrual cramping
Which OC would you choose for acne control?
Yazmin
If a patient suffers from depression or mood swings around the menstrual cycle, avoid what?
progesterone
According to a new study, women have a ___ ____ in pregnancy if on abx.
7 fold increase
Emergency contraception dosing
Progestin Only 0.75mg (plan B): must be taken within 72 hours of unprotected sex. pills stat of 1 pill 12 hours apart
If taken appropriately, how effective is plan B?
95% within 24 hours, 89% within 72 hours
What age do you have to be to buy OTC plan B?
over age 17
Plan B is less effective if BMI is >?
26 (165 lbs)- due to lower serum levels; patient may need to double the dose: also offer IUC and oral ulipristal
Does plan B disrupt or harm an implanted pregnancy?
No
Plan B MOA
inhibits ovulation, thickens cervical mucus, inhibits tubal transport of egg or sperm, may interfere with fertilization or early cell division
Ulipristal acetate (ELLA) is what kind of contraception
emergency contraception-decreases risk of unintended pregnancy by 90%
ulipristal acetate is effective for how many days after unprotected intercourse?
5 days
Ulipristal acetate loses efficacy at what BMI?
35
what is ulipristal?
mixed progestin agonist/antagonist
Is ulipristal acetate OTC?
No-prescription only; cost is 40-68$
side effect of ulipristal acetate?
dizziness, typically resolves in 1 day; also headache, nausea, tiredness, cramping, and abdominal pain
dose of ulipristal?
30mg orally in 1 dose
MOA of ulipristal?
delays ovulation. not an abortifacient; also has a direct effect on inhibiting follicular rupture making it more effective closer to obulation
when is ulipristal preferred?
for overweight and/or obese patients
What is the first line contraceptive in teens?
IUD
Can IUD’s be used as emergency contraception?
Yes-for up to 7 days after unprotected intercourse
Is an IUD an abortifacient?
no-it is not disrupting an already established pregnancy
Nuvaring contains what ingredients?
progesterone, etonogestrel, and estrogen ethinylestradiol
how long can each ring be used for?
one cycle, which consists of a 3 week period of continuous ring use followed by a ring free period of one week
how much hormone does each ring release
15 ug of ethinyl estradiol and 120 ug etonogestrel per day over the 3 week periods
What is annovera
combo estrogen progesterone ring that can be used for one year, taken out, and washed every cycle
patch is the highest dose of ?
estrogen/progesterone
what group of people does the patch not work well in?
obese patients as it is absorbed differently in adipose tissue
Does the ring/patch or pill have better adherance?
Theoretically the ring/patch as it is not daily
how often does the patch need to be changed?
every 9 days
progesterone only medications have been thought to affect ____ _____
bone density; but patient regain this when they go off of their medication, bone loss is not permanent;
While on progesterone only medications, encourage what supplements?
vitamin D (800 u) and calcium (1200mg)
which contraceptive methods are considered highly effective?
male and female sterilization, implants, hormone shot, intrauterine devices: they are not user dependent
IUD’s release how much levonorgestrel?
between 14 and 20mcg daily
how long can an IUD be left in place?
3-5 years
what is the benefit of an IUD systemically?
the small level of circulating hormone has low risk of systemic side effects
What does the IUD do?
thickening of cervical mucus, endometrial atrophy, and inhibits sperm motility and function
IUD has minimal effect on?
ovulation suppression
how long does it take for normal endometrium function to return after discontinuation of IUD
1-3 months
What IUD’s are the smallest?
Skyla and Kyleena, smaller in length and width compared to Mirena and Liletta. They have a smaller diameter insertion tube and Skyla has a silver ring at the top for visualization on ultrasound. The smaller size may make it easier to insert in nulliparous women
How long does implanon provide protection?
3 years
What is implanon made of?
one rod that contains 68mg of etonogestrel, an active metabolite of desogestrel.
Who can insert implanon?
Trained providers, it is easier now because it is only one rod to insert rather than several
What is depo-provera?
a long acting injectable, progestin only contraception.
How many miligrams in each injection and how long does it last for?
150mg IM for 12-13 weeks
how does depo provera work?
thickens cervical mucus and atrophies the endometrium.
Are their other injections rather than IM?
yes, subcutaneous 104mg injection offers a lower overall hormone dose with no change in efficacy, even in patients with a higher BMI
How early or late can they get their injection?
They should get it every 12 weeks, although a week early or late is acceptable
Will DMPA change a women’s bleeding pattern?
yes-causing an increased number of days of spotting or amenorrhea
what is the primary reason women d/c DMPA?
increased spotting or amenorrhea
What is another negative side effect of DMPA?
weight gain
How long does it take to restore normal fertility cycles after DMPA?
