Contraception products Flashcards
Dr. Flores
Risk of hormonal contraception
-STI
-menstrual changes
-hormonal side effects
-MI, CVA (stroke), VTE, HTN
-Gallbladder disease
-Hepatic tumor
-cervical cancer
-failure
Benefits other than for contraception
-reduced risk for ovarian cancer (due to suppression of ovulation)
-relief of benign breast disease (CHCs)
-prevention of ovarian cysts (CHCs)
-improvement in acne control (CHCs)
-improvement in menstruation regulation (CHCs)
-decrease in endometriosis symptoms
-reduction in anemia risk (less/shorter menses, iron)
-reduction in risk of fetal neural tube defects
-relief from PMDD symptoms (drospirenone)
-
Estrogen containing types of contraceptives
Monophasic
Multiphasic
Transdermal patch
Vaginal ring
estrogen-containing contraceptives
advantage:
can help by having a shorter and lighter period
disadvantage:
-no STI protection
-increased risk of CVA/MI/VTE
-side effects of spotting, breakthrough bleeding, nausea, bloating, breast tenderness, HA
CI: women older than 35 who smoke more than 15 cigarettes a day
< 35 mcg EE is a risk factor for CV
Monophasic products containing drospirenone
-Yasmin
-Safyral
Extended cycle:
-Yaz
-Beyaz
Clot risk: progestin and estrogen
Drospirenone (a progestin) has a higher clot risk when combined with estradiol
Levonorgestrel or norgestrel (a progestin) has a lower clot risk
What is the purpose of extended-cycle contraceptives?
24/4 -> 4 days of placebo pills instead of 7
the hormone-free phase causes a drop in progesterone which triggers the period
-> by making it shorter, the period itself will be shorter
Products containing drospirenone
Yasmin (21/7), Yaz (24/4)
Safyral (21/7), Beyas (24/4)
higher clot risk
How do extended-cycle contraceptives cause fewer periods (instead of shorter periods)?
all pills contain active ingredients: progesterone
Amethyst (levonorgestrel)
Seasonale, Introvale
since all contain progesterone, there is no drop in progesterone that stimulates the period
Multiphasic oral contraceptives
-amount of estrogen varies
-the same amount of progesterone
How to counsel patients who use multiphasic contraceptives and suffer from heavy periods
choose a product that has estrogen in the progesterone-free phase
COC Missed pills
Missed 1 pill: take the missed pill ASAP and continue with the pack
Missed 2 pills (48h after it should be taken): take the missed pill ASAP and continue with the pack, abstain from unprotected sex until hormonal pills have been taken for 7 days, consider an emergency pill when 2 pills were missed during the hormonal phase
missed 2 pills in the last week of the hormonal phase:
take the remaining hormonal pills -> skip hormone-free pills and start a new pack the next day, consider back up contraception (condom) for 7 days
Transdermal patch product
Xulane
-monophasic: 35 mc EE/1.5mg norelgestromin
-should be changed every week, but has enough hormones for 9 days
-apply patch for 1 week and change, repeat for 3 weeks -> then 1 week without the patch -> repeat the cycle
Advantages/disadvantages of contraceptive Transdermal patches
-advantage:
less DDI bc no oral absorption
consider for patients with dysphagia
-disadvantage:
bypassing first-pass metabolism
-> more exposure -> higher risk of clotting, and side effects
CI if BMI > 30
may be less effective
Delayed application or detachment
if <48h: apply a new patch ASAP and keep the same patch change day, no backup is needed
if >48h: apply a new patch ASAP, and keep the same change day, abstain from sex or use a barrier for 7 days
if >48 in the last hormone week: finish the hormone patch and skip to the hormone-free week -> start a new pack, consider emergency contraception if they had sex
Counseling Nuvaring (monophasic)
-keep in refreigerator
-leave it inside for 3 weeks, then 1 week without the ring
-insert on the 5th or before the 5th day of menses
-if it falls out for < 3hr -> use back up for > 7 days
Advantages/disadvantages Nuvaring
advantage:
-lower estrogen exposure
-lower incidence of spotting/breakthrough bleeding after 2nd cycle
-protection continues for 4 weeks if left in place
disadvantages:
-foreign body sensation, vaginal symptoms, expulsion
what is the standard dose for estrogen-containing contraceptives?
