Contraception & Infertility Flashcards
1
Q
How long does a normal menstrual cycle range?
A
A normal menstrual cycle ranges from 23-35-days (average 28 days)
2
Q
What is considered day 1 of a menstrual cycle?
A
The start of bleeding (menses) indicates that the next cycle has begun and is counted as day 1 of the cycle; the remnants of the previous cycle (the thick, blood endometrial lining) are sloughing off
3
Q
What are the different phases of the menstrual cycle?
A
Follicular, ovulatory, luteal
4
Q
What phase does menses occur?
A
Menses occurs during the follicular phase, when the estrogen and progesterone levels start off low
5
Q
What happens during the follicular phase of the menstrual cycle?
A
Each follicle in an ovary contains an oocyte (immature egg). Follicle stimulating hormone (FSH) spurs follicle development and causes estrogen to surge. Estrogen peaks by the end of the phase. The surge in estrogen causes luteinizing hormone (LH) and FSH to increase
6
Q
What happens in the ovulatory phase?
A
The LH surge triggers ovulation 24-36 hours later. Ovulation is the release of the egg (ova) from the ovary
7
Q
What happens in the luteal phase?
A
The start of ovulation begins the luteal (last) phase, which lasts ~14 days. Progesterone is dominant in this phase
8
Q
What significance does estrogen and progesterone have on the menstrual cycle?
A
Estrogen and progesterone cause the endometrium to thicken to prepare for an embryo, and progesterone causes the cervical mucus to thicken and body temperature to increase. When estrogen and/or progesterone are low during the cycle, blood can drip off the lining, causing spotting (which can require an increase in estrogen or progesterone in birth control pills)
9
Q
What is the significance of the luteinizing hormone in the menstrual cycle?
A
Luteinizing hormone causes corpus luteum development in the ovary. LH and FSH work together in the ovulatory phase to trigger ovulation
10
Q
What happens during the mid-cycle luteinizing hormone surge?
A
The mid-cycle luteinizing hormone surge results in release of the oocyte from the ovary into the fallopian tuber. The oocyte lives for 24 hours once released, and sperm can survive for ~3 days
11
Q
How do ovulation kits utilize the luteinizing hormone?
A
Ovulation kits predict the best time for intercourse based on ovulation in order to try to conceive. Some kit test for LH in the urine and are positive if LH is present
*A person wishing to conceive should have intercourse when the LH surge is detected, and for the following 2 days (based on sperm survival of ~3 days)
12
Q
What hormone is released when a fertilized egg attaches to the lining of the uterus?
A
Human chorionic gonadotropin
13
Q
How do pregnancy tests utilize hCG?
A
Detecting hCG in the urine or blood indicates pregnancy. A home urine test can detect pregnancy sooner if the woman tests the first urine in the morning, when the hCG level is highest
14
Q
What preconception health steps should any woman planning to conceive take?
A
- Increase their folic acid (folate, vitamin B9) consumption from a combination of dietary supplements and fortified foods. Folate requirement increases during pregnancy to 600 mcg DFE/day
- Stop smoking, using illicit drugs and drinking excessive amounts of alcohol
- Keep vaccinations current. Attempt to avoid illnesses that will adversely affect the baby
- Avoid toxic chemicals, including drugs on the Hazardous Drug List developed by NIOSH
15
Q
What is the only reversible contraceptive method that has a delay in return to fertility?
A
Medroxyprogesterone injection
16
Q
What kind of condoms provide more protection from STDs?
A
Condoms provide protection from some infections - female internal condoms provide more protection than male external condoms
17
Q
What are the most effective contraceptive methods?
A
Implant (0.05%), Intrauterine device (0.2% with LNG and 0.8% with Copper T), male sterilization (0.15%) and female sterilization (0.5%)
18
Q
What are the second most effective contraceptive methods?
A
Injectable (6%), pill (9%), patch (9%), ring (9%) diaphragm (12%)
19
Q
What are some other contraceptive methods?
A
Male condom (18%), female condom (21%), withdrawal (22%), sponge (24% parous women and 12% nulliparous women), fertility-awareness based methods (24%), spermicide (28%)
20
Q
What is the only 100% effective way to prevent pregnancy and STDs?
