Contraception Reproductive Physiology

Question 1

Most women have menstrual cycles lasting 24-35 days with an average of 28 days. The first day of blood flow is day 1 of the cycle. 20% of women experience irregular cycles. The normal menstrual cycle has 2 phases: The______ phase is variable lasting an average of 10-17 days while the_____ phase is more constant at 14 days.

Answer 1

follicular

luteal

Question 2

Hypothalamic GnRH is secreted in a pulsatile fashion every 60-90 minutes and travels via the portal circulation to the anterior pituitary to produce

Answer 2

LH and FSH

Question 3

promotes ovarian follicular growth by causing granulosa cells that line each follicle to proliferate and **produce estradiol **

Answer 3

FSH

Question 4

promotes androgen production in theca cells adjacent to the granulosa cells

Answer 4

LH

Question 5

The_____ diffuse from the theca cells –> granulosa cells where they are converted by the enzyme aromatase to estrogen

Answer 5

androgens

Question 6

FSH promotes ovarian ______to proliferate and secrete estradiol resulting in follicular growth

Answer 6

granulosa cells

Question 7

As estradiol levels rise a positive feedback loop of rising LH stimulates increased estrogen resulting in greater pituitary secretion of

Answer 7

LH >> FSH

Question 8

About 2 days prior to ovulation secretion of___ rises 6-10 fold

LH surge causes resumption of_____ in the dominant oocyte, luteinization of granulosa cells with increased progesterone and slowed estrogen synthesis

Answer 8

LH

meiosis

Question 9

Follicular rupture occurs 32- 44 hours after onset of _____ and 10-12 hours after _____

Answer 9

LH surge

LH peak

Question 10

Onset of the LH surge is the most reliable predictor of _____

During the luteal phase shift is to________ dominance which suppresses new follicular growth and causes secretory changes to the endometrium

Answer 10

ovulation

progesterone

Question 11

If pregnancy does not occur the declines 9-11 days after ovulation with a drop in ______, ______, and ______ levels with resultant shedding of the endometrial lining, rise in FSH and LH, and development of a new follicle

Answer 11

progesterone, estrogen, and inhibin

Question 12

After ovulation the oocyte retains potential for fertilization for ________

Sperm remain viable in the reproductive tract for up to _____

Answer 12

12- 24 hours

120 hours

Question 13

Oocyte is swept into lumen of the fallopian tube by the fimbria

Fertilization occurs in the______ portion of the tube

Answer 13

ampullary

Question 14

After fertilization the zygote reaches the uterine cavity by day ____and implantation begins day____ when embryo is at the blastocyst stage

Answer 14

4-5

5-7

Question 15

Combined hormonal contraceptives, contraceptive implant, contraceptive injection

Answer 15

• Prevent ovulation

Question 16

Abstinence, fertility awareness methods, intrauterine device, progestin only pill, barrier methods, spermicides, withdrawal, sterilization

Answer 16

• Prevent fertilization

Question 17

Estrogen PLUS Progestin

– Three formations

What is the mechanism?

Answer 17

“ The Pill”, Transdermal patch, Vaginal ring

Prevent ovulation and Thicken cervical mucous

Question 18

Prevention of Ovulation

• is the dominant hormone in CHC formulations
• diminishes frequency of hypothalamic GnRH pulse frequency
• inhibits the estrogen induced LH surge at mid-cycle

Answer 18

Progestin

Question 19

suppresses FSH preventing selection and emergence of dominant follicle

Answer 19

Estrogen

Question 20

OCP: Majority contain _______, few 50 mcg formulations with mestranol, one with estradiol valerate.

Progestins vary by pill formulation: Estranes - norethindrone (1st generation)

• norgestimate, desogestrel (3rd gen) Gonanes- norgestrel, levonorgestrel (2nd gen) Spironolactone analogue- drospirenone (4th gen)

Answer 20

ethinyl estradiol

Question 21

suppression of ovulation, Flexible ring delivers 15 mcg ethinyl estradiol and 120 mcg etonogestrel (active metabolite of desogestrel)

Answer 21

Combined Contraceptive Vaginal Ring

Question 22

• 20 cm2 patch delivers 20 mcg of _______and________

(active metabolite of norgestimate)

• One patch per week for 3 weeks then one patch free week.
• Less effective in women >90 kg

Answer 22

ethinyl estradiol and norelgestromin

Question 23

Combined Hormonal Contraceptives

• _____ levels of pro-coagulant factors II, VII, VIII, X, and fibrinogen
• _____ anticoagulants protein S, anti- thrombin, and tissue factor pathway inhibitor
• Induce resistance to the natural anticoagulant activated protein C

Answer 23

Increase procoagulants

Decrease procoagulants

Question 24

Contraindications to CHC

Answer 24

History of venous thromboembolic event (VTE), inherited or acquired thrombophilia

Postpartum – initial 3-6 weeks after delivery

History of myocardial infarction or coronary

artery disease

History of cerebrovascular accident

Cigarette smokers > age 35

Complicated diabetes, vascular disease

Question 25

Contraindications to CHC

Answer 25

Severe hypertension BP \> 160/100 Migraine with aura Severe active liver disease, cirrhosis, history of hepatic adenoma Personal history of breast or endometrial cancer Undiagnosed abnormal uterine bleeding Pregnancy

Question 26

What three methods involve progestin only?

