Contraceptives Flashcards
Methods of birth control?
- Abstience
-Male/female sterilization
-natural family planning
-spermicides
BARRIRERS:
1. Diaphragm or cervical cap
2. condom
3. female condom
4. sponge
HORMONAL CONTRACEPTIVES:
1. COC
2. Transdermal
3. Vaginal ring
4. PROGESTIN-ONLY - progestin-only pill
- progestin only injectable
-implanted rod
IUD/IUS:
-copper IUD - progestin-containing IUD/IUS
Most effective form of contraception?
female/male sterilization
least effective form of contraceptives?
Spermicides, sponge, fertility awareness based methods
FDA indications for COC?
- prevents pregnancy
- acne
- pre mensural dysphoric disorder
off label COC uses?
- Hirsutism
- cycle control
- headaches
- pre mensural syndrome
- Iron deficiency anemia
- relief of mensural cramps
Pharmacologic actions of estrogen in contraceptives?
1) Feed back to pituitary= inhibits FSH and ovulation
2) increases aldosterone C%
3) Increases sex-hormone-binding globulin
Pharmacologic actions of progestins in contraceptives
i. Feeds back to pituitary and helps inhibit ovulation.
ii. Causes endometrial atrophy (thinning of uterus lining).
iii. Thickens cervical mucus (inhibits sperm from traveling).
Category 4 contraindications for combined hormonal contraceptives
- Bp greater than 160/100
- CVD risk
- smoker
- < 21 days postpartum for women with no risk factors for DVT
- 42 days for women with risk of DVT
COC contraindications?
- Vascular disease
- stroke
migraine
ischemic heart disease - surgery with prolonged immobilization
- Liver tumor
- complicated diabetes
- DVT
-Breast cancer - systemic lupus erythematous
- complicated solid organ
Breakthrough bleeding in COC?
Consider new product after trying the product for 3 months, assess adherence.
ii. Select new birth control according to when bleeding occurs.
iii. If early in the cycle, there is probably not enough estrogen; select a regimen
with higher estrogen activity.
iv. If late in the cycle, there is probably not enough progestin; select a regimen with
higher progestin activity.
v. In general, if breakthrough bleeding occurs, it is best to select a regimen with
higher estrogen and progestin activities.
Nausea-induced COC?
- related to estrogen
- take pill at night with food
- try the product for 3months= nausea may subside
Acne caused by COC?
- Acne is related to progestin component
- select product with lower androgenic property & higher estrogen activity
Serious complications of COC?
ACHES: A:BDOMINAL PAIN C: CHEST PAIN H: HEADACHE E: EYE PROBLEM S:SEVERE LEG PAIN
Types of Hormonal Contraceptives
- Monophasic
- Biphasic
-Triphasic: Traditional
(Progestin changes & estrogen stays the same)
-Quadri phasic:
Same amount of hormone in pill every day except in placebo
pills
monophasic
Amount of hormone may change halfway through cycle.
Biphasic
Amount of hormone changes every week.
Triphasic
types of triphasic?
(a) Traditional: Progestin usually changes and estrogen stays the same.
(b) Estrophasic: Estrogen changesv
Estrogen changes and progestin changes; four varying
amounts throughout monthly pack
Quadriphasic
COC regimens?
i. High-dose estrogen: Higher than 35 mcg (up to 50 mcg)
ii. Low-dose estrogen: Less than 35 mcg (generally 20–35 mcg)
iii. Very low-dose estrogen: Less than 10 mcg
COC starting methods?
i. Same-day start: Start taking an active pill the first day of menses.
ii.Sunday start: Start taking an active pill the first Sunday after menses begins
iii. Quick start: Start taking an active pill at the physician’s office or first day of
prescription, regardless of menstrual cycle day.
what should you do when switching from one brand to the other?
When changing pills from brand to brand, start the new pack of pills after
finishing the placebo pills from the old pack.
COC counselling points?
1) Proper use: take 1 tablet once daily at the same time everyday
2) adverse effect: usually decreases after 3 months: (stay on a brand for at least 3 months if adverse
effects are not excessively inconvenient).
DEF: Missed doses in COC?
Missed COC pill means more than 24 hours
between doses.
missed one pill?
Take missed dose as soon as possible, continue taking the remaining
doses at the usual time even if it means taking 2 tablets in one day, no
backup method needed;generally emergency contraception (EC) is not
necessary but may be considered if the patient missed doses earlier in
the cycle or in the last week of the previous pack.
missed 2+ pills?
if its been more than 48 hours?:
- take most recent dose as soon as possible
-continue taking remaining doses at the usual time even if it means
taking 2 tablets in one day
- use back up method or avoid intercourse all together until 7 active tablets have been take for 7 days
- use EC if unprotected intercourse occurred in 5 days
advantages of COC?
- Effective
- Easy to use
- reversible
- regular menstrual cycle
- improves acne
- sexual enjoyment
- emergency contraception
disadvantage of COC?
- Drug interactions
-No HIV or STI protection
• Patient adherence
• Expensive
• Adverse effects
• Circulatory complications
• Menstrual cycle changes
transdermal patch is less effective in__
women weighing more than 90kg
comment about transdermal patch adherence?
Better adherence rates than pill, especially
in teens
transdermal patch counselling points?
(a) Place patch on a dry, hairless area of upper arm, shoulder,
abdomen, or buttocks. Should not be placed on the breast.
(b) Rotate site of patch each week.
(c) One patch per week for 3 weeks; week 4 is patch free (menses will
occur then)
Transdermal patch adverse effect?
