Contraception and Fertility Flashcards
Normal menstrual cycle day range
23 - 35 days
What is day 1 of the cycle?
The start of bleeding, menses
Follicular Phase
Each follicle in an ovary contains an oocyte (immature egg)
-FSH spurs follicle development and causes estrogen to surge
-estrogen peaks by the end of the phase
-surge in estrogen cause LH and FSH to increase
Ovulatory Phase
LH surge from the end of follicular phase triggers ovulation 24 - 36 hours later
-ovulation is the release of the egg (ova) from the ovary
How long does the oocyte liver once released?
24 hours (happens mid-cycle)
Luteal Phase
Start of ovulation begins the luteal (last) phase which lasts 14 days
-progesterone is dominant in this phase
When should someone trying to conceive have sex?
Once LH surge is detected (meaning end of follicular stage and start of ovulatory phase when oocyte is released) for the following 2 days
-sperm can survive for 3 days
Human chorionic gonadotropin (hCG)
released when a fertilized egg attaches to this lining of the uterus (implantation)
Key Preconception Tips
-increase folate and vitamin B9 (400mcg dietary folate/day then 600mcg during pregnancy)
-stop smoking and drinking
-keep vaccinations current
-avoid toxic chemicals
What is the only reversible contraceptive method that delays the return of fertility?
medroxyprogesterone injection
What is the typical temperature prior to ovulation?
96 - 98%
What is the typical temperature during ovulation?
97 - 99%
Phexxi
vaginal gel that maintains an acidic pH ranging from 3.5 - 4.5 which does not allow sperm to live
-do not use with vaginal rings or in those with recurrent infections
How do hormonal contraceptives work?
inhibit the production of FSH and LH which prevents ovulation
-alter cervical mucus which inhibit sperm from penetrating the egg
Health benefits provided by hormonal contraception
-decrease in menstrual pain/ irregularity
-endometriosis
-acne
-ectopic pregnancy
-noncancerous breast lumps
-decreased risk of endometrial and ovarian cancer
Combination Oral Contraceptives (COCs)
ethinyl estradiol (EE) and progestin
progestin can be in the form of:
-norethindrone
-levonorgestrel (LNG)
-drospirenone
Monophasic: same dose throughout pack
Biphasic, triphasic and quadriphasic also available to mimic levels during menstrual cycle
Unique progestin: Drospirenone
-used in some COCs to reduce adverse effects
-mild potassium-sparing diuretic
-decreases bloating, PMS symptoms and weight gain
-less acne
products that have anti-androgenic activity
-drospirenone
-norgestimate
-desogestrel
-dienogest
First line treatment of polycystic ovary syndrome (PCOS)
COCs
“Lo”
indicates 35mg or less of estrogen causing less estrongenic side effects
“Fe”
iron supplement is included
“24”
indicates a shorter placebo time
-24 active pills, 4 placebo to make a 28 day cycle
Monophasic COC formulation
Junel Fe 1/20
Microgestin Fe 1/20
Sprintec 28
Loestrin 1/20
Yasmin 28
-21/7 pack
*contains 1mg norethindrone and 20mch EE
Loestrin 24 Fe, Yaz (24/4 pack)
Lo Loestrin Fe (24/2/2 pack)
triphasic formulation (COC)
Tri-Sprintec (7/7/7)
Quadiphasic Formulation (COC)
Natazia
Extended Cycle COC Formulations
Seasonique
84 days of EE and LNG followed by 7 days of low dose EE
Drospirenone containing formulations
Yasmin 28, Yaz
-contraindicated in renal or liver disease
-monitor potassium and kidney function during use
Continuous COC formulations
Amethyst
-no inactive pills
-28 days of EE and LNG with no placebo
patches
Xulane
-higher AUC than pills
-contains both EE and progestin
Xulane and Zafemy less effective in those greater than 198 lbs
Rings
Nuva Ring
-lower AUC than pills
-contains both EE and progestin
Annovera: lasts for 1 year
Progestin only pills
-Erin
-Camila
-Nora-BE (nor indicates norethindrone)
-incassia
-Slynd (drospirenone -only)
First line for endometriosis
COCs
Products indicated for heavy menstrual bleeding
COC Natazia
Mirena IUD
Primary uses for POPs (Progestin-Only Pills)
