Contraception/Infertility/HSDD

Question 1

Folate

Answer 1

• Deficiency can cause birth defects (neural tube)
• Adult recommendation: 400 mcg/d
• Preggo: 600 mcg/d

Question 2

Hormonal Contraception

Answer 2

• 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

Question 3

Progestin Examples

Answer 3

• Norethindrone
• Levonorgestrel
• Drospirenone

Question 4

Drospirenone

Answer 4

• 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

Question 5

Other Low Androgenic Progestins

Answer 5

• Norgestimate**
• Desogestrel
• Dienogest

Question 6

COC Indications

Answer 6

• First line for menses control in PCOS
• First line for endometriosis
• Natazia (COC) and a levonorgestrel-releasing IUD are indicated for heavy menstrual bleeding

Question 7

POP Indications

Answer 7

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)

Question 8

Xulane

Answer 8

• 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

Question 9

Depo-Provera

Answer 9

• 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

Question 10

Continuous Contraception

Answer 10

• 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

Question 11

Monophasic COC Formulations

Answer 11

-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)

Question 12

Biphasic/Triphasic COC Formulations

Answer 12

-Ortho Tri-Cyclen Lo
-Tri-Sprintec
-Nortrel 7/7/7
(“Lo” indicates estrogen is =< 35 mcg)

Question 13

Quadriphasic COC Formulations

Answer 13

-Natazia

Question 14

Extended Cycle Formulations

Answer 14

• Seasonique**
• Jolessa
• Camrese

Question 15

Drospirenone Containing Formulations

Answer 15

-Yasmin 28
-Yaz
(Mild potassium-sparing diuretic)

Question 16

CHC Patches

Answer 16

• Xulane

- Twirla

Question 17

CHC Rings

Answer 17

• NuvaRing

- Annovera

Question 18

POP

Answer 18

-Errin
-Camila
-Nora-BE
(“Nor” contains norethindrone)

Question 19

Estrogen AE

Answer 19

• Nausea
• Breast tenderness
• Bloating/weight gain
• Increase BP
• Breakthrough bleeding; especially early/mid-part of cycle (need to increase dose)
• Serious AE: thrombosis

Question 20

ACHES

Answer 20

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)

Question 21

Progestin AE

Answer 21

• Breast tenderness
• Headache
• Fatigue
• Depression

Question 22

Persistent Bleeding?

Answer 22

• Currently taking < 30 mcg estrogen daily; increase estrogen daily
• Currently taking >= 30 mcg estrogen daily; try different progestin

Question 23

Drugs that Decrease Contraception Efficacy

Answer 23

• 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

Question 24

Ethinyl Estradiol DDI

Answer 24

Don’t use with (increased liver toxicity risk):

• Technivie
• Viekira

Question 25

Mirena

Answer 25

• Hormonal Intrauterine Device
• Contains levonorgestrel
• FDA approved for heavy menstrual bleeding
• Used for up to five years

Question 26

Paragard

Answer 26

• Copper IUD
• Used for EC (within 5 days) or birth control
• Used for up to 10 years
• Causes heavier menstrual bleeding/cramping

Question 27

Nexplanon

Answer 27

• Arm implant
• Contains etonogestrel (progestin)
• Use for 3 years

Question 28

Ella

Answer 28

• Ulipristal 30 mg, AKA RU-486 (“abortion pill”)
• Works by delaying ovulation, doesn’t abort pregnancy
• Use ASAP, within 5 days
• Rx

Question 29

Plan B

Answer 29

• 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

Question 30

Clomiphene

Answer 30

• First-line treatment for women with irregular or absent menses
• SERM
• SE: hot flashes, clotting risks
• Risks of multiple births

Question 31

Gonadotropins

Answer 31

• Act similar to endogenous FSH/LH
• Trigger ovulation
• Risks of multiple births
• SQ or IM injection

Question 32

Addyi

Answer 32

• 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

Question 33

Vyleesi

Answer 33

• Bremelanotide
• Nonselective melanocortin receptor antagonist
• CI: uncontrolled HTN or known CVD
• ONLY indicated for premenopausal women with HSDD