A
Abstinence
21
Q
What are some other non-pharmacological methods of contraception?
A
Temperature and cervical mucus tracking and the use of barrier methods. Spermicide can be used alone or with other barrier methods as another OCT option for contraception
22
Q
How does keeping track of body temperature and cervical mucus be used as a contraceptive method?
A
Keeping track of body temperature and cervical mucus are used primarily to avoid pregnancy by abstaining from intercourse on days when a woman is fertile. Tracking basal body temperature is used to predict ovulation
23
Q
Describe the temperature and cervical mucus method
A
Changes in temperature are recorded on a calendar and used to predict ovulation in the following months. The temperature needs to be taken first thing each morning, prior to any other activity. Temperature methods work best when done in conjunction with tracking changes in the cervical mucus, which has slight changes in color, texture and volume during ovulation
24
Q
What is the barrier method?
A
Barrier methods of contraception include condoms, diaphragms, caps and shields. They are non-pharmacologic options that form a physical barrier preventing passage of sperm to the oocyte
25
What are diaphragms, caps and shields?
These options are soft latex or silicone barriers that cover the cervix and prevent sperm passage. They can be used with or without spermicide. The Caya diaphragm is a single size and does not require fitting
26
What are condoms?
Male condoms are think latex or plastic sheath worn on the penis. Female condoms are inserted into the vagina.
27
What is an advantage of condoms?
Condoms help protect against many STDs (only if latex or synthetic condoms, not "natural" sheepskin)
28
What can the combination of a condom and nonoxynol-9 spermicide cause?
Can cause irritation and increase risk of STD/HIV transmission
29
How can the use of lubricants with condoms be beneficial?
Lubricant makes condoms less likely to break by reducing dry friction. Never recommend oil-based lubricant for use with a latex or non-latex synthetic condom; only recommend water or silicone-based lubricants
30
What are some other OTC contraceptive methods?
Other OTC contraceptive methods include foams, film, creams, suppositories, sponges and jellies which contain spermicide nonoxynol-9. Do not use spermicide with anal sex. It is irritating and can increase the risk of STDs.
31
How is the sponge used as contraception?
The sponge is a round piece of white, plastic foam that is inserted prior to intercourse and continuously releases spermicide. It is removed and discarded after use
32
What is Phexxi and how should it be used?
A recently approved prescription-only option is Phexxi, a vaginal gel that maintains an acidic pH (range 3.5-4.5), which is inhospitable to sperm and reduces their mobility. It should not be used with vaginal rings or in those with a history of recurrent UTIs or urinary tract abnormalities
33
How do hormonal contraceptives work?
Hormonal contraceptives work by inhibiting the production of FSH and LH, which prevents ovulation. They alter cervical mucus, which inhibits the sperm from penetrating the egg.
34
What is an important counseling point of hormonal contraceptives?
If implantation of the fertilized egg in the uterus has already taken place, none of these methods are effective, and the pregnancy will proceed normally
35
What are some available treatments of hormonal contraceptives?
Available treatments include progestin-only options (pill, injectable, implant and IUD) or estrogen/progestin combinations (pill, patch, vaginal ring). The estrogen/progestin combination pills are called combination oral contraceptives (COCs). Non-oral contraceptives that contain both estrogen and progestin are referred to as combined hormonal contraceptives
36
What health benefits do hormonal contraceptives provide?
A decrease in menstrual pain, menstrual irregularity, endometriosis, acne, ectopic pregnancy, noncancerous breast cysts/lumps and risk of endometrial and ovarian cancer
37
What does the FDA require to be dispensed with oral contraceptives?
The Patient Package Insert (PPI)
38
What do most COCs contain?
Most COCs contain the estrogen ethinyl estradiol (EE) and a progestin (e,g, norethindrone, levonorgestrel (LNG), drospirenone)
39
Describe monophasic COCs
Monophasic COCs have the same dose of estrogen and progestin throughout the pill pack
40
Describe biphasic, triphasic and quadriphasic
Biphasic, triphasic and quadriphasic pill packs mimic the estrogen and progesterone levels during a menstrual cycle. The type of formulation refers to the number of times the amounts of hormones change
41
What is Drospirenone and what are its benefits?
