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Reproductive System > Contraceptive Reproductive Physiology > Flashcards

Contraceptive Reproductive Physiology Flashcards

1
Q

What is the definition of contraception?

A

Deliberate use of artificial methods to prevent pregnancy as a consequence of sexual intercourse

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2
Q

What are the 3 general strategies of contraception?

A
  • Prevent ovulation
    • Combination hormonal pill, patch, ring
    • Etonogestrel implant
    • Depot Medroxyprogesterone acetate injection
  • Prevent fertilization
    • Abstinence, periodic abstinence
    • Intrauterine devices
    • Progestin only pill
    • Barrier contraceptives (male/female condom, diaphragm, cervical cap)
    • Spermicides, sterilization
    • Withdrawal
  • Prevent implantation
    • (?) Secondary mechanism for hormonal contraception & IUDS
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3
Q

What is the mechanism of action of combination hormonal contraceptives?

A
  • Contain both estrogen & progestin
    • Pill, patch, ring
  • Primary mechanism: prevention of ovulation
  • Generally used for 21-24 consecutive days followed by 4-7 hormone free days
  • Progestins inhibit the estrogen-induced LH surge at mid-cycle
  • Estrogen suppresses FSH –> prevents selection & emergence of a dominant follicle
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4
Q

What are the 3 primary **estrogens **used in combined hormonal contraceptives?

A
  • **Ethinyl estradiol **
    • Ethinyl group at 17 position of estradiol
  • Mestranol
    • Metabolized to ethinyl estradiol (liver)
  • **Estradiol valerate **
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5
Q

_______ provides the majority of the Pill’s contraceptive activity.

A

Progestin

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6
Q

What is the contraceptive mechanism of progestin?

A
  • Thickening of the cervical mucus
    • Hampers transport of sperm
    • Decreases sperm penetration
    • Thins endometrial lining
    • Decreases peristalsis of the fallopian tubes
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7
Q

What are the 3 progestin formulations used in the oral contraceptive pill?

A
  • Estranes
    • Norethindrone
    • Norgestimate, desogestrel
    • Less androgenic activity
  • Gonanes
    • Norgestrel, levonorgestrel
    • Greater progestational activity & greater potency
  • Spironolactone analogue
    • Drospirenone
    • Anti-androgenic & anti-mineralocorticoid activity
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8
Q

What is the composition & mechanism of action of the combination intravaginal ring?

A
  • Mode of action: suppression of ovulation
  • Ethinyl vinyl acetate ring
  • Ring inserted & removed by woman herself
  • Left in place for 3 wks –> then removed to allow withdrawal bleeding
  • After 7 days, new ring placed for next cycle
  • Each day 15 mcg of ethinyl estradiol & 120 mcg of Etonogestrel is released from the ring
  • Efficacy & side effects similar to combination oral contraceptive pills
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9
Q

What is the composition & mechanism of action of the combination transdermal patch?

A
  • Surface area = 20 cm2
  • Delivers progestin norelgestromin (active metabolite of Norgestimate) & 20 mcg of ethinyl estradiol into the systemic circulation for 7 days
  • Patch removed after 7 days & new patch placed at new anatomic site
  • 1 patch/wk used for 3 wks followed by patch-free week to allow withdrawal bleed
  • Efficacy, bleeding patterns, side effects similar to combination oral contraceptives pills
  • Patch less effective for women w/ BMI >90 kg (190 lb)
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10
Q

What are the contraindications to estrogen containing contraceptives?

(sorry for the long card)

A
  • history of venous thromboembolic event
  • inherited/acquired thrombophilia
  • postpartum during initial 3 wks after delivery
  • history of MI or CAD
  • history of cerebrovascular accident
  • women >35 YO who smoke cigarettes
  • vascular disease
  • complicated diabetes
  • severe HTN (BP >160/100)
  • migraine w/ aura
  • severe acute liver disease
  • uncompensated cirrhosis
  • history of hepatic adenoma
  • personal history of breast or endometrial cancer
  • undiagnosed abnormal uterine bleeding
  • **pregnancy **
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11
Q

What are the effects of estrogen on the clotting cascade?

A
  • increased levels of procoagulant factors II, VII, VIII, X, fibrinogen
  • decreased anticoagulants protein S, antithrombin, tissue factor pathway inhibitor
  • induces resistance to natural anticoagulant activation protein C
  • CHC should be stopped 1 mo prior to major surgery
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12
Q

What are some non-contraceptive benefits of combination hormonal contraceptives?

