Contraception Exam 3 Flashcards
1
Q
Nonpharmacologic contraception options
A
- periodic abstinence
- barrier methods
2
Q
periodic abstinence
A
- avoiding intervcourse during ovulation
- FDA approved an app that will track of ovulation
3
Q
What are the types of barrier methods?
A
- male condom
- female condom
- diaphragm
- cervical cap (Femcap)
- sponge (Today)
4
Q
What is something to consider when a pt is using the barrier method?
A
failure rates are high; counsel pt on emergency contraceptive
5
Q
Barrier method: male condom
A
- Single-use, mechanical barrier
- prevent direct contact -> prevent STDs
- contraindications: allergy to latex or rubber
6
Q
Barrier method: female condom
A
- single use
- latex free
- prevent direct contact -> prevent STDs
- contraindications: allergy to synthetic nitrile, hx of toxic shock syndrome
7
Q
Barrier method: diaphragm
A
- reusable
- use with spermicide
- has to be fitted: rx
- decrease incidence of cervical cancer
- contraindications: allergy to latex or spermicide, recurrent UTI, history of TSS, abnormal gynecologic anatomy
8
Q
Barrier method: cervical cap
A
- reusable
- blocks sperm access to uterus
- latex free
- use with spermicide
- rx
- contraindications: allergy to spermicide, history of TSS, abnormal gynecologic anatomy, abnormal pap smear
9
Q
Pharmacologic contraception options
A
- spermicides
- hormonal contraception
10
Q
Pharmacologic contraception options: spermicides
A
- destroy sperm cell walls
- barrier that prevents sperm from entering the cervix
- non-rx
- contraindications: allergy to spermicide, do not use with women who has HIV (or high risk)
11
Q
Pharmacologic contraception options: spermicide products
A
- Nonoxynol-9 is the primary ingredient
- Various formulations: creams, films, foams, gels, suppositories, sponges, and tablets
- Disadvan: increase risk of UTI
12
Q
combination hormone contraception contraindications
A
- H/O thromboembolism or thrombophillia
- H/O vascular disease (CVA, CAD, PVD)
- Diabetes with vascular involvement
- Migraine headaches with focal aura
- Uncontrolled hypertension (> 160 systolic or > 90 mm Hg diastolic)
- Breast cancer
- Acute or chronic hepatocellular disease with abnormal liver function, cirrhosis, hepatic adenomas, or hepatic carcinomas
- Age > 35 years and currently smoking > 15 cigarettes per day
- Breastfeeding women < 6 weeks postpartum
13
Q
combination hormone contraception relative contraindications
A
- Multiple risk factors for arterial cardiovascular disease
- Hyperlipidemia (uncontrolled)
- H/O hypertension (uncontrolled)
- Migraine headache without aura in women > 35
- Cirrhosis, mild and compensated
- Symptomatic gallbladder disease
- Postpartum < 3 weeks and not breast-feeding
- Breastfeeding women < 6 months postpartum
- Commonly use drugs that induce liver enzymes and reduce efficacy
(i. e. rifampin, phenytoin, carbamazepine, barbiturates, primidone, topiramate)
14
Q
monophasic oral contraceptives
A
- Same amount of estrogen and progestin for 21 days followed by 7 days of placebo (21/7 regimen).
- Selected products: Ovcon, Ovral, Necon, Yasmin, Apri
15
Q
biphasic and triphasic oral contraceptives
A
- Contain variable amounts of estrogen and progestin for 21 days followed by 7 days of placebo.
- Selected products: Ortho Tri-Cyclen, Estrostep Fe
16
Q
extended cycle regimens
A
- Designed to reduce menstrual flow intensity & duration to reduce withdrawal symptoms
- 24/4 regimen: Loestrin-24 FE, YAZ
- 26/2, 4-phasic regimen: Natazia
- 84/7 regimen: Seasonale, Seasonique
- Disadvan: bleeding irregularities
17
Q
combination oral contraceptives: continuous regimens
A
- Designed to eliminate menses and reduce withdrawal symptoms
- equally effective to 21/7 regimen
- Lybrel
18
Q
ADE of continuous regimens
A
increase in bleeding irregularities
19
Q
oral contraceptives: progestin only
A
- progestin only for all 28 days
- Must be taken at the same time every day to maintain efficacy
- If > 3 hours late, use back up contraception for 48 hours
- Micronor, Ovrette
20
Q
ADE of progestin only products
A
- Increased bleeding irregularities
- May not block ovulation, so ectopic pregnancy more likely
21
Q
choosing oral contraceptives
A
- consider low androgenic or antiandrogenicOCs in women with acne and hirsutism
- consider extended or continuous cycle OC in women desiring to reduce or eliminate menstrual cycle and those with menstrual-related symptoms
- consider progestin-only pills or other progestin only methods in women to contraindications / precautions for estrogen
22
Q
initiating an oral contraceptive
A
- First Sunday start method: Take first pill on the first Sunday after menstruation begins. If menses begin on a Sunday, begin on that day.