Drospirenone is a unique progestin that is used in some COCs to reduce adverse effects commonly seen with oral contraceptives. It is a mild potassium-sparing diuretic which decreases bloating, PMS symptoms and weight gain; drospirenone-containing products are also associated with less acne, as they have anti-androgenic activity
42
What are other progestins with low adrogenic activity?
Norgestimate, desogestrel and dienogest
43
What are some other indications that COCs can be used for?
COCs are used for other indications besides pregnancy prevention, including dysmenorrhea (menstrual cramps), premenstrual syndrome (PMS), acne (in females), anemia (by reducing blood loss), peri-menopausal symptoms (hot flashes), night sweats) and menstrual-associated migraine prophylaxis. The use of COCs to regulate menses is first-line treatment for polycystic ovary syndrome (PCOS)
44
What indication is COCs used as first line-treatment?
Endometriosis in which endometrial tissue grows outside the uterus. COCs reduce the symptoms of dysmenorrhea and heavy bleeding
45
What COC is FDA-approved from moderate to severe pain associated with endometriosis?
Elagolix (Orilissa)
46
What is the COC Natazia and the levonorgestrel-releasing IUD Mirena indicated for?
Heavy menstrual bleeding (menorrhagia)
47
What is Oriahnn?
Oriahnn, which contains estradiol, norethindrone and elagolix, is indicated for heavy menstrual bleeding associated with uterine fibroids but not a contraceptive
48
What is Lysteda?
Lysteda, an oral formulation of tranexamic acid (antifibrinolytic), is a nonhormonal treatment for menorrhagia
49
Describe progestin-only pills and how they can prevent pregnancy
Progestin-only pills contain no estrogen and have 28 days of active pills in each pack. POPs prevent pregnancy by suppressing ovulation, thickening the cervical mucus to inhibit sperm penetration and thinning the endometrium
50
Which population primarily use POPs?
POPs are primarily used in women who are lactating (breastfeeding) , because estrogen decreases milk production. POPs can be useful for women with a contraindication or intolerance to estrogen and can be started soon after delivery (3-6 weeks postpartum). It is not safe to use estrogen this soon after delivery because of an increased risk of thrombosis
51
What is required of patients taking POPs?
POPs require good adherence; the pill must be taken within 3 hours of the scheduled time
52
What is another indication that POPs can be used for?
POPs are sometimes used for migraine prophylaxis and are safe in women who have migraines with aura
53
What are some examples of non-oral hormonal contraceptives?
Contraceptive patch, vaginal contraceptive rings, injectable contraception, intrauterine devices
54
What are some similarities and differences between the patch and oral contraceptives?
The patch has the same side effects, contraindications and drug interactions as COCs, but the patch causes a higher systemic estrogen exposure
55
Who should not use the contraceptive patch?
It should not be used in anyone with clotting risk factors. The patch is less effective in women > 198 pounds (Xulane) or BMI > 30 kg/m2 (Twirla). Do not use the patch in women > 35 years old who smoke
56
Describe vaginal contraceptive rings
The vaginal rings have the same side effects, contraindications and drug interactions as oral contraceptives. These are small, flexible rings that are inserted into the vagina once a month. The exact position of the ring in the vagina does not matter
57
Describe injectable contraception
The injection (Depo-Provera, Depo-subQ Provera 104) is depot medroxyprogesterone acetate (DMPA), a progestin. It suppresses ovulation, thickens cervical mucus and causes thinning of the endometrium. DMPA is given by IM or SC injection every 3 months
58
Describe intrauterine devices (IUDs)
IUDs are long-acting, reversible forms of contraception. Some IUDs contain hormones to exert their effects
59
Describe how COC formulations sync up with menstrual periods
Most COC formulations involve 28 days (4 weeks) of pills, with 21-24 pills containing active hormone and the remaining pills containing no hormone. During week 4, bleeding (menses) occurs for 3-7 days. Fewer inactive pills results in a shorter hormone free interval and shorter bleeding time. Women who take COCs often have lighter bleeding because the endometrium remains relatively thin
60
When does bleeding occur with women who take the patch or the ring or injection?
Bleeding occurs during the patch-free or ring-free interval (week 4). About half of medroxyprogesterone acetate users will be amenorrheic (no menses) after 1 year of use
61
What are extended cycle COCs?
