Contraception and Infertility Flashcards by Grace Whitham

How long is a normal menstrual cycle and what is considered day 1?

23-35 days (28 average)

Day 1 of period = day 1 of cycle

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What are the 3 phases of the menstrual cycle? What happens in each stage?

Follicular - FSH causes follicle development and estrogen surge; this surge causes increase in LH and FSH; estrogen peaks at end of this phase
Ovulatory - LH surge triggers ovulation 24-36 hours later
Luteal: start of ovulation begins this phase; progesterone is dominant; lasts ~14 days

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How long does an oocyte live once released?

24 hours

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What hormone is released when a fertilized egg attaches to the lining of the uterus?

Human chorionic gonadotropin (hCG)

Can be detected in urine or blood

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What should women planning to conceive do to protect the future baby?

Folic acid supplements (400 mcg/d)
Stop smoking, using drugs, and drinking excessive alcohol
Keep vaccinations current
Avoid hazardous drugs

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What contraceptive method has a delay in return to fertility?

medroxyprogesterone injection

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What contraceptive methods are most, moderately, and least effective?

Most: Implant, intrauterine device, sterilization
Moderate: Injectable, pill, patch, ring, diaphragm
Least: Condom, withdrawal, sponge, spermicide, calendar tracking

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What type of condoms don’t protect against STDs

“Natural” sheepskin

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What types of lubricants should be recommended for use with latex or non-latex synthetic condoms?

Water or silicone-based

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What is the name of spermicide and why should it not be used with anal sex

Spermicide nonoxynol-9

Can cause irritation and increase risk of STDs

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What is in a combination oral contraceptive (COC)

estrogen and progestin

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What is CHC?

Combined hormonal contraceptives

Combined contraceptive that is not in an oral formulation

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What does the FDA recommend is dispensed with oral contraceptives?

Patient Package Insert

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What indications do COCs have?

Dysmenorrhea (menstrual cramps), premenstrual syndrome, acne (in females), anemia (by reducing blood loss), menses regulation in PCOS, endometriosis

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Why is drospirenone a unique progestin?

Mild potassium-sparing diuretic which decreases bloating, PMS symptoms and weight gain

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Progestin only pills (POPs) MOA; what population are they used in?

MOA: suppress ovulation
Used in lactating women because estrogen decreases milk production (start 3-6 weeks postpartum) and estrogen increases risk of thrombosis
Safe in women with migraines with aura

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Contraceptive patch important notes

Higher systemic estrogen exposure; do not use in someone with clotting risk factors
Less effective in women >198 pounds or BMI >30
Do not use in women > 35 who smoke

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How often is Depo-Provera given?

every 3 months

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What oral contraceptive is approved for continuous contraception

Amethyst

Others are used off-label

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What do the following mean when included in the name of an oral contraceptive:
Lo
Fe
24

Lo: 35 mcg or less of estrogen (less estrogen related SE)
Fe: iron supplement included
24: shorter placebo time

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What are monophasic formulations of oral contraceptives?

Junel, Microgestin, Sprintec, Loestrin, Yasmin, Lo Loestrin

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What are biphasic, triphasic formulations of oral contraceptives?

Ortho Tri-Cyclen Lo, Tri-Sprintec

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What are extended cycle formulations of oral contraceptives?

Seasonique, Camrese, Jolessa, Amethia

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What are drospirenone containing formulations of oral contraceptives?

Yasmin, Yaz

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What contraceptives come in the ring formulation?

NuvaRing | Annovera

What contraceptives are progestin-only?

Errin Camila Nora-BE

What to do if patient is having breakthrough bleeding

If on estrogen: Switch to product with higher estrogen dose Wait 3 cycles before changing doses If on pogesterone: increase dose

Estrogen-containing products BBW

Do not use in women > 35 who smoke due to risk of serious CV events

Estrogen + progestin transdermal patch BBW

increased risk of DVT/PE compared to COC

Depo-provera BBW

loss of bone mineral density

When should estrogen containing contraceptives be avoided?

