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Hormonal & Reproductive Week 4 - WLB > Contraception - Pearson > Flashcards

Contraception - Pearson Flashcards

1
Q

Method effectiveness

A

theoretical effectiveness if used perfectly

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2
Q

User effectiveness

A

actual effectiveness when studied in a non-perfect world

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3
Q

Categories of Contraceptive Options

A

Natural methods

Barrier methods

Hormonal methods

Emergency contraception

IUD’s

Sterilization

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4
Q

Natural Methods Goal

A

Avoid intercourse and/or ejaculation around time of ovulation to prevent conception from occurring

***Requires female with regular, predictable cycles

***Both partners dedicated = There may be long periods of abstinence

Timing is everything!

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5
Q

Natural Method Strategies

A

Withdrawal method

Calendar Method: abstinence from intercourse from 5 days prior to 3 days after ovulation

Basal body temperature

Cervical consistency

Other ovulation predictors

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6
Q

When would a women with a 32 day cycle ovulate?

A

14 days before day 32

Day: 18

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7
Q

Natural Methods: Ovulation Timing

A

Ovulation generally 14 days “prior to” 1st day menses

Avoid intercourse 5 days prior and 3 days after ovulation

Determine cycle variability

To determine fertile period:
Subtract 18 days from length of shortest cycle
Subtract 11 days from length of longest cycle

Abstinence during this fertile window

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8
Q

Natural Methods: Basal body temps + Cervical Mucous

A

Take temp before getting out of bed

Increased temp after LH Surge (follows progesterone level)

Avoid intercourse 5 days prior and 5 days after temp increase

At time of ovulation cervical mucous is: Most abundant, Watery, Has consistency of “egg whites”

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9
Q

Barrier Methods Goal

A

Prevent sperm from fertilizing egg by use of physical and/or pharmacological barrier

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10
Q

Barrier Methods Strategies

A 
Female condom
Male condom
Spermicide
Diaphragm
Cervical cap
Sponge
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11
Q

Condoms

A

BEST STI PROTECTION!

Male condom more effective and more commonly used than female condom

Effectiveness is highly user dependent

Most effective if used with spermicide (nonoxynol-9)

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12
Q

Diaphragm

A

Requires fitting by a trained physician (bi-manual exam to measure cervical os)

Decreases (but does NOT prevent) STI’s

Use with spermicide

Insert up to two hours before sex

***Must leave in at least 6 hours after (not more than 24 hours total)

Increased rate of UTI’s (puts pressure on urethra)

Latex

Must be re-fit if: more than 10# weight change; pregancy since last fitting; pelvic surgery

Patient must be comfortable doing self exam

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13
Q

Cervical Cap (“bouncer to your uterus”)

A

Fem Cap – silicone rubber

Must be fit by a trained provider

Comfort with self exam

Must leave in minimum of 6 hours after coitus (max of 48 hours total)

Harder to fit and to use

Option if patient is having problems with increased UTI’s from diaphragm

Question of increased risk cervical dysplasia

Increased risk for toxic shock

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14
Q

Sponge

A

Discontinued in 1995, re-introduced in 2005

“Today” sponge (also Protectaid and Pharmatex)

Circular disc with 1000 mg nonoxynol-9

Moisten with tap water, insert deep into vagina and leave in place for up to 24 hours

Less effective than other methods

Increased rate of yeast infections, UTI’s and toxic shock syndrome if left in place for extended period

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15
Q

Hormonal Methods Mechanism

A

Primary mechanism is estrogen-progesterone induced inhibition of the midcycle surge of gonadotropin secretion (as well as FSH/LH), so that ovulation does not occur.

Also makes cervical mucous inhospitable to sperm transit and makes endometrium less hospitable to conceptus (see supplemental slides included for physiology review).

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16
Q

Combined Estrogen / Progesterone Absolute Contraindications

A

Previous thromboembolic event or stroke

Hx of CAD

Hx of estrogen dependent tumor

Liver disease

Pregnancy

Undiagnosed abnormal uterine bleeding

Smoker over age 35

Migraine headaches w/ neurologic symptoms

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17
Q

Combined Estrogen / Progesterone Relative Contraindications

A

Obesity

Inherited thrombophilias

Anticonvulsant therapy

Migraine headaches

Hypertension

Depression

Lactation (prefer progesterone only)