Extended-cycle COCs involve 84 days of active hormonal pills followed by 7 days of inactive or very low dose estrogen pills. With this schedule, bleeding occurs every 3 months rather than every month. By taking continuous contraception, it is possible to suppress menses altogether
62
What is an example of an extended cycle COC?
Amethyst
63
What are some counseling points regarded extended-cycle COCs?
With continuous use, it can be difficult to tell if a woman becomes pregnant. Spotting occurs commonly with continuous contraception, which can lead to discontinuation. It is important to counsel patients that this typically resolves after 3-6 months. There are benefits to continuous use, such as less anemia and menstrual migraines
64
What are some general tips for contraceptive names?
- "Lo" indicates < 35 mcg of estrogen; less estrogen causes less estrogenic side effects
- "Fe" indicates an iron supplement is included
"24" indicates a shorter placebo time 24 active + 4 placebo = 28 day cycle
65
What are some examples of monophasic formulations?
65
What are some examples of monophasic formulations?
Junel Fe 1/20, Microgestin Fe 1/20, Sprintec 28, Loestrin 1/20, Yasmin 28, Apri, Aviane, Cryselle-28, Levora, Nortrel 1/35, Ocella, Portia-28, Zovia 1/35E, Loestrin 24 Fe, Yaz, Beyaz, Minastrin 24 Fe, Nikki, Lo Loestrin Fe
66
Describe monophasic formulations
Provides the same dose of progestin and estrogen throughout the active pill days
67
What are the examples of monophasic formulations that are 21/7 pill pack that contains 21 active hormonal pills, 7 inactive pills?
Junel Fe 1/20, Microgestin Fe 1/20, Sprintec 28, Loestrin 1/20, Yasmin 28, Apri, Aviane, Cryselle-28, Levora, Nortrel 1/35, Ocella, Portia-28, Zovia 1/35E
68
What are the examples of the monophasic formulations that are 24/4 pill pack that contains 24 active hormonal pills, 4 inactive pills?
Loestrin 24 Fe, Yaz, Beyaz, Minastrin 24 fe, Nikki
69
What is an example of monophasic formulations that is a 24/2/2 pill pack that contains 24 active combined hormonal pills, 2 pills of just EE, and 2 inactive pills?
Lo Loestrin Fe
*Very low dose of estrogen used (EE 10 mcg)
70
What are some examples of biphasic, triphasic formulations?
Ortho Tri-Cyclen Lo, Tri-Sprintec, Nortrel 7/7/7, Trivora, Velivet
71
Describe biphasic, triphasic formulations
"Phasic" in the name refers to the hormone dose being delivered in phases. The beginning of the name indicates the number of phases throughout the cycle
*3 different weeks (7/7/7) or "tri" indicates a triphasic formulation
72
What is an example of a quadriphasic formulation?
Natazia
73
Describe quadriphasic formulations
Hormone doses change over 26 days (four phases of estradiol valerate and progestin dienogest) followed by 2 placebo pills to mimic menstrual cycle and minimize menstrual bleeding
74
What are some examples of extended cycle formulations?
Jolessa, Seasonique, Camrese, Camrese Lo, Amethia
75
Describe extended cycle formulations
Period occurs every 3 months
76
Which extended cycle formulation has 84 days of EE + LNG followed by 7 days of placebo?
Jolessa
77
Which extended cycle formulations have 84 days of EE + 7 days of low dose EE?
Seasonique, Camrese, Camrese Lo, Amethia
78
What is an example of a continuous formulation?
Amethyst
79
Describe continuous formulations
No inactive pills (taken continuously); no period occurs
*28 days of EE + LNG with no placebo pills
80
What are some examples of Drospirenone containing formulations?
Yasmin 28, Yaz, Loryna, Ocella, Zarah, Nikki, Safyral, Syeda, Beyaz
81
Describe the effects of Drospirenone Containing Formulations
- Mild potassium-sparing diuretic to reduce bloating and other effects
- Contraindicated in renal or liver disease
- Monitor potassium, kidney function during use
82
What are some examples of contraceptive patches?
Xulane, Twirka
83
Describe the contraceptive patches
Higher AUC than pills
*Weeks 1-3: apply once weekly; week 4: off
84
What are examples of vaginal rings?
