Contraception & Infertility Flashcards
Follicular phase
GnRH releases FSH to secrete estrogen & stimulate follicle to develop. LH increases androgens
Ovulation
Mature follicle ruptures. LH surge just before ovulation
Luteal phase
Progesterone more dominate
COCs FDA approved for acne
estrostep fe
ortho tri-cyclen
yaz
beyaz
COCs FDA approved for PMDD
yaz
beyaz
Purpose of estrogen in COC
-Inhibits FSH & ovulation
-Increases aldosterone = increased sodium/water retention
-Increases sex hormone binding globulin = clears up hormone-related acne & unwanted facial hair
Estrogen ADR in COC
N/V
Bloating, edema
Irritability
Cyclic weight gain, headache
HTN
Breast fullness/tenderness
Progestational progestins
prevent ovulation & lessen bleeding
high activity: desogestrel, etonogestrel, levonorgestrel
Androgenic progestins
Contributes to acne, hirsutism
high activity: levonorgesterl, norgestrel
Antiestogenic progestins
Contributes to androgenic side effects (hair loss, hirsutism, acne, oily skin)
High activity: norethindrone, ethynodiol diacetate
Progestin action in COCs
Thicken cervical mucus - prevent sperm
Endometrial atrophy (thins uterus linig)
prevent ovulation
Progestin ADRs in COCs
HA
Increased appetite, weight gain
Depression, fatigue
Change in libido
Androgenic: hair loss, hirsutism, acne, oily skin
Management of breakthrough bleeding
Try x 3 months
Late in cycle = choose higher progestin activity
Otherwise choose higher estrogen/progestin activity
Acne management from COC
Choose lower androgenic activity progestin
Serious adverse effects from COC
ACHES
A: abdominal pain = liver, gallbladder issue
C: chest pain, SOB, coughing up blood = MI, PE
H: headache = stroke, blood clot
E: eye problems = optic neuritis, stroke, clots
S: severe leg pain = DVT
Drugs that may decrease effectiveness of COC
-HIV drugs (NRTIs, maraviroc, INSTI, NNRTI, PI)
-Antiepileptics
-Rifampin/rifabutin
-Tetracycline, minocycline, erythromycin, pcn, cephalosporins = back up for abx therapy + 7 days after
Dosing of estrogen (high, low, very low) in COC
High: >35 mcg
Low-dose: <35 mcg
Very low-dose: <=10 mcg
Back up method needed when starting COC
Sunday start or quick start (first day of prescription) = back up for 7 days - 1 month
1 COC pill missed or late
Take ASAP & continue pack as normal
NO additional contraception needed
Emergency contraception not needed but can be considered
> =2 COC pills missed
Take most recent missed pill ASAP
Back up or abstinence for 7 days
If missed in last week of hormonal pills, then skip placebos and start new pack
Emergency contraception considered if missed during 1st week & unprotected sex or other times
Drosperienone progestin containing COC
yaz, beyaz
Analog of spironolactone (so may inc. potassium)
No diuretic effect but decreases bloating from estrogen
Best for acne, hirsutism, or male pattern balding in women
Increased risk of DVT
Birth control patch
Place on dry hairless area of upper arm, shoulder, abdomen, buttocks (NOT breast)
Possibly less effective if > 90 kg
Higher rate of blood clots
Birth control patch missed dose <48 hours
apply ASAP
Keep same change patch day
No additional contraceptive or EC needed
Birth control patch missed dose >= 48 hours
Apply ASAP & keep same change patch day
Back up or abstinence for 7 days
If occurred during 3rd week, omit patch free week
Consider EC (especially if occurred in 1st week)
Vaginal ring contraceptive
Has etonogestrel (active form of desogestrel)
May be used during intercourse & with tampon
If removed <3 hours, rinse with water and reinsert
If removed >3 hours, reinsert and use back up x 7days
Annovera
Vaginal ring for contraception - same ring used for 13 cycles (1 year)
If out <2 hours, rinse and reinsert
If out >2 hours, back up needed x7 days
Avoid oil-based suppositories, like miconazole 1-3 day treatments, due to increased exposure to hormones.
Progestin only pill
Norethindrone: Must take at the same time each day. If > 3 hours late, use back up for 48 hours
No hormone-free days.
Drospirenone: not as time sensitive. same missed dose guidelines as cocs
Medroxyprogesterone acetate depot
IM injection q 11-13 weeks
>13 weeks, pregnancy test then readminister
ADE: progressive significant weight gain.
BBW: loss of bone, especially > 5 years. Reversible. Exercise & get adequate calcium/vit D
Delayed return to fertility for up to 18 months
Copper IUD duration
10 years
Readily reversible
Levonorgesterl IUD duration
Kyleena: 5 years
Liletta: 8 years
Mirena: 8 years (also indicated for menorrhagia)
Skyla: 3 years
Readily reversible
IUD ADEs
PAINS
P: period late, abnormal bleeding/spotting
A: abdominal pain, pain w/ intercourse
I: STI
N: not feeling well, fever, chills
S: string missing, shorter, longer
Nexplanon
3 years prevention of pregnancy
Return to fertility in 1-3 months
Emergency contraception timing
within 120 hours
EC options
Levonorgestrel 1.5mg
Ulipristal 30mg (Rx only)#
Copper IUD^ > levonorgestrel IUD
Yuzpe method (high dose estrogen + progestin using COCs)
*=preferred if BMI >25
#= pump and dump x24 hours if breastfeeding
^=recommended if BMI >35
Clomiphene
SERM- blocks estrogen receptors. Body perceives hypoestrogenic state and releases GnRH, which stimulates FSH and LH
Stimulates ovulation or off-label to increase sperm production in men
First line agent
ADE: hot flash, abdominal/breast tenderness, mood swings, visual alterations
May add on metformin if PCOS
Letrozole, anastrozole
Off label for anovulatory women
Less risk of multiple births
ADE: HA, GI, joint/bone pain, edema, sweating, flushing
Human menopausal gonadotropin (hMG)
Injection
Derived from urine of post-menopausal women
Given on day 2-3 of cycle x7-10 days - use ultrasound to monitor follicle development
ADE: flu-like symptoms, muscle aches, malaise, HA, dizziness, pain @ injection site
FSH for infertility
Injection given in first half of cycle to stimulate development of follicles in ovary
Naturally occurring (urine): Bravelle urofollitropin
Recombinant: follitropin alpha, follitropin beta
ADE: mood swings, depression, breast tenderness, swelling, pain at injection site
Human chorionic gonadotropin (hCG)
Injection, similar to LH, given 36 hours before insemination or harvest to help stimulate release of egg
GnRH analogs
Used to prevent LH surge that occurs before ovulation to help with timing of ovulation – optimizes effectiveness of hMG or FSH
GnRH agonists: leuprolide, naferlin
GnRH antagonists: ganirelix, cetrorelix (more recently used for infertility protocols)
Ovarian Hyperstimulation Syndrome
Complication of fertility treatment that is life-threatening
Watch for rapid weight gain
Will need thrombosis ppx if inpatient