A
  • Fewer menstrual problems
  • More regular, less flow, less dysmenorrhea, less anemia
  • Improvement in acne & hirsutism
  • Increase in SHBG resulting in less free androgen
  • Fewer ectopic pregnancies
  • Decreased risk of endometrial cancer (50%)
  • Decreased risk of epithelial ovarian cancer (50-80%)
  • Decreased risk of functional ovarian cysts
  • Decrease in benign breast disease
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13
Q

What are the therapeutic uses of combined hormonal contraceptives?

A
  • Treatment of abnormal uterine bleeding
  • Fibroids, anovulation, bleeding disorders
  • Endometriosis prophylaxis
  • Hormone therapy for hypothalamic hypogonadotropic amenorrhea
  • Decreased androgens & provides endometrial protect for women w/ POS
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14
Q

What are some drug interactions of combined hormonal contraceptives?

A
  • Estrogens & progestins metabolized by CYP3A4
    • Anti-epileptic drugs: phenytoin, phenobarbital, carbamazepine
    • Antibiotics: rifampin
    • Antifungals: griseofulvin
    • St. John’s Wort
    • HIV protease inhibitors
    • Non-nucleoside reverse transcriptase inhibitor: Nevirapine
  • Enhanced metabolism of either estrogen and/or progestin component of CHC pills, patches, rings, implants
  • **Reduces efficacy in prevention of pregnancy **
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15
Q

What are some examples of Progestin-only contraceptive methods?

A

Progestin only pill (mini-pill)

Injectable Depot Medroxyprogesterone (DMPA)

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16
Q

What is the mechanism of action of the progestin only pill?

A
  • Low dose of progestational agent (25% of that on combined oral)
  • Must be taken daily in continuous fashion
  • Does not consistently suppress ovulation
  • 50% of women will ovulate normally
  • Contraceptive action
    • Creation of thick impermeable cervical mucus
    • Decidualizes the endometrium
    • Decreases tubal peristalsis
  • Should be taken w/i same hour of every day for optimal efficacy
  • Primary used for women w/ contraindications to estrogen
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17
Q

What is the mechanism of action of DMPA?

Where is its primary site of action?

A
  • Primary mechanism of action: inhibition of ovulation
  • Secondary mechanism: impeding sperm transport
    • Thick impermeable cervical mucus
    • Thinning of endometrium
  • Site of action: hypothalamus
    • Inhibition of GnRH pulsatility
    • Suppression of LH & FSH
    • Elimination of LH surge
  • Ovulation may not return for 9-10 mo after last dose
  • Unaffected by enzyme inducing drugs
  • Should not rely on for contraception after 15 wks from time of last dose
  • Two formulations
    • 150 mg/1 ml intramuscular injection every 3 mo
    • 104 mg/0.65 ml subq injection every 3 mo
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18
Q

What are the side effects of DMPA?

A
  • Alteration in menstrual cycle
  • Worsening of acne
  • Weight gain
  • Bone density
  • Decrease in bone density
  • W/i first 2 yrs of use
  • Typically reversible
  • Not linked to increase risk of bone fracture
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19
Q

What are the benefits of DMPA?

A
  • Treatment of abnormal uterine bleeding
  • Treatment of dysmenorrhea
  • Endometriosis prophylaxis
  • Minimal drug interactions
    • Unaffected by enzyme inducing drugs
  • Decreased frequency of sickle cell pain crises
  • Decreased frequency of seizures
    • GABA receptors in hypothalamus
20
Q

What are the long-acting reversible contraceptives (LARCs)?

A
  • Subdermal Etonogestrel Implant
  • Intrauterine Contraception
  • Copper T380A
  • Levonorgestrel Intrauterine Device
21
Q

Subdermal Etonogestrel Implant

  • Mechanism of Action
  • Efficacy
  • Side Effects
  • Benefits
A
  • Primary mechanism of action: inhibition of ovulation
  • Single 4 cm x 2 mm ethylene vinyl acetate rod
    • 68 mg of Etonogestrel (active metabolite of desogestrel)
  • Contraceptive efficacy for 3 yrs
  • Lowest failure rate of any reversible contraceptive method
  • Pregnancy rate = <1 per 1000 insertions
  • Rapid return to fertility
    • Undetectable Etonogestrel levels w/i 7 days
    • Resumption of ovulation w/i 6 wks after removal
  • Side effects: irregular menstrual bleeding
  • Benefits
    • High efficacy, ease of use, discreet
    • No estrogen, relief of dysmenorrhea
22
Q