NuvaRing, EluRyng, Annovera
85
Describe vaginal rings
- Lower AUC than pills
- Insert monthly: in x 3 weeks; remove x 1 week
*Annovera: reusable vaginal ring; wash and store when it is removed, then reinsert; used for 1 year
86
What are some examples of progestin-only pills?
Errin, Camila, Nora-BE, Incassia, Slynd
87
Describe the progestin-only pills
- Errin, Camila, Nora-BE contain a fixed dose of norethindrone; take active tablet daily (no placebo days); "Nor" in the name indicates it contains norethindrone
- Slynd is drospirenone-only
88
What is an example of a contraceptive injection?
Depo-Provera
89
Describe Depo-Provera
Contains depot medroxyprogesterone (DMPA): injected every 3 months (50 mg IM or 104 mg SC)
*"Pro" in the name indicates it contains a progestin
90
What are some side effects of estrogen?
Nausea, breast tenderness/fullness, bloating, weight gain and increased blood pressure, melasma (dark skin patches, most often on the face)
91
What is the effect of reducing the estrogen dose?
Reducing the estrogen dose reduces the side effects, but a dose that is too low will cause breakthrough bleeding
92
What are the severe and rare adverse effects of estrogen?
- Abdominal pain that is severe: can indicate a ruptured liver tumor or cyst, mesenteric or pelvic vein thrombosis or the pain could be due to liver or gallbladder problems or an ectopic pregnancy
- Chest pain: sharp, crushing, or heavy pain can indicate a heart attack (SOB can indicate PE)
- Headaches: sudden and severe with vomiting or weakness/numbness on one side of the body can indicate a stroke
- Eye problems: blurry vision, flashing lights or partial/complete vision loss can indicate a blood clot in the eye
- Swelling or sudden leg pain: can indicate a DVT
93
What increases the risk of clots?
Increases as the woman ages, if she smokes, if she has diabetes or hypertension, if she requires prolonged bed rest and if she is overweight
*The higher the estrogen dose or exposure, the higher the clotting risk
94
What should be considered when evaluating clotting risks from use of a pill?
When evaluating risks from use of the pill, also consider risks with an unintended pregnancy. the risk of blood clots during pregnancy and postpartum is higher than clotting risk with any birth control pill formulation
95
What are some side effects of progestin?
Progestin can cause breast tenderness, headache, fatigue and depression
96
What are some other side effects specific to Drospirenone?
Drospirenone has a slightly higher risk of clotting, and should not be used in women with clotting risk. It can also result in increased potassium; do not use with kidney, liver or adrenal gland disease as these can increase potassium
97
What are some side effects specific to injectable depot medroxyprogesterone?
The injectable depot medroxyprogesterone acetate can cause a loss in bone mineral density. Minimally, women should be taking adequate calcium and vitamin D
98
How long does it take for breakthrough bleeding to resolve?
2-3 months
*Always check adherence; spotting can be due to a fast drop in estrogen from a missing pill
99
What is the recommendation if spotting persists and currently taking < 30 mcg estrogen daily?
Increase estrogen dose
100
What is the recommendation if spotting persists and currently taking > 30 mcg estrogen daily?
Try a different progestin
101
What is the boxed warning of all estrogen-containing products?
Do not use in women > 35 years old who smoke due to risk of serious cardiovascular events
102
What is a boxed warning of estrogen + progestin transdermal patch?
Increased risk of venous thromboembolism (DVT/PE) compared to COCs
103
What is a boxed warning of Depo-Provera?
Loss of bone mineral density with long-term use
104
What conditions should estrogen not be used with?
History of DVT/PE, stroke, CAD, thrombosis of heart valves or acquired hypercoagulabilities, breast/ovarian/liver cancer; liver disease; uncontrolled hypertension; severe headaches or migraines with aura; diabetes with vascular disease; unexplained uterine bleeding; others
105
What are some product selection considerations for patients with acne or hirsutism?
Use COC with a progestin that has lower androgenic activity or no androgenic activity
106
What are some product selection considerations for patients who are breastfeeding?
Choose POPs or nonhormonal method
107
What are some product selection considerations for patients with estrogen contraindication?