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18
Q

Non-contraceptive Benefits of Combined Estrogen / Progesterone

A

Reduction in dysmenorrea

Reduction in menorrhagia

Reduction of ovarian, endometrial, and colorectal cancers

Improves acne

Improves benign breast disease

Improves osteopenia or osteoporosis

Decreases functional ovarian cysts

Decreases ectopic pregnancy rates

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19
Q

Medications interactions of Combined Estrogen / Progesterone

A

Antimicrobials (Rifampin)

Anticonvulsants

Anti-HIV

Herbal products (St. John’s Wort)

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20
Q

Medical concerns of Combined Estrogen / Progesterone

A

Increase in thromboembolic events

Breast cancer risks – controversial and unproven

Cervical cancer risks

Medication interactions

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21
Q

Formulations of Combined Estrogen / Progesterone

A

Estrogen: Ethinyl estradiol with doses from 10-50 mcg

Progestin:

First Generation: norethindrone, norethindrone acetate, ethynodiol diacetate

Second Generation: levonorgestel, norgestrel

Third Generation: norgestimate, desogestrel

Spironolactone analogue: drospirenone

Latest iteration: dienogest

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22
Q

Side effects of Combined Estrogen / Progesterone

A

Androgenic side effects: Increased LDL and/or decreased HDL, Acne, Hirsutism

General side effects:
 Breast tenderness
 Nausea
 Headaches
 Mood changes- anxiety, irritability, depression
 Irregular bleeding/spotting
 Weight changes/fluid retention
23
Q

First and second generation progestins:

A

Norethindrone- least androgenic 1st/2nd generation progestin. Slight improvement in lipid profile which is different than other 1st/2nd gen. pills. More androgenic than newer progestins

Levonorgestrel is the most widely perscribed. In many formulations including Plan B and extended cycle pills as well.

24
Q

Third generation progestins:

A

Norgestimate and desogestrel:

Less androgenic effect = good choice for patients with dyslipidemia, acne or other possible androgenic SE’s

Higher thromboembolic potential = 2-3 X higher than first or second generation progestins

