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Endo/Eye/Derm - Women/Men > Contraception products > Flashcards

Contraception products Flashcards

Dr. Flores

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1
Q

Risk of hormonal contraception

A

-STI
-menstrual changes
-hormonal side effects
-MI, CVA (stroke), VTE, HTN
-Gallbladder disease
-Hepatic tumor
-cervical cancer
-failure

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2
Q

Benefits other than for contraception

A

-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)
-

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3
Q

Estrogen containing types of contraceptives

A

Monophasic
Multiphasic

Transdermal patch
Vaginal ring

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4
Q

estrogen-containing contraceptives

A

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

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5
Q

Monophasic products containing drospirenone

A

-Yasmin
-Safyral

Extended cycle:
-Yaz
-Beyaz

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6
Q

Clot risk: progestin and estrogen

A

Drospirenone (a progestin) has a higher clot risk when combined with estradiol

Levonorgestrel or norgestrel (a progestin) has a lower clot risk

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7
Q

What is the purpose of extended-cycle contraceptives?

A

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

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8
Q

Products containing drospirenone

A

Yasmin (21/7), Yaz (24/4)
Safyral (21/7), Beyas (24/4)

higher clot risk

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9
Q

How do extended-cycle contraceptives cause fewer periods (instead of shorter periods)?

A

all pills contain active ingredients: progesterone
Amethyst (levonorgestrel)
Seasonale, Introvale

since all contain progesterone, there is no drop in progesterone that stimulates the period

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10
Q

Multiphasic oral contraceptives

A

-amount of estrogen varies
-the same amount of progesterone

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11
Q

How to counsel patients who use multiphasic contraceptives and suffer from heavy periods

A

choose a product that has estrogen in the progesterone-free phase

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12
Q

COC Missed pills

A

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

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13
Q

Transdermal patch product

A

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

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14
Q

Advantages/disadvantages of contraceptive Transdermal patches

A

-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

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15
Q

Delayed application or detachment

A

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

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16
Q

Counseling Nuvaring (monophasic)

A

-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

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17
Q

Advantages/disadvantages Nuvaring

A

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

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18
Q

what is the standard dose for estrogen-containing contraceptives?

A

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

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19
Q

When considering low progestin/androgenic activity products

A

-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)

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20
Q

Which products should be used in patients with heavy bleeding, anemia, dysmenorrhea (pain), patients decreased menses

A

-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

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21
Q

Products for patients with PMDD

A

PMDD: emotional and physical symptoms (mood)

extended cycle or drospirenone-containing products

Yaz, Beyaz, Introvale

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22
Q

Products for patients with acne

A

Yaz

bc it contains drospirenone which has low androgenic activity (evaluate clot risk)

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23
Q

Products with weight concerns

A

-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

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24
Q

Products for patients with dysphagia

A

Twirla (patch)
Layolis FE (chewable)

Nexplanon (subQ implant, biceps)
IUDs

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25
Q

Products that can be taken postpartum

A

DMPA
progestin-only

IUD copper

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26
Q

LARC: Nexplanon

A

-68 mg of etonorgestel (progesterone)
-insertion: between day 1 and 5 -> when inserted on other days -> use backup

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27
Q

Patients with estrogen side effects

A

progestin-only products

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28
Q

Monitoring of potassium levels is recommended when using which products?

A

DMPA

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29
Q

Advantage/disadvantage progestin only

A

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

30
Q

Active ingredient in Camila (Erin, Heather)

A

Norethindrone

also called Mini-pill

31
Q

Why do progestin-only pills cause breakthrough bleeding?

A

bc there is no estrogen that stabilizes the endometrial lining

32
Q

Disadvantage of Progestin-only Pill Camila

A

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

33
Q

Name different POP products

A

-Camila
-Opill
-Slynd

34
Q

What is the delay window for the Drospirenone-only pill?

A

48h

if more than 48hr: take the pill ASAP and use back up for 7 days

35
Q

What is the formulation of DMPA?