Choose POPs or nonhormonal method
108
What are some product selection considerations for patients with migraines?
If with aura, choose POPs or nonhormonal method; do not use estrogen. If no aura, choose any method
109
What are some product selection considerations for patients with fluid retention/bloating?
Choose a product containing drospirenone
110
What are some product selection considerations for patients with heavy menstrual bleeding?
The COC Natazia and the levonorgestrel-releasing IUD Mirena are indicated for this condition. COCs with only 4 placebo pills (rather than 7) or continuous/extended regimens will minimize bleeding time
111
What are some product selection considerations for patients with hypertension?
If BP is uncontrolled, some estrogen formulations are contraindicated. Choose POPs or nonhormonal method
112
What are some product selection considerations for patients with mood changes or disorder?
Use monophasic COC - extended cycle or continuous with drospirenone is preferred
113
What are some product selection considerations for patients with nausea?
Take at night, with food; consider decreasing estrogen dose or switching to POP, vaginal ring or nonhormonal method (ideally after a 3 month trial)
114
What are some product selection considerations for patients who are overweight?
Choose any method. Counsel patient about the possibility of reduce effectiveness with the contraceptive patch. Do not use DMPA if trying to avoid further weight gain
115
What are some product selection considerations for patients who are 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
116
What are some product selection considerations for patients with premenstrual dysphoric disorder?
Choose Yaz or antidepressant
117
What are some product selection considerations for patients with spotting?
Common when initiating extended cycles or continuous regimens; usually resolves within 3-6 months. When starting conventional formulations, wait 3 cycles before switching. If early or mid-cycle spotting occurs, the estrogen dose may need to be increased. If later in the cycle, the progestin dose may need to be increased
118
What are some product selection considerations for patients with wishes to avoid monthly cycle/menses?
Use extended (91-day) or continuous formulations. Alternative: monophasic 28-day formulation and skip placebo pills
119
What should be considered if there is a long-term interaction with hormonal contraceptives?
Consider an IUD or the birth control injection
*the birth control injection has lower drug interaction risks as it bypasses first-pass metabolism and achieves higher serum concentrations
120
What are some examples of drug interactions that decrease hormonal contraception efficacy?
- Some antibiotics (e.g. rifampin, rifabutin and rifapentine)
- Anticonvulsants (carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, lamotrigine, barbiturates and perampanel)
- St. John's Wort
- Smoking tobacco
- Ritonavir-boosted protease inhibitors, bosentan, mycophenolate
- Colesevelam: separate by at least 4 hours
- Byetta: take contraceptive at least one hour prior to injection
121
What is a counseling point of the concomitant use of antibiotics and rifampin?
With rifampin, the induction can be prolonged; a back-up contraception method is needed for 6 weeks after rifampin has been discontinued
122
What Hepatitis C treatments have risks with contraception?
Technivie and Viekira Pak cannot be used with any formulation containing ethinyl estradiol due to the risk of liver toxicity
123
What are some examples of Drospirenone drug interactions?
Risk of increased potassium; caution must be used with potassium-sparing drugs, including aldosterone antagonists, potassium supplements, salt substitutes, ACE inhibitors, angiotensin receptor blockers, heparin, cangliflozin and calcineurin inhibitors
124
In general, how long does it take for hormonal pills to achieve contraceptive efficacy?
Seven days
125
Describe the Start Today method of starting birth control pills
Best practice recommendation. Maximizes time protected from unintended pregnancy. This method requires back-up (nonhormonal) contraception for 7 days
126
Describe the Sunday Start method of starting birth control pills
Starts the Sunday after onset of menstruation. This is commonly used if the patient prefers that menstruation occur during the week and is complete before the following weekend. It can lead to missed doses if the patient inadvertently runs out of refills over the weekend. This method requires back-up contraception for seven days
127
What is another option for starting birth control pills?
COCs can also be started on the first day of menses. If started within 5 days after the tart of the period, no back-up method of birth control is needed; protection is immediate. If not within 5 days, use back-up for seven days
128
When should progestin-only pills?
Start any time. Use another method of birth control for the first 48 hours of progestin-pill use; protection begins after two days. All come in 28 day packs and all pills are active
129
What should be done if there is 1 late or missed pill (< 48 hours since last dose) of COCs?