Intrauterine Contraception

3 Types

Advantages vs. Disadvantages

A
  • 3 IUDs in US: 1 copper, 2 levonorgestrel
  • Advantages
    • Highly effective
    • Convenient
    • Long duration of action
    • Safe, cost effective
    • High continuation rates
  • Disadvantages
    • Higher initial cost
    • Requires clinician visit to insert & remove
    • 5% risk of expulsion
    • Rare risks of uterine perforation (1/1000)
23
Q

Intrauterine Contraception

Contraindications

A
  • Active chlamydial or gonorrheal disease or purulent cervicitis
  • History of pelvic inflammatory disease or endometriosis in the prior 3 mo
  • Distorted uterine cavity or müllerian anomaly
  • Cervical cancer
  • Breast cancer (LNG IUD)
  • Wilson’s disease (Copper IUD)
24
Q

Copper T380A

Mechanism of Action

Composition

A
  • Primary mechanism of action: prevention of fertilization
  • Increase in copper ions, PGs, enzymes, MΦ in uterine & tubal fluids that impair sperm function, interfere w/ capacitation, toxic to oocytes
  • Appear to prevent normal fertilization
  • T-framed device made of polyethylene w/ barium sulfate
    • Each horizontal arm has copper sleeve
    • Fine copper wire wound around vertical stem
    • Combined surface area of copper = 380 mm2
  • Approved by FDA for 10 yrs of use
25
Q

Copper T380A

Advantages vs. Disadvantages

A
  • Advantages
    • Highly effective
    • Long duration of action
    • High rates of continuation
    • Decreased risk of endometrial cancer
  • Disadvantages
    • Heavier menses
    • Dysmenorrhea
    • 5% expulsion risk
    • 1/1000 risk uterine perforation
    • Increased risk of PID only w/i initial 3 wks after insertion
26
Q

Levonorgestrel Intrauterine Device

Mechanism of Action

A
  • Main mechanism of action: prevention of fertilization
  • Creation of thick impenetrable cervical mucus
  • Impaired spermatozoa migration
  • Sterile inflammatory rxn w/i endometrial cavity
  • Ovum destruction
  • Impaired speed of fallopian tube transport
27
Q

Levonorgestrel Intrauterine Device

Formulations (2)

A

20 mcg/24 hr Levonorgestrel releasing IUD

13 mg Levonorgestrel release IUD

28
Q

20 mcg/24 hr Levonorgestrel releasing IUD

Mechanism of Action

A
  • FDA approved for 5 yrs to prevent pregnancy & to treat abnormal uterine bleeding
  • T-shaped barium containing polyethylene frame w/ reservoir in the vertical stem that releases levonorgestrel directly into the uterine cavity
  • 20 mcg/day –> 14 mcg/day by end of year 5
  • 1st yr failure rate = 0.14 pregnancies per 100 women
  • Cumulative 5 yr failure rate = 0.7 pregnancies per 100 women
29
Q

20 mcg/24 hr Levonorgestrel releasing IUD

Advantages vs. Disadvantages

A
  • Advantages
    • Highly effective
    • Long duration of action
    • Safe, high rates of continuation
    • 90% reduction in menstrual bleeding
    • Less dysmenorrhea
    • Provides protection against endometrial hyperplasia & cancer
  • Disadvantages
    • 5% expulsion risk
    • 1/1000 risk uterine proliferation
    • Increased risk of PID only w/i the initial 3 wks after insertion
30
Q

13 mg Levonorgestrel release IUD

Mechanism of Action

A
  • FDA approved for 3 yrs to prevent pregnancy
  • Smaller framed T-shaped IUD
  • Teens & nulliparous women
  • Lower rates of amenorrhea compared to 20 mcg/24 hr LNG IUD
31
Q

What are the barrier contraceptives & spermacides?

A
  • Male condom
  • Female condom
  • Diaphragm
  • Contraceptive Sponge
  • FemCap
  • Spermicide
32
Q

Male condom

Mechanism of Action

Advantages vs. Disadvantages

A
  • Most effective barrier method
  • Latex condoms reduce risk of pregnancy & transmission of STIs & HIV
  • Advantages
    • Inexpensive
    • Available w/o prescription
    • Easy to use
  • Disadvantages
    • Coital dependent
    • Need to use consistently & correctly
    • Risk of breakage, slippage
  • Perfect use failure rate = 2%
  • Typical use failure rate = 15-18%
33
Q

Female condom

Composition

Use

A
  • Soft, loose-fitting silicone lubricant coated nitrile sheath
    • 7.8 cm diameter, 17 cm long
  • Contains 2 flexible polyurethane rings
    • One ring: insertion mechanism & internal anchor
    • Other ring: external open edge of device outside vagina
  • Single use only
  • _Do not use simultaneously w/ male condom _
34
Q