20-25 mcg
10 mcg for women < 100 lbs and adolescents, good adherence needed
30-35 mcg: consider if breakthrough bleeding on lower doses or significant obesity -> evaluate CV risk
When considering low progestin/androgenic activity products
-low progestin: progestin-sensitive women (weight gain, fatigue)
-low androgenic activity products: androgen-sensitive women (oily skin, acne, hirsutism)
-> Norgestimate, desogestrel, drospirenone products (evulate clot risk)
Which products should be used in patients with heavy bleeding, anemia, dysmenorrhea (pain), patients decreased menses
-extended cycle products
-Progestin-only products (but may cause breakthrough bleeding - bleeding outside of normal cycle)
so that there is more progestin exposure that prevents menses stimulation
Products for patients with PMDD
PMDD: emotional and physical symptoms (mood)
extended cycle or drospirenone-containing products
Yaz, Beyaz, Introvale
Products for patients with acne
Yaz
bc it contains drospirenone which has low androgenic activity (evaluate clot risk)
Products with weight concerns
-Nextstellis (estetrol/drospirenone) - monophasic
-Natazia (confusing regimen for missed dose) - multiphasic
-Xulane (patch), BMI > 30 - monophasic
-Twirla (patch), BMI > 30 - monophasic
-Vaginal ring (Annovera), BMI > 29
-Slynd (POP), BMI > 30
-planB Levonorgestrel 1.5 mg, BMI > 26
-planB Ella Rx, BMI > 30
Products for patients with dysphagia
Twirla (patch)
Layolis FE (chewable)
Nexplanon (subQ implant, biceps)
IUDs
Products that can be taken postpartum
DMPA
progestin-only
IUD copper
LARC: Nexplanon
-68 mg of etonorgestel (progesterone)
-insertion: between day 1 and 5 -> when inserted on other days -> use backup
Patients with estrogen side effects
progestin-only products
Monitoring of potassium levels is recommended when using which products?
DMPA
Advantage/disadvantage progestin only
Advantage:
-no estrogen risk (highest clot risk is postpartum)
-can be used postpartum and when breastfeeding (may reduce milk supply)
minimizes menses
disadvantage:
-no STI protection
-unpredictable bleeding, amenorrhea
-mood changes weight gain
Active ingredient in Camila (Erin, Heather)
Norethindrone
also called Mini-pill
Why do progestin-only pills cause breakthrough bleeding?
bc there is no estrogen that stabilizes the endometrial lining
Disadvantage of Progestin-only Pill Camila
must take it at the same time every day! 3hr our window for delay
-if later than 3hr: take the dose and use back-up for 48 hours, consider emergency contraception if had sex
Name different POP products
-Camila
-Opill
-Slynd
What is the delay window for the Drospirenone-only pill?
48h
if more than 48hr: take the pill ASAP and use back up for 7 days
What is the formulation of DMPA?
-Depo-medroxyprogesterone acetate (DMPA)
-progesterone only
-incejtable progestin
When to administer DMPA
Depo-Provera: every 3 months (12 weeks)
-> rule out pregnancy when taken after 13 weeks
Depo-SubQ-Provera: every 12-14 weeks
-> rule out pregnancy when taken after 14 weeks
first dose with 5th day of menses -> use backup for 7 days when administered >7 days after menses
if administered LATE, verify that the patient is NOT pregnant and use backup
Advantages/disadvantages Depo Provera
advantage:
no DDIs -> so can be given with anti-seizure drugs
can be given postpartum, wait 6 weeks if breast-feeding
disadvantage:
BBW: don’t use for more than 2 years if possible
menstrual changes
!!reduced bone-mass density –> supplement with calcium and Vitamin D + exercise
weight gain, breast tenderness, amenorrhea
delayed return to fertility (10-12 months)
higher risk for HIV acquisition (use condoms)
Benefit of Progestin IUD
last for 8 years
helps with menorrhagia (5 years) (heavy bleeding) and dysmenorrhea
by regulating the growth of the endometrium and preventing excessive thickening
Copper IUD
-nonhormonal, works for 10 years
-can be used as EC when used within 5 days after sex
-no DDI
-no weight limit
-disadvantage: increased menstrual blood flow, dysmenorrhea (info: Levonorgestrel IUD works against dysmenorrhea)
-CI in Wilson disease
Emergency contraception Levonorgestrel
Levonorgestrel 1.5 mg OTC planB onestep
-should be taken ASAP after sex, ideally within 72 hours -> up to 120 hours
-may cause nausea -> can take meclizine 1h before
-when vomiting within 2hr -> take antiemetic and take it again
may be less effective in patients >75 kg/BMI > 26
Emergency contraception Ella
-prescription and negative a pregnancy test is needed
-should be taken within 120 hr after sex
-MOA: progesterone agonist/antagonist to prevent ovulation
-less effective when >95 kg/BMI >30
Considerations of age and anatomical abnormalities
Age: any age from menstruation start to >45 is okay
Anatomical abnormal: no IUDs if distorted uterine cavity
Considerations of breast disease and breastfeeding
breast cancer: no hormones (progesterone or estrogen)
breast-feeding: progestin is ok (consider breastfeeding success), no estrogen in first 21 days, relative CI in days 21-42 days postpartum with other risk factors,