Take missed pill as soon as possible and take next dose on schedule (even if that makes 2 pills in 1 day. Backup contraception is not required. Consider if missed doses earlier in the same cycle or in week 3 of the previous cycle
130
What should be done if there is 2 missed pills (> 48 hours since last dose) of COCs?
Take the most recent missed pill as soon as possible (discard any other missed pills). Take next dose on schedule (even if that makes 2 pills in 1 day). If a pill is missed on week 3, omit hormone-free week: start next pack of pills right after finishing current pack. Back up contraception is required for 7 days
131
What should be done if a POP dose is missed by > 3 hours past scheduled time?
Take pill as soon as possible and take next dose on schedule. Back up contraception is required for 48 hours
132
What are some examples of long-acting reversible contraceptives
Intrauterine devices (Mirena, Skyla, Kyleena, Liletta), the copper-T IUD (Paragard), the implant (Nexplanon)
133
Describe intrauterine devices
Intrauterine devices are hormonal IUDs that contain the progestin levonorgestrel. These cause lighter menstrual bleeding and minor or no cramping
*Mirena is FDA-approved for heavy menstrual bleeding. Liletta can be used up to 6 years, Mirena and Kyleena can be used up to 5 years and Skyla up to 3 years
134
Describe the copper-T IUD
The copper-T IUD can be used for emergency contraception and/or regular birth control. It can be used for up to 10 years, but causes heavier menstrual bleeding and cramping
135
Describe the implant (Nexplanon)
The implant is a plastic rod placed subdermally in the arm. It reales the progestin etonogestrel for three years
136
What is emergency contraception?
Emergency contraception is a form of contraception that prevents pregnancy after unprotected intercourse
137
What are some examples of emergency contraception?
Copper IUD (Paragard), Ulipristal (Ella), Levonorgestrel (Plan B)
138
What is the effectiveness of Copper IUD?
Most effective (99.9%)
139
When should the copper IUD be used?
Within 5 days
140
What are some considerations of copper IUD?
- Must be placed in the uterus by a doctor or nurse
| - Lasts for up to 10 years
141
What is the effectiveness of Ulipristal (Ella)?
More effective than Plan B but less effective is > 195 pounds or BMI > 30 kg/mg (consider IUD)
142
When should Ulipristal be taken?
ASAP, within 5 days
143
What are some considerations of Ulipristal?
- Prescription required
| - Must be taken after every episode of unprotected sex
144
What is the effectiveness of Plan B?
Less effective if > 165 pounds or BMI > 25 kg/m
145
When should Levonorgestrel be used?
ASAP, within 3 days
146
What are some considerations of Levonorgestrel?
- Available OTC
| - Must be taken after every episode of unprotected sex
147
What is the MOA of Levonorgestrel?
Primarily works by preventing or delaying ovulation and thickens cervical mucus
148
What is the preferred regimen of Plan B?
Preferred regimen is 1.5 mg as a single dose with the sooner it is taken, the higher the efficacy
149
Up to how long can Plan B be used for?
This type of EC can be used for up to 5 days after unprotected intercourse. The package indicates within 3 days, but is used up to 5 days off label
150
What is the primary side effect of Levonorgestrel?
The primary side effect is nausea, which occurs in 23% of women, and 6% have vomiting. If the woman is easily nauseated, an OTC antiemetic (one hour prior to use and caution if driving home due to sedation) should be recommended to avoid losing the dose. If a patient vomits within two hours of taking the medication, she should consider repeating the dose
151
What is the regimen of Ulipristal?
Given as a single 30 mg dose. Requires a prescription
152
What is the indication for Ulipristal?
Indicated for up to 5 days after unprotected intercourse. More effective than levonorgestrel if 72-120 hours since unprotected intercourse or if the woman is overweightq
153
What are the primary side effects of Ulipristal?
Primary side effects are headache, nausea, and abdominal pain. Some women have changes in their menstrual cycle, but all should get their period within a week. Can only use once per cycle. Use a barrier method of contraception the rest of the cycle as ovulation may occur later than normal
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What are some key counseling points of diaphragms?