-breast feeding women
(EE decreases milk production)
-contraindication to estrogen use
-can be started 3-6 weeks postpartum
(EE this soon after delivery increases risk of thrombosis)
-migraine with aura (EE cannot be used because of stroke risk)
Downside:
-require very good adherence (within 3 hours of scheduled time)
Patch considerations
-higher systemic estrogen exposure
-not to be used in anyone with high clotting risk
High clot risk considerations with estrogen
-greater than 35
-smoker
-cerebrovascular disease or previous blood clots
-postpartum
-BMI greater than 30
Side effects of estrogen
-Nausea
-breast tenderness
-bloating
-weight gain
-increased blood pressure (fluid retention)
-melasma (dark skin patches on the face)
(reduced dose helps, but too low will cause breakthrough bleeding)
Progestin side effects
breast tenderness, HA, fatigue, depression
Drospirenone side effects
slightly higher risk of clotting
(avoid in high clot risks)
-increased potassium
(avoid in kidney, liver, or adrenal gland disease since these can also increase potassium levels)
Side effect of Depo-provera shot
-loss in bone mineral density
-need to supplement vitamin D and calcium
Contraindication with the Estrogen + Progestin patch
-do not use in women with a BMI greater than 30 because of increased risk of thromboembolism (Xulane and Zafemy)
-decreased efficacy (Twirla)
Contraindications to using estrogen
-history of DVT/PE/stroke, CAD
-breast, ovarian or liver cancer
-migraines with aura
Drug selection of patient with acne or hirsutism
COC with a progestin that has low androgenic activity (norgestimate Sprintec 28) or no androgenic activity like drospirenon (Yaz, Yasmin)
Drug selection of patient breastfeeding
-POP
-nonhormonal method
Drug selection for estrogen contraindication (clot risk)
-POP
-non hormonal
Drug selection for a patient with heavy menstrual bleeding (menorrhagia)
-COC Natazia
-Mirena IUD
-COCs with 4 placebos instead of 7
Drug selection for those with mood changes or mood disorder
-monophasic COC
-extended cycles
-continuous drospirenone preferred
Drug selection for premenstrual dysphoric disorder
-yaz (just drospirenone)
-SSRI may be needed
Spotting/ break through bleed dose adjustment
early in cycle: increase estrogen
late in cycle: increase progestin
Benefit of injection
-less drug interaction since it bypasses first-pass metabolism An
Antibiotics that decrease hormonal contraceptive efficacy
-rifampin (back up for 6 weeks after ABX is discontinued)
-rifabutin
-rifapentine
Anticonvulsants that decrease hormonal contraceptive efficacy
-carbamazepine
-oxcarbazepine
-phenytoin
-primidone
-topiramate
-lamotrigine
-barbiturates
-perampanel
Miscellaneous drugs that interact with birth control
-st. John’s wort
-smoking tobacco
-ritonavir boosted protease inhibitors (Mycophenolate)
-colesevelam
-Byetta
Risks with Hepatitis C treatment
Mavyret cannot be used with any formulation containing EE due to risk of liver toxicity
Infertility is defined as how long of actively trying to become pregnant
1 year of unprotected sex
Clomiphene
-selective estrogen receptor modulator (SERM)
-causes LH and FSH surge to trigger ovulation
-surge in LH causes hot flashes
SERMs
-act as estrogen agonists in some tissues and antagonists in others
-clotting risks
Letrozole
-aromatase inhibitor
-impacts ovulation through estrogen negative feedback
Gonadotropins
-trigger ovulations by acting similar to the endogenous FSH and LH
-used after poor response to clomiphene
-used to spur egg release during in vitro fertilization
Leuprolide
-gonadotropin releasing hormone agonists
-used to trigger ovulation
Clotting risk with progestin
-drospirenone has a slightly higher risk of clotting compared to other progestins
Weeks of first trimester
0 - 12 weeks
organ development, most at risk of teratogens
Gravida (G)
Para (P)
G = # of times pregnant
P = # of times given birth `
Calcium requirements of a pregnant woman
1,000 mg/day calcium
15 mcg/day (600 IU) Vitamin D
