Contraception & Infertility Flashcards by Jimmy Hayden

Normal menstrual cycle range

23- 35 days (average 28)

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Follicular phase

1st phase of menstrual cycle

FSH stimulates egg development and increases estrogen

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Ovulatory phase

brief phase in between follicular and luteal phase

surge of LH, which leads to ovulation 24-26 hrs later

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Luteal phase

final phase, which includes ovulation and last about 14 days

High amounts of progesterone in this phase

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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)

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What hormone does ovulation kits measure?

Luteinizing hormone (LH)

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What hormone is measured in pregnancy tests?

human chorionic gonadotropin (hCG)

best to use first urine in the AM when hCG is highest

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Recommended folate supplementation for child-bearing age women

400 mcg/day

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Primary MOA of combo oral contraceptives

inhibit FSH and LH, which prevents ovulation

also alter endometrial lining, alter cervical mucus, interfere with fertilization

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Most common estrogen used in oral contraceptives

ethinyl estradiol (EE)

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Other indications for oral contraceptives

dysmenorrhea
PMS
peri-menopausal symptoms
acne
PCOS
endometriosis (uterine lining outside of the uterus)

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Other name for progestin only oral contraceptives and MOA

“mini-pill”

suppress ovualation (in some women), thickening cervical mucus, inhibit sperm penetration

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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)

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Women on oral contraceptives or patches/rings will have lighter periods (t/f)

True

thinner endometrium lining

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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)

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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

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Names of common combo bi-/triphasic oral contraceptives

Necon 10/11
Orth Tri-cyclen
Trinesssa

dose changes to try to mimic menstrual cycle

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Quadriphasic combo oral contraceptives

Natazia

estradiol valerate and dienogest

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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)