Contraception Medications Flashcards
how does estrogen in CHC inhibit contracenption
how does progesterone
Estrogen
- supresses FSH release from the pituitary
- body thinks there is enough, so it doesnt release FSH, thus no maturation of a follicle
- inhibition of LH = no ovulation
- no maturation of the follicule: no LH surge
Progesterone
- suppressed LH release
- consistent amout of progesterone stops LH from spiking
- inhibtis LH surger: prevents ovulation
- thickens cervical mucus
- induces endometrial atrophy
- slows tubal motility and delays sperm transport
Estrogen Types in Contraceptions
- which one has high, medium and low
Estrogen: types
Ethinyl Estradiol (EE)
- high dose (50mcg) (rarely used since high SE profile)
- low dose (25-35 mcg)
- very low dose (20 mcg)
Mestranol
- 50% less potenet thatn EE
- converted to EE by the liver
Estradiol valerate (E2V)
- more potent: 2mg = 20 of EE
Progestins in Contraceptives
androgen activity
Progestins
- mutliple types depending on generation
- differ by prgestin activity, androgen effects, etc.
Androgen Activity by type
Low Activity
- norgestimate
- desogesterol
- etonorgesterl
- norethindrone
Medium
- ethynodiol diacetate
High
- norgesterel
- levonorgesterol -.15
NO activity: medroxyprogesterone (injectable)
ANTI-androgen: drosprenone (like spironolactone: watch potassium) AND Dienogest
Side Effects of
Estrogen
too much or too little?
Estrogens : SE
if these symptoms are seen; think you have too high of a rx. of estrogen, decreased dose
- Nausea/vomiting
- bloating/edema
- HTN
- HA
- breast tenderness
- decreased libido
- weight gain: cyclical! with menses
- heavy mentrual flow
too little estrogen with the following effects
- early cyclical bleeding (days 1-9)
- amenorrhea
- vaginal dryness
Side Effects of
Progestins
- too much or too little
Progestins: Side Effect
Too much if
- weight gain
- increased appetit
- fatigue
- depression
- vaginal yeast infections
too little
- LATE cycle bleeding (days 10-21)
- dysmenorrhea
- heavy flow
dont change amout until about 2-3 cycles in: need to adjut
androgenic side effects
Androgenics
- acne/oily skin
- weight gain
- hirsutism
- fatigeu
- depression
Types/Options of Contraception Methods
Combined Hormonal Contraceptives (CHC)
- oral CHC
- hormonal patch
- hormonal vaginal ring
Progestin-Only Contraceptives (POCs)
- oral (POPs)
- Implants (like nexplanone)
- IM injection
Intrauterine devices
- LNG IUD
- Copper IUD
with proper adhearnce and use, these (pathces, pills,etc.) can be extremely effective!! more thatn condoms, etc.
How is the righ Contraceptive Method determined for your pt
- Decide what is SAFE for the pt as an option: use the US MEC
- any speciif pt or drug conditions to consider
- pt. perfers for how they want their contraceptives
- pt. fertility plan
- methods most accessible to pt.
described the US MEC categories 1-4
US MEC Categories
1 = safe to use, no restrictions
2 = advnatages generally outweigh risks
3 = risks outweigh advantages
4 = unaccetable health risks (DO NOT USE)
The Considerations of the Table
- age > 40
- smoking status (20 cigs per pack)
- themboembolsim
- HTN
- migraine HA
- Breast Cancer
- DM
- obestiy
- postpartum
Thromboembolism risk and estrogen, progestin
Trhoboembolism
Estrogen
- stimulates the hepatic clotting factors production (up to 2-3x risk in those with CHC)
Progestins
- drospirenone, desogesterl both increased the throboembolism risk
CHC uses are at an increse risk fo clotting, but even more so IN
- obestiy
- smokers
- personal/fam. hx. of VTE
- prolonge immobilizaion
- HTN
Migraines and Contraceptive USe
Migraines = without aura = all good
migraines + aura: cannot used CHCs
- increased risk of ischemic stroke!!! avoid
Considerations for
breast cancer
DM
obestiy
postpartum
Breast cancer
- prognosis can worsen if exposed to hormones
DM
- wont impact insulin contorl, but be aware of the complicaitons that can result and otehr comorbid conditions
Obestiy
- concenrs for comined hormone patches & their effectiveness (weight cut off)
Postpartum
- consider length of time since they gave birth and if breast feeding
- CHC within 21 days of brith are CI for incresed risk of VTE
Drug Drug Interactions with Estrogen and Progesteins
most interations with the POPs and the CHCs
Antiretrovirals
Anticonvuslants (decreased the efficacy of teh contraceptive method) if using: must have at least 30mcg of the estrogen
Rifampin (the only true abx .to decreased Contraceptive efficacy)
progestin-only pills and estrogen have this effect: with these meds so need to be aware
Combiniation Oral contraceptives (COCs)
types: mono vs multiphascis
conventional extended v continuous
Combined: porgestins and estrogen
- ensure proper adhearence of the medications
Monophasic
- usually start pt. here
- same amount of estrogen/progestin in every pill
- followed with 7 days of placebo pills to allow menses
Multiphastic
- if you want to avoid the cyclical effects
- varibale amounts of either the progestin/estrogen for 21 days
- followed by 7 days of placebo for menses
Conventional
- pills that give you 21 days of hormones, followed by 7 days of placebo pills
- allows for monthly menses
Extended
- pilles that give you 84 days of hormones, then 7 days of placebo
- allows for menses 1x every 3 months
- can lead to possible amenorrhea: desired or not!
