Contraception & Infertility Flashcards by Navita Ramdin

Fertility Awareness

-LH surge causes the release of the oocyte from the ovary
-Oocyte lives for 24 hours
-Ovulation kits predict the best time for intercourse through LH surge
-To conceive, have intercourse when LH is detected and for the following 2 days.

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Preconception Health

1) Folic Acid Supplementation
-400 mcg/day to help prevent neural tube defect

2) Lifestyle changes
-No alcohol or illicit drugs
-Avoid smoking
-Keep vaccinations up to date
-Avoid toxic chemicals (HD drugs)

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Most Effective Contraception Method

Reversible:
-Implant
-IUD

Irreversible:
-Male Sterilization (Vasectomy)
-Female Sterilization

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Least Effective Contraception Method

1) Spermicide (Non-Oxynol-9)
2) Calender Method

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Hormonal Contraceptives

MOA: Inhibits the production of FSH and LH, which prevents ovulation

1) Progestin-only
2) Estrogen/Progestin Combination

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What are the Estrogen and Progestin COC?

Most contain Ethinyl Estradiol (EE) and a Progestin (Norethindrone, levonorgestrel, drospirenone)

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What is meant by ‘monophasic’?

Same dose of estrogen and progestin

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Bi-, Tri-, Quadri-Phasic

Hormone strengths change to mimic estrogen and progesterone levels during a menstrual cycle

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What are other uses for Estrogen and Progestin Combination Oral Contraceptives?

1) Dysmenorrhea
2) Premenstrual Syndrome
3) Acne
4) Anemia
5) Polycystic Ovary Syndrome
6) Endometriosis

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What is Drospirenone?

-Unique progestin
-Found in some COC to reduce adverse effects commonly seen with oral contraceptives,
-It is a mild K-sparing diuretic which decreases bloating, PMS symptoms and weight gain
-Anti-androgenic

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Progestin-Only Pills (mini pills)

Norethindrone: Errin, Camila, Nora-BE
Drospirenone: Slynd

-28 day packs
-All are active
-Backup contraceptive is needed for 48 hours after starting.

When to use?
1) Breastfeeding (since estrogen decreases milk production)
2) Migraines with aura (estrogen increases risk of stroke)

Adherence is essential!
1) Take at the same time of day, everyday
2) If >= 3 hours have elapsed from the regularly scheduled time, a back-up contraceptive is required for 48 hours

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What are the non-oral Hormonal Contraceptives?

1) Xulane Patches - estrogen/progestin
-Higher estrogen exposure
-Less effective in women >198lbs

2) Vaginal Rings (Nuvaring, Haloette) - estrogen/progestin
-Lower AUC than pills
-Insert monthly x 3 weeks, remove for 1 week

3) Injectables (Depo-Provera) - Progestin Only
-Medroxyprogesterone acetate (DMPA)
-IM or SQ every 3 months

4) IUD

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What are the Monophasic Brand names?

1) Junel Fe 1/20
2) Microgestin Fe 1/20
3) Sprintec 28
4) Loestrin 1/20
5) Yasmin 28
6) Crystelle 28

-Provides the same dose of progestin and estrogen throughout the active pill days
-Junel Fe 1/20: 1 mg Norethindrone and 20 mcg EE
-28’s contain 21 days hormonal pill + 7 days inactive pill

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Biphasic and Triphasic Formulations

1) Trisprintec
2) Nortrel 7/7/7

-3 different weeks (7/7/7)

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Quadriphasic Formulations

1) Natazia

-Hormone doses change over 26 days

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Extended-Cycle Formulation

1) Seasonique

-Period occurs every 3 months

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Continuous Formulations

1) Amethyst

-No inactive pills (taken continuously)
-No periods

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Drospirenone Containing Formulation

1) Yaz
2) Yasmin 28

-Mild potassium-sparing diuretic to reduce bloating and other effects
-CI: renal or liver disease
-Monitor K and kidney function

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Adverse Effects of Hormonal Contraceptives (ESTROGEN)

-Nausea
-Breast tenderness
-Bloating
-Weight Gain

A-Abdominal Pain (Mesenteric or Pelvic vein thrombosis)
C-Chest Pain (Heart Attack or PE)
H-Headaches (Stroke)
E-Eye Problem (Vision loss due to blood clot in eyes)
S-Swelling (DVT)

*Lower Estrogen = less side effects but more breakthrough bleeding (spotting)
-Spotting mid-cycle? —> More estrogen is needed

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Adverse Effects of Hormonal Contraceptives (PROGESTIN)

-Breast tenderness
-Headache
-Fatigue
-Depression

-Drospirenone has a higher risk of clotting and should not be used in women with clotting risk
-Depo-provera causes a loss in Bone Mineral Density. This is especially importent for teens and young women who are still accumulating bone mass.
-If there is a late-cycle breakthrough bleeding —> a higher dose of progestin is needed

Boxed Warning for all estrogen-containing products (pills, ring, patch)

1) Do not use in women > 35 years old who smoke due to serious CV risk

Boxed Warning for Estrogen+Progestin Transdermal Patch

Do not use in women with a BMI >= 30 due to increased risk of thromboembolism

Boxed Warning for Depo-Provera

Loss of bone mineral density with long-term use

When to NOT use Estrogen?