Diaphragm

Composition

Use

A
  • Dome-shaped silicone cup inserted into vagina prior to intercourse
    • Dome covers cervix
    • Spermicidal cream or jelly is applied to the inside of the dome prior to insertion
  • May be inserted up to 6 hrs prior to intercourse
  • Must remain in vagina at least 6 hrs & not more than 24 hrs after intercourse
  • 6 sizes (50 mm to 95 mm)
  • Fit by clinician, requires prescription
35
Q

Contraceptive Sponge

Composition

Use

A
  • Polyurethane sponge containing 1 g of nonoxynol-9 spermicide
  • One size cover, over the counter product
  • Moisten w/ water prior to use
  • Protects against pregnancy for up to 24 hrs
  • Must be left in place at least 6 hrs after intercourse & no longer than 24-30 hrs due to risk of toxic shock syndrome (TSS)
36
Q

FemCap

Composition

Use

A
  • Bowl-shaped silicone rubber cap w/ outward flared rim
  • Concave side fits over the cervix
  • Rim fits into the vaginal fornices
  • Used w/ a spermicide
  • 3 sizes, requires a prescription
  • Can be used up to 48 hrs
37
Q

Spermicide

Composition

Use

A
  • Active ingredient in over the counter spermicides: Nonoxynol-9
  • Chemical detergent
  • Damages sperm cell membranes, killing the cells
  • Cream, gel, foam, suppository, film
  • If used frequently, can cause vaginal epithelial disruption
  • Potentially increases the risk of transmission of **STIs or HIV **
38
Q

What are the Fertility Awareness Methods? (5)

A
  • Calendar Method
  • Standard Days Method
  • Billings Ovulation Method
  • Two Day Method
  • Symptothermal Method
39
Q

Calendar Method

Assumptions

Fertile Period

A
  • Can only be used by women w/ regular cycles
  • Requires that women chart their menstrual cycles for 6-12 mo
  • Based on 3 assumptions:
    • Ovum can be fertilized for ~24 hrs after ovulation
    • Spermatozoa retain their fertilizing ability for up to 5 days
    • Ovulation occurs 12-16 days prior to onset of menses
  • Fertile period determined by subtracting 18 days from the shortest cycle & 11 days from the longest cycle
  • Couple abstains from intercourse during this time
  • Menses 26-30 days –> fertile interval day 8-19 of cycle
40
Q

Standard Days Method

When to use

Fertile days

A
  • Appropriate for women w/ cycles 26-32 days
  • Days 8-19 are fertile days
  • Should avoid intercourse/use a barrier method
  • Color-coded string of beads used to keep track of cycle
41
Q

Billings Ovulation Method

Mechanism

A
  • Avoid intercourse/use barrier from first day cervical secretions are detected until 4 days after peak day when ovulatory secretions noted
  • **Ovulatory secretions: abundant, clear, stretchy, slippery **
42
Q

Two Day Method

Mechanism

A

If a woman detects cervical secretions of any type TODAY and YESTERDAY she considers herself fertile TODAY and should avoid intercourse/use barrier

43
Q

Symptothermal Method

Mechanism

Fertile Interval

A
  • Uses cervical secretions & basal body temperature to determine fertile interval
  • Must check basal body temperature every morning at the same time before getting out of bed & record on a graph
  • Must check cervical secretions
  • Fertile interval begins w/ onset of secretions & ends w/ sustained increased basal body temperature by at least 0.4 degrees F for 3 days following 6 days of lower temperatures
44
Q

What are the 3 types of emergency contraception?

A

Levonorgestrel 1.5 mg tab

Ulipristal acetate 30 mg tab

Copper T380A IUD

45
Q

Levonorgestrel is taken w/i ____ days of unprotected intercourse.

Ulipristal acetate is taken w/i ____days of unprotected intercourse.

Copper T380A is inserted w/i ____ days of unprotected intercourse.

A

3

5

5

46
Q

What are the 3 methods of female sterilization?

A

Postpartum tubal ligation

Laparoscopic tubal sterilization

Transcervical sterilization

47
Q

How is Transcervical Sterilization performed?

A
  • Hysteroscopic procedure
  • Performed in the office w/ local anesthetic
  • Soft, flexible microinserts placed in proximal section of each fallopian tube
  • Polyethylene fibers w/i coils causes ingrowth of tissue & tubal occlusion
  • Takes ~3 mo
  • Confirmation hysterosalpingogram performed to confirm tubal ligation
  • Women must used alternative contraception until confirmation

Reproductive System (35 decks)

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