Considerations of cervical and endometrial cancer
no IUDs
Considerations of chronic kidney disease and cirrhosis
CKD: no estrogen (clot risk), relative CI with DMPA (DMPA may also increase clot risk), concern with progesterone
monitor potassium when Drospirenone is used, bc its structure is similar to spironolactone and potassium goes up in CKD
cirrhosis:
no estrogen (clot risk), relative CI with DMPA (clot risk)
Consideration of DVT/VTE
-when on prophylactic anticoagulation (with a history for DVT):
no estrogen if high risk of recurrence, relative CI if low risk
relative CI to DMPA if high risk of recurrence
-therapeutic anticoagulation:
relative CI to estrogen
-no anticoagulation:
no estrogen if high risk of recurrence, relative CI if low risk
relative CI to DMPA if high risk of recurrence
-> Go with non-estrogen and non-DMPA
-> avoid Drospirenone (increased clot risk)
Consideration of diabetes
-no estrogen/relative CI to estrogen
-relative CI to DMPA if: nephropathy, neuropathy, retinopathy (diabetes blindness), other vascular disease, or DM for > 20 years
Consideration of Gallbladder Disease
relative CI to estrogen if: gallbladder is current or medically treated
Consideration with headache
-no estrogen if: migraine with aura
Consideration with Bariatric surgery, malabsorptive
-Relative CI to oral!! estrogen and POP
Consideration with Cholestasis, past COC-related
relative CI to estrogen
Consideration with HTN
-No estrogen or relative CI to DMPA if: SBP > 160 and DBP > 100
-relative CI to estrogen if: controlled, SBP 140-159 or DBP 90-99
Consideration with Ischemic heart Disease
-no estrogen
-relative CI to DMPA and continuation of Levo-IUD, Implant, or POP
Consideration with Hepatocellular adenoma or malignant hematoma
-NO estrogen
-Relative CI to DMPA
-Also Relative CI to IUD, Implant, and POP in malignant hematoma
Consideration with Multiple risk factors for ASCVD
-NO or Relative CI to estrogen
-Relative CI to DMPA
Considerations with Obesity
-higher failure rate with oral contraceptives and patches (BMI > 30), also higher risk for DVT
-consider using 35mcg EE or extended cycle formulation
-non-estrogen if over the age 35 due to thrombosis clot risk
-monitor breakthrough bleeding
Consideration Pelvic inflammation disease
-no new Cu-IUD or Levo-IUD if purulent cervicitis, chlamydial infection, or gonococcal infection
-but if already inserted, can continue
Consideration with postpartum patients
-wait on estrogen, can use progestins or
copper if no postpartum sepsis
-NO estrogen if < 21 days postpartum
-Relative CI to estrogen until 42 days
-Can insert IUD as early as after delivery of
the placenta if no postpartum sepsis
Consideration with patients who smoke
-Relative CI to estrogen if Age > 35 and < 15
cigarettes/day
-NO estrogen if Age > 35 AND > 15 cigarettes/day
Consideration with stroke
-NO estrogen
-Relative CI to POP or Implant continuation, and
DMPA
Consideration with Pelvic tuberculosis
-NO estrogen
-Relative CI to POP or Implant continuation, and
DMPA
Consideration with Thrombophilia
-No estrogen
Consideration with unexplained bleeding
-NO new IUDs
-Relative CI to Implant or DMPA
Consideration when using POPs (DDIs)
-relative CI with CYP inducers: Phenytoin, phenobarbital, primidone, topiramate, oxcarbazepine, carbamezapine, rifampin, rifabutin
-use backup for 6 weeks after
Consideration when using estrogen (DDIs)
–relative CI with CYP inducers: Phenytoin, phenobarbital, primidone, topiramate, oxcarbazepine, carbamezapine, rifampin, rifabutin
+ fosamprevir
-DDI with lamotrigine (estrogen lowers conctration of lamotrigine)
Common DDIs
-antibiotics: no effects on hormone levels, but backup is still recommended
-breakthrough bleeding: use backup, bc it is a sign that hormone levels have fallen too low
-rifampin: DDI -> use backup
Additive effects: potassium-sparing diuretics (spironolactone, eplerenone), ACEs, ARBs, NSAIDs
-reduced absorption of estrogens: GLP-1-agonists: Ozempic, Wegovy, semaglutide; missed doses
Which symptoms does Estrogen excess cause?
-N/V
-Breast tenderness
-headache
-bloating
-> reduce estrogen activity
-> consider drospirenone for bloating
Which symptoms does Estrogen deficiency cause?
-early break-through bleeding
-spotting
-amenorrhea (negative feedback to GnRH at low levels -> no ovulation -> no menses)
-vaginal dryness
-> increase estrogen activity
Which symptoms does Porgestin excess and deficiency cause?
Excess:
-mood changes
-increased appetite and weight gain (DMPA causes weight gain)
Deficiency:
-Late breakthrough bleeding
-dysmenorrhea
-menorrhagia (heavy and longer period)
Which symptoms does Androgen excess cause?
-Acne
-Hirsutism
-oily skin
-depression
-fatigue
-increased libido
-choleastiatc jaundice
-hair loss
-swelling in arm/legs
-decreased HDL, increased LDL
-reduce androgen activity, increase estrogen or use extended cycle or consider anti-androgenics: drospirenone
Which symptoms does SHB excess cause?
decreased libido
increase testosterone/androgen activity or progestin activity