A

-Depo-medroxyprogesterone acetate (DMPA)
-progesterone only
-incejtable progestin

36
Q

When to administer DMPA

A

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

37
Q

Advantages/disadvantages Depo Provera

A

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)

38
Q

Benefit of Progestin IUD

A

last for 8 years
helps with menorrhagia (5 years) (heavy bleeding) and dysmenorrhea

by regulating the growth of the endometrium and preventing excessive thickening

39
Q

Copper IUD

A

-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

40
Q

Emergency contraception Levonorgestrel

A

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

41
Q

Emergency contraception Ella

A

-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

42
Q

Considerations of age and anatomical abnormalities

A

Age: any age from menstruation start to >45 is okay

Anatomical abnormal: no IUDs if distorted uterine cavity

43
Q

Considerations of breast disease and breastfeeding

A

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,

44
Q

Considerations of cervical and endometrial cancer

A

no IUDs

45
Q

Considerations of chronic kidney disease and cirrhosis

A

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)

46
Q

Consideration of DVT/VTE

A

-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)

47
Q

Consideration of diabetes

A

-no estrogen/relative CI to estrogen

-relative CI to DMPA if: nephropathy, neuropathy, retinopathy (diabetes blindness), other vascular disease, or DM for > 20 years

48
Q

Consideration of Gallbladder Disease

A

relative CI to estrogen if: gallbladder is current or medically treated

49
Q

Consideration with headache

A

-no estrogen if: migraine with aura

50
Q

Consideration with Bariatric surgery, malabsorptive

A

-Relative CI to oral!! estrogen and POP

51
Q

Consideration with Cholestasis, past COC-related

A

relative CI to estrogen

52
Q

Consideration with HTN

A

-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

53
Q

Consideration with Ischemic heart Disease

A

-no estrogen
-relative CI to DMPA and continuation of Levo-IUD, Implant, or POP

54
Q

Consideration with Hepatocellular adenoma or malignant hematoma

A

-NO estrogen
-Relative CI to DMPA
-Also Relative CI to IUD, Implant, and POP in malignant hematoma

55
Q

Consideration with Multiple risk factors for ASCVD

A

-NO or Relative CI to estrogen
-Relative CI to DMPA

56
Q

Considerations with Obesity

A

-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

57
Q

Consideration Pelvic inflammation disease

A

-no new Cu-IUD or Levo-IUD if purulent cervicitis, chlamydial infection, or gonococcal infection

-but if already inserted, can continue

58
Q

Consideration with postpartum patients

A

-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

59
Q

Consideration with patients who smoke

A

-Relative CI to estrogen if Age > 35 and < 15
cigarettes/day
-NO estrogen if Age > 35 AND > 15 cigarettes/day

60
Q

Consideration with stroke

A

-NO estrogen
-Relative CI to POP or Implant continuation, and
DMPA

61
Q

Consideration with Pelvic tuberculosis

A

-NO estrogen
-Relative CI to POP or Implant continuation, and
DMPA

62
Q

Consideration with Thrombophilia

A

-No estrogen

63
Q

Consideration with unexplained bleeding

A

-NO new IUDs
-Relative CI to Implant or DMPA

64
Q

Consideration when using POPs (DDIs)

A

-relative CI with CYP inducers: Phenytoin, phenobarbital, primidone, topiramate, oxcarbazepine, carbamezapine, rifampin, rifabutin

-use backup for 6 weeks after

65
Q

Consideration when using estrogen (DDIs)

A

–relative CI with CYP inducers: Phenytoin, phenobarbital, primidone, topiramate, oxcarbazepine, carbamezapine, rifampin, rifabutin
+ fosamprevir

-DDI with lamotrigine (estrogen lowers conctration of lamotrigine)

66
Q

Common DDIs

A

-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

67
Q

Which symptoms does Estrogen excess cause?

A

-N/V
-Breast tenderness
-headache
-bloating

-> reduce estrogen activity
-> consider drospirenone for bloating

68
Q

Which symptoms does Estrogen deficiency cause?

A

-early break-through bleeding
-spotting
-amenorrhea (negative feedback to GnRH at low levels -> no ovulation -> no menses)
-vaginal dryness

-> increase estrogen activity

69
Q

Which symptoms does Porgestin excess and deficiency cause?

A

Excess:
-mood changes
-increased appetite and weight gain (DMPA causes weight gain)

Deficiency:
-Late breakthrough bleeding
-dysmenorrhea
-menorrhagia (heavy and longer period)

70
Q

Which symptoms does Androgen excess cause?

A

-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

71
Q

Which symptoms does SHB excess cause?

A

decreased libido

increase testosterone/androgen activity or progestin activity

Endo/Eye/Derm - Women/Men (30 decks)

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