25
Drospirenone
A spironolactone analogue Both anti-mineralocorticoid & lower androgenic effects Potential benefits: Improves weight stability/water retention, Improves other possible androgenic SE’s May increase serum potassium: Thus contraindicated in certain patients ***New warning regarding VTE (venous thromboembolic) risk
26
Dienogest
Latest addition FDA approved 2010 4 phase Marketed for metromennorhagia
27
Monophasic
Same fixed dose for three weeks, then placebo week
28
Biphasic, Triphasic, +
Varying doses through first three weeks then placebo week Similar SE profile to monophasics
29
Extended cycle (i.e. Seasonale / Lybrel)
Seasonale & Seasonique: 84 days fixed dose hormones then placebo week Lybrel (Amethyst): Fixed dose of estrogen/progestin 365 days/yr Breakthrough bleeding more common, but decreases over time ? Whether increased amount of hormone exposure over time will lead to greater long term side effects
30
How to prescribe “The Right” pill
Start with low to moderate dose estrogen with most appropriate progestin considering co-morbid conditions Allow at least 2-3 cycles to assess Adjust based on side effects Follow-up based on side effects and co-morbid conditions
31
Common side effects and what to adjust
Breakthrough bleeding: In first 10 days - increase estrogen, After 10 days - increase progestin No withdrawal bleed: Do pregnancy test, Continue pills, If patient wants menses to return, can increase estrogen Typical “hormone related side effects”: Adjust appropriate hormone component
32
NuvaRing
15 mcg ethinyl estradiol and 120 mcg of etonogestrel daily Worn intravaginally for three weeks, then out for one When to start
33
Transdermal Patch
Ortho Evra - 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily Change once a week for 3 weeks then one week patch free How to start Apply to buttock, abdomen, upper arm or torso (not breast)
34
Indications for Progesterone Only
Patients who want effective contraception but want or need to avoid estrogen: - Medical contraidications to combination contraception - Side effects to combo options that are prohibitory to using - Lactation/Nursing - Prefer prescribing schedule
35
What is the biggest issue to consider when starting patient on Progesterone only methods?
***Irregular bleeding
36
Non-contraceptive benefits of Progesterone only methods
Eventual reduction of menstrual flow LITTLE risk of stroke, MI or thromboembolic event Reduced risk of endometrial cancer and PID (with medroxyprogesterone acetate/Depo-Provera)
37
What is the most important patient instruction with the Minipill?
***Timing critical (within 3 hours) or backup contraception needed***
38
Injectable Progesterone Only
Medroxyprogesterone acetate (Depo-Provera) IM every 3 months (4x per year) Start within 5 days of first menstrual day Irregular periods for year after stopping, variable return for fertility *Concern with bone health: Evidence for bone resorption and reduction in BMD presumably due to induced estrogen deficiency, Will normalize in healthy subjects once off DMPA, Current labeling recommends limiting use to 2 yrs, If long term use necessary, BMD needs to be evaluated and followed, Calcium and weight bearing exercise recommended
39
Progesterone Only Implant
Rods implanted subcutaneously under skin- remove once no longer effective *Implanon/Nexplanon (etonogestrel) One rod system – effective for 3 yrs FDA approved
40
Emergency Contraception Definition
The Prevention of pregnancy within 72-120 hours of unprotected intercourse or failure of a contraceptive method
41
Emergency Contraception Mechanism
Depending on timing within menstrual cycle, can inhibit ovulation or prevent fertilization Greater possibility of a post-fertilization effect => Endometrial changes inhospitable to a fertilized ovum
42
Emergency Contraception: Plan B
Progestin only Less nausea and vomiting TWO STEP (originally, now generic) Gained OTC approval in 2006 One tablet within 72 hours of unprotected intercourse, repeat with second tablet 12 hours late ONE STEP: Take within 72 hours of unprotected intercourse Available OTC to ALL AGES since June of 2013!
43
Emergency Contraception: Ella (Ulipristal Acetate)
The latest to hit the market (FDA approved in 2010) Can use up to 120 hours or five days post un-protected intercourse ***Requires prescription! Progesterone agonist/antagonist SE’s: headache, nausea, abdominal discomfort, dysmenorrhea, fatigue, dizziness
44
Emergency Contraception: Using Combo pill packs (estrogen + progestin) “Yuzpe method”
Depending on estrogen/progestin dose, taking 2 or 4 pills initially within 72 hours of unprotected intercourse, and repeating dose in 12 hours. May cause nausea therefore pre-medicate if necessary
45
Copper IUD (ParaGard)
Mechanism: Pre-fertilization effect; induces foreign body reaction in endometrium, with resulting inflammatory response preventing viable sperm from reaching fallopian tubes Effective for 10 years
46
Slow release levonorgestrel (Mirena)
Non-contraceptive benefits: decreases menstrual blood loss and relieves dysmenorrhea Effective for 5 years
47
Lower dose levonorgestrel (Skyla)
Effective for 3 years Marketed & FDA approved in nulliparous women
48
Copper IUD (Paragard) vs. LNG IUD (Mirena, Skyla) for appropriate candidates
``` Copper IUD (Paragard) Want more regular periods Want no hormones No h/o dysmenorrhea No h/o menorrhagia ``` ``` LNG IUD (Mirena, Skyla) OK w/ irregular bleeding OK w/ ammenorrhea H/o dysmenorrhea H/o menorrhagia ```
49
IUD Safety issues
IUDs DO NOT cause PID. Incidence is similar to that of the general population Risk is increased only during the first month after insertion Preexisting STI at time of insertion, not the IUD itself, increases risk RULE OUT GC/Chlamydia prior to insertion ***IUDs DO NOT cause infertility
50
IUD Contraindications
Pregnancy Congenital or acquired uterine cavity malformation Acute STD, cervicitis, or vaginitis Postpartum endometritis or infected abortion within 3 months Known or suspected uterine or cervical neoplasia Unresolved abnormal pap smear Genital bleeding of unknown cause Acute liver disease Immunodeficiency states Hx previously inserted IUD that has not been removed Allergy to copper (for ParaGard) Known or suspected breast carcinoma Artificial heart valves Wilson’s disease (for ParaGard) Contraindications or sensitivity to levonorgestrel (for Mirena/Skyla)
51
Surgical Tubal Occlusion
Laparoscopic procedure Ligation and section removal, clips, rings, coils, plugs, cauterization Can do during Cesarean section or postpartum Main adverse effects are surgery related If pregnancy does occur, higher risk for ectopic Post tubal ligation patients at decreased risk for ovarian cancer
52
Nonsurgical Sterilization Method(s)
Brand name: Essure = microinserts placed into proximal fallopian tubes Brand name: Adiana = Silicon insert + radiofrequency ***NO LONGER AVAILABLE as of 2015 **Less invasive, but 3 months of backup contraception needed
53
How long after Vasectomy is sterilization effective?
MUST have semen analysis to assure no motile sperm** Approx 20 ejaculations or 3 months following Need to use other form of contraception until cleared

Hormonal & Reproductive Week 4 - WLB (8 decks)

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