Contraception & Infertility

Question 1

Follicular phase

Answer 1

GnRH releases FSH to secrete estrogen & stimulate follicle to develop. LH increases androgens

Question 2

Ovulation

Answer 2

Mature follicle ruptures. LH surge just before ovulation

Question 3

Luteal phase

Answer 3

Progesterone more dominate

Question 4

COCs FDA approved for acne

Answer 4

estrostep fe
ortho tri-cyclen
yaz
beyaz

Question 5

COCs FDA approved for PMDD

Answer 5

yaz
beyaz

Question 6

Purpose of estrogen in COC

Answer 6

-Inhibits FSH & ovulation
-Increases aldosterone = increased sodium/water retention
-Increases sex hormone binding globulin = clears up hormone-related acne & unwanted facial hair

Question 7

Estrogen ADR in COC

Answer 7

N/V
Bloating, edema
Irritability
Cyclic weight gain, headache
HTN
Breast fullness/tenderness

Question 8

Progestational progestins

Answer 8

prevent ovulation & lessen bleeding

high activity: desogestrel, etonogestrel, levonorgestrel

Question 9

Androgenic progestins

Answer 9

Contributes to acne, hirsutism

high activity: levonorgesterl, norgestrel

Question 10

Antiestogenic progestins

Answer 10

Contributes to androgenic side effects (hair loss, hirsutism, acne, oily skin)

High activity: norethindrone, ethynodiol diacetate

Question 11

Progestin action in COCs

Answer 11

Thicken cervical mucus - prevent sperm
Endometrial atrophy (thins uterus linig)
prevent ovulation

Question 12

Progestin ADRs in COCs

Answer 12

HA
Increased appetite, weight gain
Depression, fatigue
Change in libido
Androgenic: hair loss, hirsutism, acne, oily skin

Question 13

Management of breakthrough bleeding

Answer 13

Try x 3 months
Late in cycle = choose higher progestin activity

Otherwise choose higher estrogen/progestin activity

Question 14

Acne management from COC

Answer 14

Choose lower androgenic activity progestin

Question 15

Serious adverse effects from COC

Answer 15

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

Question 16

Drugs that may decrease effectiveness of COC

Answer 16

-HIV drugs (NRTIs, maraviroc, INSTI, NNRTI, PI)
-Antiepileptics
-Rifampin/rifabutin
-Tetracycline, minocycline, erythromycin, pcn, cephalosporins = back up for abx therapy + 7 days after

Question 17

Dosing of estrogen (high, low, very low) in COC

Answer 17

High: >35 mcg
Low-dose: <35 mcg
Very low-dose: <=10 mcg

Question 18

Back up method needed when starting COC

Answer 18

Sunday start or quick start (first day of prescription) = back up for 7 days - 1 month

Question 19

1 COC pill missed or late

Answer 19

Take ASAP & continue pack as normal

NO additional contraception needed

Emergency contraception not needed but can be considered

Question 20

> =2 COC pills missed

Answer 20

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

Question 21

Drosperienone progestin containing COC

Answer 21

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

Question 22

Birth control patch

Answer 22

Place on dry hairless area of upper arm, shoulder, abdomen, buttocks (NOT breast)

Possibly less effective if > 90 kg

Higher rate of blood clots

Question 23

Birth control patch missed dose <48 hours

Answer 23

apply ASAP

Keep same change patch day

No additional contraceptive or EC needed

Question 24

Birth control patch missed dose >= 48 hours

Answer 24

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)

Question 25

Vaginal ring contraceptive

Answer 25

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

Question 26

Annovera

Answer 26

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.

Question 27

Progestin only pill

Answer 27

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

Question 28

Medroxyprogesterone acetate depot

Answer 28

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

Question 29

Copper IUD duration

Answer 29

10 years

Readily reversible

Question 30

Levonorgesterl IUD duration

Answer 30

Kyleena: 5 years
Liletta: 8 years
Mirena: 8 years (also indicated for menorrhagia)
Skyla: 3 years

Readily reversible

Question 31

IUD ADEs

Answer 31

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

Question 32

Nexplanon

Answer 32

3 years prevention of pregnancy

Return to fertility in 1-3 months

Question 33

Emergency contraception timing

Answer 33

within 120 hours

Question 34

EC options

Answer 34

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

Question 35

Clomiphene

Answer 35

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

Question 36

Letrozole, anastrozole

Answer 36

Off label for anovulatory women

Less risk of multiple births

ADE: HA, GI, joint/bone pain, edema, sweating, flushing

Question 37

Human menopausal gonadotropin (hMG)

Answer 37

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

Question 38

FSH for infertility

Answer 38

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

Question 39

Human chorionic gonadotropin (hCG)

Answer 39

Injection, similar to LH, given 36 hours before insemination or harvest to help stimulate release of egg

Question 40

GnRH analogs

Answer 40

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)

Question 41

Ovarian Hyperstimulation Syndrome

Answer 41

Complication of fertility treatment that is life-threatening

Watch for rapid weight gain

Will need thrombosis ppx if inpatient