1) History of DVT/PE, Stroke, CAD, thrombosis of heart valve
2) History of breast, ovarian or liver cancer, liver disease, uncontrolled HTN, severe headaches, Migraine with Aura

When is Progestin-Only Pill prefererd?

1) Breastfeeding 2) 3-6 weeks Postpartum 3) Contraindicated to Estrogen 4) Migraine with Aura 5) Uncontrolled Hypertension

When is Drospirenone-Containing Product preferred?

1) Acne 2) Fluid retention/bloating 3) Mood changes or disorder 4) PMDD (Yaz)

What are the drugs which decrease hormonal contraceptive efficacy?

1) Rifampin (requires a backup method for 6 weeks after discontinuation) 2) Anticonvulsants (phenytoin, carbamazepine, topiramate) 3) St. John’s Wort 4) Tobacco

Starting COC

-Takes ~7 days of treatment to achieve efficacy (Requires back-up for 7 days) -Start today, or -Start Sunday after onset of menstruation

Starting progestin-only pills

-Takes ~48 hours to achieve efficacy (use backup for 48 hours) -Start at any time: all come in 28-day packs and all pills are active

Late or Missed Pills

Combined-Oral Contraceptives 1) 1 late or missed pills (<48 hours since last dose) -Take ASAP, and take next dose on schedule -Backup contraception not needed 2) 2 missed pills (>48 hours since last dose) -Take the most recent missed pill as soon as possible (discard any other missed pills) -Take next dose on schedule -Backup contraception need for 7 days Progestin-Only Pills 1) >3 hours past scheduled time -Take ASAP and take next dose on schedule -Backup contraception needed for 48 hours

Xulane Contraceptive Patch

-Place on clean, dry skin of buttocks, stomach, upper arm, or upper torso -Apply once weekly for 21 of 28 days -Start on day 1 (no back-up needed) or Sunday (back-up needed for 7 days) *There is a higher exposure to estrogen from the patch than from the COC

NuvaRing Vaginal Contraceptive Ring

-Insert into the vagina once a month -Keep in place for 3 weeks, then remove for 1 week -Start on day 1 of menstrual bleeding

IUD Devices

Hormonal: <—Contains Levonorgestrel -Mirena (5 years) - also approved for menorragia -Skyla (3 years) Copper-T: -Paragard (10 years) - can also be used for emergency contraception

Implant Contraception

Nexplanon -Plastic rod inserted subdermally -Releases Etonogestrel for 3 years

Emergency Contraception

1) Paragard IUD - 100% effective if place within 5 days 2) Ella - Ulipristal - less effective if >195 lbs. ASAP: Works better the sooner. Max 5 days 3) PlanB Once-Step - Levonorgestrel - less effective if >165 lbs. ASAP: Works better the sooner. Max 2 days

What is Infertility?

Inability to get pregnant after >=1 year of unprotected intercourse

Medications to promote female ovulation

1) Clomiphene (1st line) 2) Gonadotropins (2nd line)

Contraception for ACNE/HIRSUTISM

1) COC with low androgenic activity (e.g. norgestimate) 2) COC with no androgenic activity (drospirenone)

Contraception while BREASTFEEDING

1) Progestin Only 2) Non-hormonal

Contraception if there is an ESTROGEN CONTRAINDICATION (e.g. clotting risk)

1) Progestin Only 2) Non-hormonal

Migraine with Aura

1) Progestin-Only 2) Non-hormonal

Fluid Retention or Bloating

1) Drospirenone containing product

Heavy Menstrual Bleeding

1) Natazia 2) Mirena IUD

Hypertension

If uncontrolled, some estrogen formulations are contraindicated 1) Progestin only 2) Non hormonal method

Mood changes/disorder

1) Monophasic COC - Extended cycle 2) Contnuous cycle with drospirenone

Nausea with Contracteption

-Take at night with food -Consider decreasing estrogen dose -Consider switching to Progestin-only

Postpartum

-Do not use CHC for 3 weeks, or 6 weeks if the patient has additional risk factors for VTE 1) Progestin-only 2) Non-hormonal

Premenstrual dysphoric disorder

1) Drospirenone containing product

Patient wishes to avoid monthly cycle/menses

1) Extended (91 day) formulation 2) Continuous formulation