Contraception/Infertility/HSDD Flashcards
Folate
- Deficiency can cause birth defects (neural tube)
- Adult recommendation: 400 mcg/d
- Preggo: 600 mcg/d
Hormonal Contraception
- Prohibit FSH and LH production therefore inhibiting ovulation
- Available in progestin-only formulations or combined contraception (estrogen/progestin)
- Formulations: pill, patch, ring, injection, implant, IUD
- COC: combined oral contraception
- CHC: combined non-oral contraception
- Oral contraception MUST be dispensed with PPI
Progestin Examples
- Norethindrone
- Levonorgestrel
- Drospirenone
Drospirenone
- Reduced AE commonly seen with oral contraceptives
- Mild potassium-sparing diuretic
- Decreases bloating, PMS sxs, and weight gain
- Also tend to have less acne from less androgenic activity
- Higher risk of clotting, hyperkalemia, do not use with kidney/liver/adrenal gland disease due to hyperkalemia risk
Other Low Androgenic Progestins
- Norgestimate**
- Desogestrel
- Dienogest
COC Indications
- First line for menses control in PCOS
- First line for endometriosis
- Natazia (COC) and a levonorgestrel-releasing IUD are indicated for heavy menstrual bleeding
POP Indications
Progestin-only pills (AKA mini-pills)
- Breastfeeding; estrogen decreases breast milk and increases thrombosis risk postpartum x 3-6weeks
- Safe in migraine with aura patients (estrogen CI due to increased stroke risk)
Xulane
- Estrogen containing patch; higher systemic exposure
- DON’T use in pts with clotting risk factors or smokers over 35 yo
- Less effective in women >198 lbs
- Twirla (different contraceptive patich) less effective in BMI > 30
Depo-Provera
- Medroxyprogesterone injection (DMPA) - progestin
- Given IM or SQ Q3mo
- Loss in BMD, especially important in teens/young women still accumulating bone mass - take adequate vitamin D/calcium
- Don’t use in overweight patients to avoid further weight gain
Continuous Contraception
- Suppresses menses altogether
- Continuous active pills (no placebo)
- Amethyst is approved for this; all other brands are off-label indication
- Spotting/breakthrough bleeding can occur but should resolve after 3-6 months
Monophasic COC Formulations
-Junel Fe 1/20
-Microgestin Fe 1/20
-Sprintec 28
-Loestrin 1/20
-Yasmin 28
-Loestrin 24 Fe
-Yaz - (premenstrual dysphoric disorder)
-Lo Loestrin Fe
(“Fe” means it contains iron; 24 meaning 24 active pills and 4 placebo)
Biphasic/Triphasic COC Formulations
-Ortho Tri-Cyclen Lo
-Tri-Sprintec
-Nortrel 7/7/7
(“Lo” indicates estrogen is =< 35 mcg)
Quadriphasic COC Formulations
-Natazia
Extended Cycle Formulations
- Seasonique**
- Jolessa
- Camrese
Drospirenone Containing Formulations
-Yasmin 28
-Yaz
(Mild potassium-sparing diuretic)
CHC Patches
- Xulane
- Twirla
CHC Rings
- NuvaRing
- Annovera
POP
-Errin
-Camila
-Nora-BE
(“Nor” contains norethindrone)
Estrogen AE
- Nausea
- Breast tenderness
- Bloating/weight gain
- Increase BP
- Breakthrough bleeding; especially early/mid-part of cycle (need to increase dose)
- Serious AE: thrombosis
ACHES
DVT/PE/clot Sxs
- A - abdominal pain
- C - chest pain (PE or MI)
- H - Headaches (stroke)
- E - Eye problems (blurring vision/loss of vision)
- S - Swelling/sudden leg pain (DVT)
Progestin AE
- Breast tenderness
- Headache
- Fatigue
- Depression
Persistent Bleeding?
- Currently taking < 30 mcg estrogen daily; increase estrogen daily
- Currently taking >= 30 mcg estrogen daily; try different progestin
Drugs that Decrease Contraception Efficacy
- Antibiotics: rifampin (back-up contraception for 6 weeks post-DC), rifabutin
- Anticonvulsants: carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, lamotrigine
- St. John’s Wort
- Smoking Tobacco
- Ritonavir-boosted PI
Ethinyl Estradiol DDI
Don’t use with (increased liver toxicity risk):
- Technivie
- Viekira
Mirena
- Hormonal Intrauterine Device
- Contains levonorgestrel
- FDA approved for heavy menstrual bleeding
- Used for up to five years
Paragard
- Copper IUD
- Used for EC (within 5 days) or birth control
- Used for up to 10 years
- Causes heavier menstrual bleeding/cramping
Nexplanon
- Arm implant
- Contains etonogestrel (progestin)
- Use for 3 years
Ella
- Ulipristal 30 mg, AKA RU-486 (“abortion pill”)
- Works by delaying ovulation, doesn’t abort pregnancy
- Use ASAP, within 5 days
- Rx
Plan B
- Levonorgestrel, 1.5 mg
- Prevents or delays ovulation
- Less effective if >165 lbs or BMI > 25
- Use ASAP, within 3 days
- Take with OTC antiemetic to avoid losing dose, retake dose if vomits within 2 hours of medication
- OTC
Clomiphene
- First-line treatment for women with irregular or absent menses
- SERM
- SE: hot flashes, clotting risks
- Risks of multiple births
Gonadotropins
- Act similar to endogenous FSH/LH
- Trigger ovulation
- Risks of multiple births
- SQ or IM injection
Addyi
- Flibanserin
- Agonist for 5HT1A and antagonist for 5HT2A
- CI: with alcohol or string CYP3A4 inhibitors (REMS)
- Warning: syncope, hypotension
- ONLY indicated for premenopausal women with HSDD
Vyleesi
- Bremelanotide
- Nonselective melanocortin receptor antagonist
- CI: uncontrolled HTN or known CVD
- ONLY indicated for premenopausal women with HSDD