- Quick start method: Take first pill on the day of the office visit (given a negative pregnancy test)
- use second method of contraception for at least 7 days from start date
23
Q
oral contraceptive adverse effects
A
- nausea, bloating, breakthrough bleeding should resolve within first 3 months
- D/C if ACHES are present (Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain)
- metabolized by liver
- Anticonvulsants and Griseofulvin decrease contraceptive effect
- Antibiotics (Rifampin, rifapentine, rifabutin)
24
Q
oral contraceptive patient education
A
- Give written education and verbally review patient package insert
- Common and serious adverse effects
- Management of adverse effects
- No STI or HIV protection
- When to start i.e. quick start
- Importance of routine daily adherence
- Drug interactions
- When to expect menses: within 1-3 days after taking the last active pill
- Start next pack immediately after finishing 28 day pack even if menses is not complete
- Takes about 1-2 weeks to return back to fertility
- Could have amenorrhea for 6 months max
25
What should a pt do if she is on oral contraceptives and she misses a dose?
- If 1 active pill < 24 hours late: Take 1 active pill ASAP then continue the remaining pills at the usual time, No additional protection is necessary.
- If missed 1 or more active pills (> 24 hours late): Take 1 active pill ASAP, throw out any other missed pills, then take remaining pills at the usual time. Skip placebo week and start new pack, Use a 7 day back-up method, Consider emergency contraception ASAP if unprotected intercourse in previous 5 days
26
other forms of hormone contraception
- transdermal patch
- vaginal contraceptive ring
- long-acting injectable progestin
- long-acting implantable progestin
- intrauterine devices (IUD)
27
other forms of hormone contraception: transdermal patch product
- Ortho Evra®
28
other forms of hormone contraception: transdermal patch
- Not recommended first line if > 90 kg due to higher pregnancy rates
- Application-site reactions
- Apply new patch every week for 3 weeks, and then use no patch for week 4
29
other forms of hormone contraception: transdermal patch patient education
- if forgot to change patch within 9 days, use back up method for 7 days
- can be applied to abd, buttocks, upper torso, or upper arm
- if patch accidentally taken off for > 24h, restart cycle + back up method for 7 days
- Takes about 1-2 weeks to return back to fertility
30
other forms of hormone contraception: vaginal contraceptive ring products
- NuvaRing® - releases hormone daily for 3 week period
| - Annovera® - reusable rings that works for 1 year duration
31
other forms of hormone contraception: vaginal contraceptive ring
- releases estrogen and progestin
- insert ring vaginally on or before the 5th day of the menstrual cycle, maintain in place for 3 weeks, then remove for 1 week
- higher exposure to estrogen
32
other forms of hormone contraception: vaginal contraceptive ring patient education
- May be uncomfortable and cause vaginal discharge in some women
- If expelled for > 3 hours, use back-up contraception and insert new ring.
- Takes about 1-2 weeks to return back to fertility
33
other forms of hormone contraception: long-acting injectable progestin
- inhibits ovulation for up to 14 weeks
- Repeat injection every 3 months
- can cause menstrual irregularities, weight gain, decrease bone mineral density
- FDA and ACOG don't agree on how to use this
34
other forms of hormone contraception: long-acting injectable progestin: products
- Depo-Provera® depo-medroxyprogesterone (DMPA)
| - Depo-SubQProvera 104®
35
other forms of hormone contraception: long-acting injectable progestin patient education
- Missed dose: If lapse of > 13 weeks between IM or > 14 weeks between SC, should do pregnancy test before re-dosing and use back-up method for 7 days.
- Minimize bone loss by taking calcium and vitamin D supplementation and increasing weight-bearing exercise.
- Return to fertility: usually delayed, mean time to conception from first omitted dose is 10 months, may take up to 18 months.