Answer 26

* Pills * Injection * Subdermalimplant

Question 27

MOA of Progestin only Pills

Answer 27

Prevention of fertilization from thickening of **cervical mucus**, and slowing ovum transport through decreased tubal motility ## Footnote Possible prevention of implantation from **thinning of the endometrium**

Question 28

Profound ovulation inhibition – slow return to baseline fertility – 7-10 months 150 mg IM and 104 mg SQ formulations given every 12 weeks

Answer 28

DMPA Depot medroxyprogesterone acetate injection

Question 29

High efficacy - perfect use failure rate rate 0.3%. Typical use failure rate 3% Unscheduled bleeding with trend toward amenorrhea with continued use

Answer 29

DMPA Depot medroxyprogesterone acetate injection

Question 30

**Reversible decrease** in bone density, no evidence of fracture risk **Unaffected by hepatic** enzyme inducing drugs **Decreases frequency of seizures and sickle cell crises **

Answer 30

DMPA Depot medroxyprogesterone acetate injection

Question 31

What does implant rod contain and how does it work? How long does it work and what is the side effect?

Answer 31

Contains progestin etonogestrel and inhibits ovulation works for 3 years and irregular bleeding most common side effect

Question 32

What enzyme medications will compete for metabolism by CYP 3A4

Answer 32

Enzyme inducing medications Rifampin, Griseofulvin, St Johns Wort, Modafinil Some HIV protease inhibitors Nevirapine – non nucleoside reverse transcriptase inhibitor

Question 33

What anti-epileptics induce CYP 3A4 thus compete with estrogen and progestin?

Answer 33

Phenytoin Carbamazepine Phenobarbital

Question 34

Couples who do not use any method of contraception have an approximately ____ chance of experiencing a pregnancy over the course of a year. The typical U.S. woman wants two children. To achieve this goal, she must use a contraceptive method for roughly three decades. More than \_\_\_\_of women aged 15–44 who have ever had sexual intercourse have used at least one contraceptive method.

Answer 34

85% 99%

Question 35

Combination hormonal contraceptives (pill, patch, ring) – contain both estrogen and progestin - primary mechanism is

Answer 35

prevention of ovulation

Question 36

LARC Methods: Long Acting Reversible Contraceptives: Most effective forms of reversible contraception due to high typical use efficacy and high rates of continuation.

Answer 36

Implant and Intrauterine devices.

Question 37

Placed quickly and easily in the office without anesthesia DO NOT increase risk for infertility. Safe in nulliparous women and teens

Answer 37

Intrauterine Devices : both copper and Progestin levonorgestrel

Question 38

Mechanism of Copper IUD

Answer 38

Primary mechanism is **prevention of normal fertilization** – _Cu+ ions_ reduce motility and viability of sperm, _toxic to oocytes _

Question 39

Secondary mechanism of this method is inhibition of implantation- especially if **used for emergency contraception **

Answer 39

Copper IUD

Question 40

What is the Mechanism of Action of Levonorgestreal IUD

Answer 40

Mechanism of action: Prevention of fertilization Thick impenetrable cervical mucus Sterile inflammatory reaction within uterus Impaired sperm migration

Question 41

FDA approved to treat abnormal uterine bleeding – 90% decrease in menstrual bleeding, high rates of amenorrhea

Answer 41

5 year levonorgestrel IUD

Question 42

same as 5 year LNG IUD Smaller size of device and inserter Contains a lower dose of levonorgestrel 13.5 mg Designed for teens and nulliparous women Lower rates of amenorrhea

Answer 42

3 year levonorgestrel IUD

Question 43

IUD Efficacy Rates compared to sterilization CuT All Sterilization Postpartum Salpingectomy

Answer 43

CuT= 1.4 All sterilizaiton= 1.3 Postpartum Salpingectomy= 0.6

Question 44

Contraindications to IUD/IUS

Answer 44

Pregnancy PID current or within the past 3 months Current STI Puerperal or postabortion sepsis current or within the past 3 months Purulent cervicitis Undiagnosed abnormal genital bleeding Malignancy of the genital tract Known uterine anomalies or fibroids distorting the cavity in a way incompatible with IUD insertion Allergy to any component of the IUD or Wilson’s disease (for copper IUD)

