Contraception & Infertility Flashcards
Normal menstrual cycle range
23- 35 days (average 28)
Follicular phase
1st phase of menstrual cycle
FSH stimulates egg development and increases estrogen
Ovulatory phase
brief phase in between follicular and luteal phase
surge of LH, which leads to ovulation 24-26 hrs later
Luteal phase
final phase, which includes ovulation and last about 14 days
High amounts of progesterone in this phase
Estrogen and PG levels are high during a woman’s period (t/f)
False
estrogen and PG cause thickening of endometrium, when levels are low the lining sloughs off (period)
What hormone does ovulation kits measure?
Luteinizing hormone (LH)
What hormone is measured in pregnancy tests?
human chorionic gonadotropin (hCG)
best to use first urine in the AM when hCG is highest
Recommended folate supplementation for child-bearing age women
400 mcg/day
Primary MOA of combo oral contraceptives
inhibit FSH and LH, which prevents ovulation
also alter endometrial lining, alter cervical mucus, interfere with fertilization
Most common estrogen used in oral contraceptives
ethinyl estradiol (EE)
Other indications for oral contraceptives
dysmenorrhea PMS peri-menopausal symptoms acne PCOS endometriosis (uterine lining outside of the uterus)
Other name for progestin only oral contraceptives and MOA
“mini-pill”
suppress ovualation (in some women), thickening cervical mucus, inhibit sperm penetration
In what population is progestin only oral contraceptives preferred
pts with contraindications to estrogen
Post-partum (3-6 wks) due to incr clot risk
migraines w/ aura (estrogen can incr stroke risk)
Women on oral contraceptives or patches/rings will have lighter periods (t/f)
True
thinner endometrium lining
Extended cycle and continuous cycle contraception
extended: active pills taken for 84 days, then 7 days of palcebo/lower dose
continuous: taking only active pills (spotting can occur; usually for the first 3-6 mons)
Amethyst approved for continuous (EE + levonorgestrel)
Names of common combo monophasic oral contraceptives
Gildess Fe Junel Fe Mononessa Microgestin Orth-Cyclen yasmin Yaz, Loestrin 24, Minastrin 24 Fe: contains 24 active pills and 4 placebo
Names of common combo bi-/triphasic oral contraceptives
Necon 10/11
Orth Tri-cyclen
Trinesssa
dose changes to try to mimic menstrual cycle
Quadriphasic combo oral contraceptives
Natazia
estradiol valerate and dienogest
Extended cycle combo oral contraceptives
period every 3 months
Jolessa (84 days active, 7 placebo)
Amethia Lo, Seasonique: 84 days of lower EE, then 7 days of even lower EE
Combination patch
Xulane
1 patch q week x 3 weeks, then 1 week off
higher exposure to estrogens = higher clotting risk
Combo vaginal ring
NuvaRing
Insert for 3 weeks, then remove for 1 week
Names of progestin only oral contraceptives
Camila
Errin
Ortho-micronor
contains norethindrone
no placebo pills
Depo-Provera
medroxyprogesterone injection
150 mg IM every 3 months
Common sides effects of estrogen
nausea breast tenderness bloating/weight gain elevated BP spotting - wait 3 cycles to see if it goes away; might need higher dose
Serious side effects of estrogen
thrombosis:
heart attack
stroke
DVT/PE
risk incr with age (avoid > 35 y/o), smokers, diabetes, obesity, HTN
Side effects of progestins
breast tenderness fatigue changes in mood HA spotting incr clot risk (drospirenone) decr BMD (depo-provera)
When should combo oral contraceptives not be used:
women > 35 y/o who smoke (incr clot risk)
hx of dvt/pe, stroke, CAD, clotting disorders
Hx of breast, ovarian, liver cancer
uncontrolled HTN
severe HAs
migraine w/ aura
Signs and symptoms that all woman should be aware of when taking hormonal contraceptives
ACHES Abdominal pain that is severe (liver tumor, cyst, ectopic pregnancy) Chest pain (heart attach, PE) Headaches (sudden and severe) Eye problems ( blood clot in the eye) Swelling/ sudden pain in legs (DVT)
If spotting occurs during early or mid-cycle, what should be done?
incr dose of estrogen
spotting later in cycle: incr progestin dose
Preferred agent for pts complaining of bloating
products with drospirenone (yaz, yasmin)
works as K-sparing diuretic
Preferred agent for pts complaining of acne
low androgenic activity
Ortho cyclen
Yaz, Yasmin (no androgenic activity)
Antibiotics with evidence of decreased efficacy of hormonal contraceptives
Rifampin
rifapentine
rifabutin
use back up for 6 weeks after stopping rifampin
Other drugs that decr efficacy of hormonal contraceptives
anticonvulsants: barbs, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, lamotrigine
St john’s wort
Protease inhibitors
mycophenolate
Smoking tobacco
take at least 1 hr prior to Byetta injection
Why can’t ethiny estradiol be used certain hep C drugs?
risk of liver toxicity
Technivie and Viekira Pak
How long should back up methods be used when first starting oral contraceptives?
7 days of back-up for combo pills
“Quick start”: start day of receiving Rx
Sunday start: start sunday after onset of menstruation
Progestin pills:
back up for 48 hours
start meds at any time
What is required to be dispensed with each combo hormonal contraceptive?
patient package insert (PPI)
General rule for missed pills
If more than 1 pill is missed (2+) then back-up is required
If missed 2 pills during week 3 of cycle, omit hormone free week and start new pack right after finishing current pack
1 pill missed: take as soon as you remmeber, 2 pills iin 1 day is OK
Main benefits and risks of drospirenone containing hormonal contraceptives
benefits: less bloating and weight gain, less acne, less PMS symptoms
risks: incr clot risk
Xulane specific info
Same side effects and CIs as oral combo contraceptives
Higher exposure of estrogen: avoid in pts with high clot risk
Less effective in women > 198 lbs
application: butt, stomach, upper arm, upper torso
Start on day 1: no back-up
Sunday start: 7 days of back-up
NuvaRIng specific info
same side effects and CIs as pills
3 weeks in, 1 week out
Used 4 weeks to prevent period (off-label)
Insert ring on day 1 on menstrual bleeding
Can be stored at room temp for up to 4 months
Most effective reversible contraceptives
IUDs: Hormonal: Mirena and Kyleena ( 5 yrs) Skyla and Liletta ( 3 yrs) Copper (Paraguard) up to 10 yrs Implant: Nexplanon (etonogestrel) up to 3 yrs
Most effective form of emergency contrception
copper IUD
inserted w/in 5 days
Other options for emergency contraception:
levonorgestrel (Plan-B) OTC
89 % effective when taken w/in 72 hrs (5 days off-label)
MOA: prevents ovulation, thickens cervical mucus
1.5 mg x 1
causes n/v, vomit w/in 2 hrs of taking: consider taking again
Ulipristal (Ella) - requires Rx
30 mg once
delys ovulation, prevent implantation
use up to 5 days after intercourse
Can only use 1 per cycle
HA, nausea, abd pain
Clomiphene notes
Clomid
selective estrogen receptor modulator
incr FSH and LH
50-100 mg x 5 days, start 3,4,5 days after period starts
SEs: hot flashes, abdominal bloating, HA, incr chance of multiple births
Human chorionic gonadotropini (hCG) meds
Ovidrel - SC
Pregnyl, Novarel - IM
Gonadotropins meds
Follitropin beta - IM, SC
Gonadotropin releasing hormone agonist (GnRH)
Leuprolide (Lupron)
Goserelin (Zoladex)
Nafarelin (Synarel)