36
other forms of hormone contraception: long-acting implantable progestin products
- Implanon®
| - Nexplanon®
37
other forms of hormone contraception: long-acting implantable progestin
- remove by the end of the 3rd year and replace
| - can cause irregular menstrual bleeding
38
other forms of hormone contraception: long-acting implantable progestin patient education
- Feel arm to ensure that you can feel rod to assure proper placement
- Return to fertility: within 30 days of removal
39
other forms of hormone contraception: intrauterine devices (IUD) products
- Levonorgestrel IUD
- Mirena® (5 yrs)
- Skyla® (3 yrs)
- Liletta® (3 yrs)
- Kyleena® (5 yrs)
40
other forms of hormone contraception: intrauterine devices (IUD)
- can cause menstrual irregularities
| - some can cause pelvic inflammatory disease (PID)
41
other forms of hormone contraception: intrauterine devices (IUD) patient education
- Return to fertility: immediately upon removal
- Contact physician immediately if s/s of PID including long-lasting heavy bleeding, unusual vaginal discharge, abdominal pain, chills, and fever.
42
considerations for contraception selection
- Weigh benefits and risks & advantages and disadvantages
- Contraception should fit patient’s lifestyle and suit the patient’s needs
- If STI protection is needed, a condom should be used and can be combined with another contraceptive
- If patient has a history of noncompliance, consider long acting options
- Desire for future fertility/pregnancy
- Frequency of intercourse
- Existing medical conditions
- Smoking status
- Desired therapeutic outcomes
- Pharmacoeconomic considerations
43
hormone contraception in diabetes
- patients with diabetes are at increased risk for stroke and MI
- combined HC should not be used in women with diabetes who smoke, have HTN or vascular disease, or are >= 35
- All other forms of contraception are acceptable alternatives
44
hormone contraception in thromboembolism
- combined HC should not be used
| - All other forms of contraception are acceptable alternatives
45
hormone contraception in migraines
- Acceptable to consider CHC in nonsmoking women who are < 35 with migraines if they do not have focal neurologic signs (i.e. aura), but should be second-line therapy
- Do not use CHC in women >= 35 years old who have migraines without aura
- Do not use CHC in women of any age who have migraines with aura
- Discontinue CHC immediately in women of any age who develop migraines (with or without aura) while on CHC
- All other forms of contraception are acceptable alternatives
46
hormone contraception in women >= 35 years old
- Must weigh benefit against risk of cardiovascular disease (esp if pt smokes)
- CHC with < 35 mcg EE acceptable if nonsmoker and no significant risk factors (i.e uncontrolled dyslipidemia or HTN)
- All other forms of contraception are acceptable alternatives
47
hormone contraception in HTN
- CHC is acceptable if < 35 yo with well-controlled, frequentlymonitored blood pressure in the absence of end-organ vascular disease and smoking
- All other forms of contraception are acceptable alternatives
48
hormone contraception in smoking
- If < 35 years old, may use CHC with < 35 mcg EE
- If > 35 years old, do not use CHC
- All other forms of contraception are acceptable alternatives
49
hormone contraception in dyslipidemia
- Progestins may increase LDL levels
- Estrogens may increase triglycerides levels
- Acceptable to use CHC and progestin only methods in women with controlled dyslipidemia with periodic lipid panel monitoring
- Use alternative non-hormonal contraception in women with uncontrolled dyslipidemia and additional cardiovascular risk factors
50
hormone contraception in breast cancer
- Acceptable to use CHC in patients with benign breast disease or a family history of breast cancer
- Do not use CHC or progestin-only options in woman with a personal history of breast cancer
- Acceptable alternatives include copper IUD or barrier methods
51
hormone contraception in postpartum
- Progestin-only methods acceptable to use any time after delivery.
- CHC may be initiated after 3 wks postpartum. Avoid in first 3 wks.
- If breastfeeding, wait 6 months
52
hormone contraception in obesity
- Use of HC in obese women is still acceptable given overall pregnancy rates remain low. Avoid using CHC with < 35 mcg EE in obese women
- In women > 90 kg, may consider alternatives such as DMPA, IUD, or barrier methods
53
emergency contraception: hormone contraception
- High-dose progestin only OR combination OC pills
54
emergency contraception: hormone contraception products
- Plan B One-Step
- Next Choice One Dose
- My Way
- Nordette
- Levlen
- Levora
- Lo/Ovral
- Triphasil
- Tri-Levlen
- Trivora
- Alesse
- Levlite
55
emergency contraception: patient education
- If vomiting occurs within 1 hour of taking tablets, recommended to repeat dose
- If no menstrual cycle within 3 weeks, pregnancy test is recommended
56
emergency contraception: progesterone agonist / antagonist products
Ulipristal acetate (Ella One)
57
emergency contraception: progesterone agonist / antagonist
- Selective progesterone receptor modulator that delays or inhibits ovulation, including possibly inhibiting follicular rupture
- take within 5 days of unprotected intercourse
58
emergency contraception: copper IUD
- copper can prevent sperm from fertilizing an egg and may also prevent implantation of a fertilized egg
- insertion within 5 days of unprotected intercourse
