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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
Q

Drospirenone

A

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
Q

Dienogest

A

Latest addition

FDA approved 2010

4 phase

Marketed for metromennorhagia

27
Q

Monophasic

A

Same fixed dose for three weeks, then placebo week

28
Q

Biphasic, Triphasic, +

A

Varying doses through first three weeks then placebo week

Similar SE profile to monophasics

29
Q

Extended cycle (i.e. Seasonale / Lybrel)

A

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
Q

How to prescribe “The Right” pill

A

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
Q

Common side effects and what to adjust

A

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
Q

NuvaRing

A

15 mcg ethinyl estradiol and 120 mcg of etonogestrel daily

Worn intravaginally for three weeks, then out for one

When to start

33
Q

Transdermal Patch

A

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
Q

Indications for Progesterone Only

A

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
Q

What is the biggest issue to consider when starting patient on Progesterone only methods?

A

***Irregular bleeding

36
Q

Non-contraceptive benefits of Progesterone only methods

A

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
Q

What is the most important patient instruction with the Minipill?

A

Timing critical (within 3 hours) or backup contraception needed

38
Q

Injectable Progesterone Only

A

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
Q

Progesterone Only Implant

A

Rods implanted subcutaneously under skin- remove once no longer effective

*Implanon/Nexplanon (etonogestrel)

One rod system – effective for 3 yrs
FDA approved

40
Q

Emergency Contraception Definition

A

The Prevention of pregnancy within 72-120 hours of unprotected intercourse or failure of a contraceptive method

41
Q

Emergency Contraception Mechanism

A

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
Q

Emergency Contraception: Plan B

A

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
Q

Emergency Contraception: Ella (Ulipristal Acetate)

A

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
Q

Emergency Contraception: Using Combo pill packs (estrogen + progestin) “Yuzpe method”

A

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
Q

Copper IUD (ParaGard)

A

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
Q

Slow release levonorgestrel (Mirena)

A

Non-contraceptive benefits: decreases menstrual blood loss and relieves dysmenorrhea

Effective for 5 years

47
Q

Lower dose levonorgestrel (Skyla)

A

Effective for 3 years

Marketed & FDA approved in nulliparous women

48
Q

Copper IUD (Paragard) vs. LNG IUD (Mirena, Skyla) for appropriate candidates

A 
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
Q

IUD Safety issues

A

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
Q

IUD Contraindications

A

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
Q

Surgical Tubal Occlusion

A

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
Q

Nonsurgical Sterilization Method(s)

A

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
Q

How long after Vasectomy is sterilization effective?

A

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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