Continuous
- pills that give 21 days of homrones, then lower does hormones for days ; no placebos
- this can and most liekly will lead to amenhorrhea
How should oral contraceptive combination pills be inititated
Initiation Strategies
- first day of the bleed: start the pills
- on first sunday after then menstrual cycle started: start pills (common) “sunday start”
- “Quick Start”: take teh first pill on teh day it is Rx. get pregnancy test - first before this
if starting the pill more than 5 days after the first day of menstrual period; want to use back up protection for pregnancy for 7 days
What to Councel Pt. for Missed Doses of the Oral CHC
look at the package insert for specific instructions
Generally
1 tablet missed or late to take ?
- take as soon as you remember
- if its taking it 2 in one day, thats ok
2 or more consecuative doses mises
- take 1 missed dose as soon as you remember, throw out anoy others that you missed or forgot to take
- use backup protection for 7 days following
- if this happens on 3rd week of pack: skip the placebos
CHC: Patches
doses/delivery
instructions for application
starting medication
missed dosing
Patches
- considered as effective as the pill in those less than 90 kg.
- cannot be used in those with BMI > 30
Instructions
- abdomen, butt, upper torso, upper arm applied
- last 3 weeks then remove, and no patch 1 week (menses)
Starting Patches
- Day 1 start: dose the start on first da of teh menstraul period, durig first 24 hours of the menses
- Sunday Start: dose on the first Sunday after the mense have begun ; must us 7 days of backup protection with this
Missed Dose
- if forgotten to apply patch within 48 hours of supposed to : youre good
- if forgotten to apply patch in time > 48 hours of supposed to : use backup for 7 days following
Combined Contraceptives : Vaginal Ring
dose/delivery
insturctions
starting
missed dosing counceling
Delivery
- Nuvaring: new ring each insertion
- annorvera: same ring reinserted
Instructions
- insert ring intravaginally for 3 weeks, then remove for 1 week (menses)
Starting
- first day start: insert first day of menstrual period
- day 2-5 start: insert between day 2-5 of menstural cycle
Most Common Reasons for D/C
- foreign body sensation
- expulsion
Missed Dosing
ring out of vagina for less thatn 2-3 hours: rinse and reinsert
ring out of vagina for > 2-3 hours: consul package insert for specifics
Combined Hormonal Contraception
SIDE EFFECTS TO KNOWWWWW
ACHES
A = abdomenal pain (severe pain) (think Gallstones, liver issue)
C = chest pain (think PE)
H - headaches (severe, sudden onset) (think stroke)
E = eye problems (blurry vision, flashing lights or blindness) (think stroke or retinal thrombus)
S = severe leg pain (DVT)
if these happen, d/c immediately and contact your porvider!!!
Progestein Only Pills
considerations
missed doses
POPs Considerations
- daily dosing: STRICT ADHEARANCE: must be taken in the same 3 hour window
- if not in that window, need backup methods
Missed POP Dose
- if it is > 3 hours late or you missed 1 dose
- take pill asap, and go back to normal time of taking
- use backup for the next 48 hours
Progestin: DMPA injections
considerations
DMPA Injections
- a SQ IM injection every 3 months
Best in the following populations
- breast-feeding moms
- intolerant to estrogen
- concomitant medication condition where estrogen is not recommened
- adhearance issues
Side Effects
- Weight gain: increased appetite
- loss of BMD: reversible but cannot use this for longer than 2years!!!!