Hx of DVT/PE, stroke, CAD, breast CA, ovarian CA, liver CA, migraines with aura

Severe and rare adverse effects of estrogen

``` ACHES A - Abdominal pain that is severe - ruptured liver tumor/cyst, gallbladder, ectopic pregnancy C - Chest pain - PE, MI H - Headaches - stroke E - Eye problems - clot in eye S - Swelling or sudden leg pain - DVT ```

What contraceptive to use for someone with | Acne

COC with low (Sprintec) or no (Yaz) androgen

What contraceptive to use for someone who is | breastfeeding

POPs or nonhormonal method

What contraceptive to use for someone with | estrogen CI

POPs or nonhormonal method

What contraceptive to use for someone with | Migraine

with aura: POPs or nonhormonal methods | no aura: any method

What contraceptive to use for someone with | Fluid retention/bloating

Drospirenone containing

What contraceptive to use for someone with | Heavy menstrual bleeding

COC Natazia and IUD Mirena - indicated for this | COCs with 4 placebo pills may minimize bleeding

What contraceptive to use for someone with | HTN

POPs or nonhormonal

What contraceptive to use for someone with | Mood changes or disorder

Monophasic COC - extended cycle or continuous with drospirenone

What contraceptive to use for someone with | nausea

take at night decrease estrogen dose switch to POP or nonhormonal method

What contraceptive to use for someone who is | overweight

any method | do not use DMPA if trying to avoid further weight gain

What contraceptive to use for someone who is | postpartum

do not use CHCs for 3 weeks or for 6 weeks if patient has additional risk factors for VTE Can use POPs or nonhormonal method during this time

What contraceptive to use for someone with | premenstrual dysphoric disorder (PDD)

Yaz or an antidepressant

What medications decrease hormonal contraceptive efficacy

``` Abx (rifampin, rifabutin) Anticonvulsants (carbamazepine, oxcarbzepine, phenytoin, primidone, topiramate, lamotrigine) St. John's wort Smoking Ritonavir Colesevelam Byetta ```

What heptitis C treatments cannot be used with ethinyl estradiol containing medications and why?

Technivie and Viekira Pak | Risk of liver toxicity

When do you not have to use backup birth control when starting a COC?

If started within 5 days after the start of the period

How to start progestin-only pills

Start any time | Use backup method for first 48 hours

What to do if a patient misses a dose of COC

If <48 hours since last dose - take ASAP, no backup needed, take next dose as scheduled If >48 hours since last dose - take ASAP, backup needed x 7 days, take next dose as scheduled (if in week 3, omit placebo week or use backup until 7 days of active pill have been taken)

What to do if a patient is >3 hours late for POP

Take pill ASAP and take next dose on schedule, backup contraception x 48 hours

Which long-acting reversible contraceptive can be used for birth control and emergency contraception?

Copper-T IUD (ParaGard)

What are 3 emergency contraception options?

ParaGard IUD Ella Plan B One-Step

When to use each form of EC? How well do they work?

ParaGard: 99.9% effective, use within 5 days Ella: less effective if over 195 pounds, use ASAP up to 5 days Plan B: least effective, less effective if over 165 pounds, use ASAP up to 3 days

What is the active ingredient in Plan B One-Step and Ella?

Plan B: levonorgestrel | Ella: Ulipristal acetate

MOA and Primary side effect of Plan B One-Step and Ella

MOA: delay ovulation SE: Nausea If pt vomits within 2 hours, need to repeat dose

How long to leave in diaphragm and sponge - can you reuse?

at least 6 hours but no longer than 24 hours | Can reuse diaphragm for 2 years, do not reuse sponge

Where to apply contraceptive patch

Butt, stomach, upper arm, upper torso | Do NOT apply to breast

How long to use NuvaRing

3 weeks | Can be kept in for 4 weeks to prevent period

If NuvaRing is out for ____, use backup contraception ___

>3 hours | until ring has been in for 7 continuous days

Clomiphene indication and drug class

Indication: first-line treatment in women with irregular or absent menstrual cycle Class: selective estrogen receptor modulator (SERM)

Clomiphene MOA and SE

causes LH and FSH to surge resulting in ovulation SE: hot flashes, blood clots *can release more than one egg and result in multiple births

How do gonadotropin drugs work?

act as LH, FSH, or hCG causing ovulation | *can release more than one egg and result in multiple births

Gonadotropin indication and route

Infertility Use after clomiphene failure Used to spur eff release for intrauterine insemination and in vitro fertilization Route: SQ or IM

What medications are gonadotropin drugs?

chorionic gonadotropin-recombinant, follicle stimulating hormone-recombinant, human chorionic gonadotropin-recombinant and menotropin Menopur, Follistim AQ, Gonal-f, Pregnyl, Novarel, nad Ovidrel