9-10 months
What should you counsel patients on before prescribing depo provera
to increase dietary calcium intake and weight bearing exercise along with smoking cessation to mitigate BMD changes
Two brand names of POPs (progestin only pills)
micronor and no-QD
What is special about POPs?
They contain no estrogen
What populations are contraindicated for receiving estrogen?
migraine with aura, uncontrolled hypertension, postpartum <3 weeks, history of DVT, SMOKING (over 35 and smoking >15 cigarettes/day) and breastfeeding
Dosing specifications for POPs?
must take the dose at the exact same time every day as the medication takes 2-4 hours to work and only last for 22 hours
what is the primary contraceptive method of POPs?
thickening of the cervical mucosa and prevention of sperm penetration
Even if the POP is taken a few hours late, you must use _____ _____ for ___ ____
backup contraception: 48 hours
traditional COC dosing
21 days active pill, 7 days inactive pills
extended menstrual cycling
84 days of active pill and 7 days off; produces withdrawal bleeding every 3 months
What is different about seasonique?
considered monophasic but contain 10mcg of EE in the last week of one cycle of dosing
Lybrel dosing
continuous cycle without any hormone free weeks for 1 years.
Can other monophasic COC’s be dosed continuously?
yes-just take the active pill continuously without the inactive pill
What is the newest dosing regimen for monophasic COC’s?
24 active and 4 inactive pills per cycle
First day start
the first pill is taken on the first day of the menstrual cycle. No backup method is needed when using this initiation method because ovulation will be suppressed with the first cycle
Sunday start
the first pill is taken on the Sunday following the start of menses; a backup method is recommended for the first 7 days
Quick start
The first pill is taken on the day of the office visit; a backup method is recommended for the first 7 days. This method can be used if the clinician is reasonably sure that the patient is not pregnant
3 most common reasons for missed pills
being away from home, forgetting, or not having the pill available
If you miss one active pill
take pill as soon as you remember, taking two pills in 1 day if missed pill was the day prior (use backup contraceptive for 7 days)
missed two to four active pills
take two pills for 2-3 days (use back up contraception for 7 days)
Missed 5 or more active pills
start a new pack on the next start day (ex.Sunday for sunday starters) Use backup contraception until 7 days of active pills are taken
How much hormone does the ring release?
15 mcg of EE and 120mcg of etonogestrel daily
Dosing for vaginal ring
ring is placed in the vagina for 3 weeks and then removed for 1 week.
what is the benefit of the ring
does not need to be placed by a provider, releases a steady, low dose of hormone which offers better cycle control in the form of decreased breakthrough bleeding when compared to COCs, and offers convenient once-monthly self-administration
how much hormone is released by the ring
approximately 50% compared to COC and 30% of levels used with the patch
Extended cycling with the ring caused what?
increased serum triglycerides and HDL levels
research is being done on what types of rings?
dual purpose of contraception and protection from STI’s
dosing or ortho evra topical patch?
20mcg of EE and 150mg of norelgestromin, which is the primary active metabolite or norgestimate
does norelgestromin undergo liver metabolism?
yes, however, it results in the metabolite levonorgestrel which is highly bound to sex hormone binding globulin, limiting it biological impact
How often is the patch applied
once a week for 3 weeks and then 1 week off
when should the first patch be applied
on the first day of menses; if it is started on any other day, a backup method should be used for 7 days
where should the patch be applied
abdomen, upper torso, outer arm, or buttocks and rotated with each patch change. It should be placed on skin that is clean and dry
Side effects of patch
similar to those of COC, and skin irritation
Decreased patch efficacy in patients with?
increased BMI
bleeding is a common side effect of POP and COC, does it usually resolve?
yes, within the first 3-6 months
why do some women experience break through bleeding after extended use?
decidualization and fragility of the endometrium, which is a progestational effect-stopping the dosing regimen is unnecessary
how can you improve bleeding?
determine when the bleeding is occurring during the cycle and change pill formation
side effects from systemic absorption of levonorgestrel
breast tenderness, mood changes, and acne
commin side effects of COC, the ring, and patches
nausea, weight gain, mood swings, breast tenderness, and headaches
if patient are experiencing a lot of side effects, the provider should encourage?
the patient to try a different pill formulation to manage side effects rather than discontinuing the method altogether
what typically resolves the side effects
continued use of the same method
what are the three major influences on the continuation of contraception
the number and severity of side effects, concerns over medical risks (cancer, blood clots), and nonmedical factors such as not understanding directions and complicated packaging