- avoid this in those who havent reached their peak bone mineral density!!! can icnrease OP risk
Long Term Contraception Options
Implants
IUDs
considerations
Implants
- thin rod inserted into upper arm
- continuous contraception for 3 years
- potentially decreased effiacy overtime in overweight women
- SE: weightgain
IUD
- provider inserted into the uterus
- LNG: 3-6 years of continuous contraception
- Copper: 12 years of protection
- copper is the only non horomonal option avalible
- copper SE: menorrhagia and dysmneorrhea
- LNG IUD typically results in amenorrhea
return to fertility from
oral chc
transdermal
ring
injecable
subdermal
iud
Quick Return: 2-3 cycles
- oral chc
- transdermal
- ring
- subdermal
- iud
delayed: months to return
- injectable (depo shot) expect 10-18 months to return
Options if amenorrhea is the goal
- extended cycle or continuous COC
- LGN-IUD
- progestin-implant
- DMPA : injection
Emergency Contraception
purpose
options
- plan b
- ella
- cooper iud
Emergency Contraception
- prevents unwanted preganncy after unprotected or inadequalteyl protected sexual intercourse
Options
levonorgesterel: planb, next choice
- inhibits/delays ovulation OTC med.
- the sooner the better, within 72 hours (120 possible)
Ulipristal (Ella)
- Rx only
- inhibits/delays ovulation
- single dose within 120 hours of intercourse
Copper IUD
- can be inserted within 120 hours of intercourse
- inhibits sperm motility and viability
Effiacy of the Emergency Contraceptives
levonorgesterol
- watch normal DD interactions and Se of progestins
- may not be effective in those > 25 BMI
- potentially ineffective after LH surge occurs
Ulipristal
- same DD for progestins
- wathc in those with BMI > 30 : may be less effective
Copper IUD
- no weight cut off
ADR of emergency contraception
Oral Options
- HA
- nausea: if they vomit within 1-2 hours ; need to take it again
- irregualr menstrual bleeding
- breast tenderness
- abd. pain
- dizzy/fatigue
if taking CHC, take at normaly scheudled time
Copper IUD
- uterine crampng
- heavy bleeding
- dysmheorrhea
- uterine perforation
Hormone Replacement Thearpy
what is it used
vasomotor v vulvovaginal syptoms
HRT: What is it used for
- help with menopausal symptoms
- as a result of the estrogen lack that occurs in menopause
Vasomotor VMS
- hot flushes
- hot flashes
- night sweats
if vasomotor +/- vulvovaginal symptoms = systemic therapy
Vulvovaginal syptoms
- vaginal dryness
- vaginal irritation
- dyspareunia
- frequent UTIs
if ONLY vulvovaginal symptoms = topical, locacl, intravaginal hormone thearpy
Contraindications for Menopausal Hormone thearpy
Contraindications
- unexplained vaginal bleeding
- severe liver disease
- history of horone sensitive cancer (breast)
- history of endometrial cancer
- confirmed CVD or hx. of
- history of stroke/TIA
- history of blood clotting disorder ot VTE (DVT/PE)
Treament options for HRT
Hormone Thearpy : most effective for vasomoteor +/- vulvovaginal
- intact uterus = estrgen + progestone (needed both to prevent endometiral hyperplasia)
- hysterectomy pt: estrogen thearpy only ok
only use as long as symptom contorl is needed (usually 2-3 years) with lowest effective doses
vulvovaginal = topicl intravaginal estrogen
if CI to the HRT but have vasomotor: SSRI (paroetine)and SNRI (venlafax) are 2nd line options (clonidine, gabepentintoo)
Benefits and Risks of HRT (systemic)
Benefits
- relief of menopasusal sx.: VMS & GSM
- potential helpful for : sexual function, UTI health, QOL, mood, sleep
- potentail decrease: colon cancer and DM
Risks
- Endometrial cancer : those with estrogen only thearpy: thus always add progestin
- CVD RISK
- Stroke
- Gallbladder dsiease
- Breast Cancer
- VTE