Question 45

Perfect fail rate for condoms 1st year: Typical use rate first year: Benefits of condom use

Answer 45

3% 18% decrease risk of STI transmission \*has 3-5% breakage or slippage rate thus consider backup use

Question 46

* Nitrile sheath with 2 flexible polyurethane rings lined with silicone * Protection against STI’s * Single use only * Do not use with male condom * Typical first year failure rate 21%

Answer 46

Female Condom

Question 47

Available as creams, gels, film, foam, and suppositories containing nonoxynol-9 Used alone or ideally with a barrier method Typical one year failure rate 28%

Answer 47

Spermicide

Question 48

Nonoxynol-9 impregnated polyurethane sponge Should be removed after 24-30 hours due to increased risk of irritation and TSS Typical failure rate 24% for multiparous and 12% for nulliparous women

Answer 48

Sponge

Question 49

Prevention of fertilization Used with spermicide Multiple sizes Typical one year failure rate **12**% New silicone diaphragm Older latex diaphragm discontinued in the US

Answer 49

Diaphragm

Question 50

• Silicone cap with outward flared rim One year typical failure rate 15% Use with spermicide Leave in at least 8 hours after intercourse Do not leave in longer than 48 hours

Answer 50

Cervical Cap

Question 51

Describe using the calander method for fertility

Answer 51

– Subtract 18 days from shortest cycle and 11 days from longest cycle to calculate fertile window

Question 52

Standard Days Method – Must have regular ____ days cycle – 80% of women – Days\_\_\_are fertile days – Cumulative probability of pregnancy was 4.75% over 13 cycles with correct use and 12% probability under typical use.

Answer 52

26-32 8-19

Question 53

Cervical Mucus Ovulation Detection Method – Abstinence or use barrier with onset of cervical secretions until \_\_\_\_\_\_\_\_\_(clear, stretchy, egg white) consistency • Two Day Method – Abstain or use barrier if detect cervical secretions of any type \_\_\_\_\_\_

Answer 53

4th day after last day of peak ovulatory secretions TODAY and YESTERDAY

Question 54

Sympto-thermal Method – Fertile interval begins with ______ and ends with sustained increase in basal body temperature of ______ degrees for 3 consecutive days following 6 days of lower temperatures

Answer 54

cervical secretions at least 0.4

Question 55

Sympto-hormonal Method (Marquette Method) – Combines cervical secretion check and detection of urine LH with ovulation predictor device: how does it work?

Answer 55

Fertile period onset of cervical secretions until 3 days after PEAK LH reading

Question 56

– FDA approved for use **72 hrs after unprotected intercourse**. Can use for up to 120 hrs – **Less effective** in women with BMI \>30

Answer 56

Levonorgestrel 1.5 mg tab

Question 57

When must you take Levonorgestrel 1.5 mg tab for it to be effective in preventing pregnancy?

Answer 57

Effective only if taken 2-3 days prior to LH peak

Question 58

– Selective **progesterone receptor** modulator – FDA approved for use 120 hrs after unprotected intercourse.

Answer 58

Ulipristal

Question 59

How does Ulipristal work as an emergency contraceptive?

Answer 59

– Prevents follicular rupture 100% **if taken just prior to LH surge** – P**revents follicular rupture** for 24-48 hours if taken on day of LH peak

Question 60

99% effective if placed within 5 days after unprotected intercourse

Answer 60

Copper IUD

Question 61

MOA of copper IUD in emergency contraception

Answer 61

Copper ions toxic effect on sperm as well as negative effects on oocycte, zygote-morula- blastocyst, and endometrium

Question 62

Methods of Sterilization

Answer 62

Sterilization – Female • Laparoscopy • Mini-laparotomy post partum • Hysteroscopy – Male • Outpatient office procedure

Question 63

MOA of Hysteroscopic sterilization

Answer 63

Expandable outer coil – Alloy of nickel and titanium, polyester fibers Stainless steel inner coil that expands to fit contour of tube Over 3 months tissue grows into the device occluding the tube 0.3% failure rate at 5 years

Question 64

at high doses inhibit the LH surge thus preventing ovulation and result in thick viscous cervical mucus that is “hostile” to sperm

Answer 64

Progestins

Question 65

The ovum is fertilizable for ____ hours and sperm are viable for\_\_\_\_\_\_– hence a woman is fertile for 6 days per cycle

Answer 65

12-24 up to 5 days

Question 66

are the most effective forms of reversible contraception

Answer 66

The implant and IUDs