- Wash hands thoroughly. Place one tablespoon of spermicide in the diaphragm and disperse inside and around the rim
- Pinch the ends of the cup and insert the pinched end into the vagina
- Leave in for 6 hours after intercourse. Diaphragms should not be in place greater than 24 hours
- Reapply spermicide if intercourse if repeated or diaphragm is in place for more than two hours before sex, by inserting jelly with applicator
- Wash with mild soap and warm water after removal, air dry
- Can be used for up to two years
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What are some key counseling points of contraceptive foams, creams, suppositories and jellies?
Place deep into vagina right before intercourse where they melt (except for foam, which bubbles)
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What are some key counseling points of contraceptive sponge?
- Place deep into the vagina right before intercourse
- Leave in place for at least 6 hours after intercourse, but it can be used for up to 24 hours. Remove and discard after use
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What are some key counseling points of combination oral contraceptives?
- Can increase risk of blood clots
- Can cause nausea, weight gain and breast tenderness. Side effects often improve after three months of use. Taking the pill with food or at night helps to reduce nausea
- Take the pill at the same time each day; pick a time of day that you will remember
- Many drug interactions
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What is a key counseling point of Drospirenone formulations?
Can increase potassium
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What are some key counseling points of contraceptive patch?
- Apply to clean, dry skin of buttocks, stomach, upper arm or upper torso once a week for 21 out of 28 days. Do not apply to breasts
- Start on either day 1 or Sunday
- If the patch becomes loose or falls off for > 24 hours during the three weeks of use, or if > 7 days have passed during the 4th week where no patch is required, there is a risk of pregnancy. A back-up method should be used for one week after starting a new patch
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What are some key counseling points of NuvaRing Vaginal Contraceptive Ring?
- The ring is inserted into the vagina once a month. It is kept in place for three weeks and taken out for one week before replacement with a new ring. The ring is effective for up to four weeks, thought not FDA-approved, can be kept in place to prevent a period, If the ring is kept in place for > 4 weeks: confirm no pregnancy, then insert a new ring and use back-up contraception until the new ring has been in place for 7 continuous days
- The exact position of the ring in the vagina does not matter
- An optional applicator can be used to assist with insertion
- Starting therapy and no hormonal contraceptive use in preceding cycle: insert ring the first day of menstrual bleeding. If inserted on days 2-5 of cycle, back-up contraception should be used for the first 7 days in the first cycle
- If the ring is expelled or removed in weeks 1 and 2, if ring is out > 3 hours, rinse with cool water and reinsert. If removed in week 3, discard and insert a new ring
- Store for up to 4 months at room temperature (refrigerate prior to dispensing)
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What are some counseling points of Medroxyprogesterone?
- Can decrease bone density. Take the recommended daily intake of calcium and vitamin D
- You might experience a change in your normal menstrual cycle
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What are some counseling points of emergency contraception?
- Can cause nausea/vomiting and OTC antiemetics can help
- If you do not get your period in three weeks, a pregnancy test should be taken. Severe abdominal pain or irregular bleeding requires immediate medical attention
- Visit your healthcare provider for a regular birth control method and information about preventing STIs
- Regular hormonal contraceptive should be started on the same or the following day as taking the EC
- You should only use one type of oral EC pill. Do not use two different types together
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What is infertility?
Infertility is defined as not being able to get pregnant after one year or longer of unprotectedsex
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What is Clomiphene?
Clomiphene is the first-line treatment in women with irregular or absent menstrual cycles. Clomiphene is a selective estrogen receptor modulator (SERM)
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How is Clomiphene beneficial in treating irregular or absent menstrual cycles?
Clomiphene causes LH and FSH to surge, which triggers ovulation. The surge in LH commonly causes hot flashes
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What is the use of Gonadotropins in infertility?
Gonadotropins trigger ovulation by acting similar to the endogenous gonadotropins FSH or LH. Gonadotropins are used after a poor response to clomiphene, or to spur egg release for procedures such as intrauterine insemination and in vitro fertilization
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How are Gonadotropins administered?
They are administered by SC or IM injection
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What are the generic names of gonadotropin?
Chorionic gonadotropin-recombinant, follicle stimulating hormone-recombinant, human chorionic gonadotropin-recombinant and menotropin
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What are brand names of Gonadotropin?
Menopur, Follistin A!, Gonal-F, Pregnyl, Novarel and Ovidrel