(a) Higher incidence of blood clots
(b) Site irritation from the patch
missed doses?
(a) If patch is off for less than 24 hours, reapply patch; no back up
needed.
(b)If patch is off for more than 24 hours, open a new patch, new day 1;
must use a backup for first week of the new cycle
DEF: Missed doses in transdermal?
(a) Missed dose = delayed patch application of less than 48 hours or
recommended time for application.
if its been less than 48 hours on missed dose?
-Apply new contraceptive patch as soon as possible (if less than 24
hours, may replace same patch).
-Keep contraceptive patch on until scheduled patch change day.
-No backup needed
-In general, EC is unnecessary but may be considered, if the patient
missed doses earlier in the cycle or in the last week of the cycle
If delayed application is more than 48 hours from scheduled administration
time, may recommend the following? (Transdermal)
(1) Apply new patch as soon as possible.
(2) Keep patch on until scheduled patch change day.
(3) Use backup method or avoid intercourse until contraceptive patch has been in
place for 7 consecutive days.
(4) If doses missed were during days 15–21 of a 28-day cycle (e.g., 3 weeks active
hormone, 1 week placebo); then omit the patch-free week and apply a new
contraceptive patch.
(5) If unable to apply a new patch immediately, use a backup or avoid intercourse
until new patch has been applied for 7 consecutive days.
(c) Use EC if active hormone was missed in the first week of the cycle or
unprotected intercourse occurred in the previous 5 days
Advantages/Disadvantages of transdermal patch?
advantages: - Efficacy - Adherence - user controlled - readily reversible --- Disadvantages: - site reaction - patch detachment - appearance ; less privacy - Shouldn't be used in women that weight more than 90kg
Product inserted vaginally; delivers ethinyl
estradiol and etonogestrel (active form of
desogestrel) daily
Vaginal Ring
Adherence of vaginal ring?
(a) Higher than in women using the COC pill.
(1) “Not having to remember anything”
(2) “Ease of use”
Vaginal ring counseling?
(1) Insert vaginal ring into vagina and leave for 3 weeks. Week 4, remove ring and menses will occur. (2) Should not be removed during intercourse. (3) May be worn with tampon if there is breakthrough bleeding
DEF:Missed dose in vaginal ring?
Missed doses: Unintentional removal, expulsion, or prolonged ringfree interval
Missed dose in vaginal rings?
(1) If 3 hours or less, rinse with cool to lukewarm water and reinsert as
soon as possible.
(2)If more than 3 hours, reinsert and use a backup method until ring
has been used continuously for 7 days.
Vaginal ring adverse effects?
- Yeast infection
- Dysmenorrhea
- Vaginal discharge
- UTI
- Genital itching
advantages/Disadvantages of vaginal rings?
Advantages: • Efficacy •Adherence • User controlled • Cycle control • Readily reversible • Privacy Disadvantages: • Adverse effects similar to other combined regimens • Vaginal discomfort • Potential partner awareness of ring
Extended Regimens?
3 months: results in menses every 3 months instead of once a month
1 year: using active form of combined hormonal contraception for 1 yr
indications for progestin-only contraceptives’ ?
- smoker
- MI history
- Atrial fibrillation
- bp 160/100 mmHg
- Breastfeeding
- surgery within past 4 weeks
Progestin- drug interactions
Major interactions: Edoxaban, Morphine, Venetoclax, Co-administration with P-gp inhibitors
Moderate Interactions:
- Antibiotics ( CYP 450 inducer/inhibitors):
How do antibiotics interfere with progestin-?
Antimicrobials interfere with the enterohepatic
recirculation of estrogens by decreasing
bacterial hydrolytic enzymes in the
gastrointestinal tract that are responsible for
regenerating parent estrogen molecules
following first-pass metabolism.
Antibiotics that dont induce hepatic enzymes?
rifamycins and possibly griseofulvin
Advantages/Disadvantages of progestin-only contraceptives?
Advantages: Efficacy, decreased menstural blood, reversible, preferable in lactating women disadvantages: -Progestin-related adverse effects -Irregular menses - Adherence: Short time window for a missed pill -Low dose progestin= patients might ovualte
Adverse effects of progestin? IMP*
- Depression
-Boxed warning: Loss of bone; women who used depotmedroxyprogesterone acetate or DMPA (Depo Provera) for at least 5 years
have significantly reduced bone mineral density (BMD) of lumbar spine and
femoral neck, particularly after 15 years of use and if initiated before age 20.
counselling for ppl on Depot-medroxyprogesterone acetate?
- should be placed on Ca+2 supplements & exercise regularly
counselling for patients on progestin-only contraceptives?
i. Wait a few hours before massaging area where shot was given.
ii. Irregular bleeding or spotting in the beginning which will decrease over time.
iii. Take calcium if not achieving 1000–1200 mg/day through diet.
iv. Return in 11–13 weeks for next injection. Use backup method if ever more than
13 weeks.
v. If ever changing from DMPA to another method, start method when next
injection is due.
vi. May have delayed return to fertility for up to 18 months. Use with caution
in women 35 years or older who express interest in future conception.
used by women who wish to prevent pregnancy long term & have heavy menses who elect to use IUD for contraception?
Levonorgestrel IUS
- delays pregnancy for up to 2 yrs
IUS/IUDs include:
- copper (IUD)
- progestin-only (IUS)
Copper IUD MOA?
Spermicidal; inhibits sperm motility & acrosomal enzymes activation
T/F: Is copper IUD an abortifacient?
False; doesn’t interfere with ovulation & isnt abortifacient
Contraindications specific to copper IUD?
- Allergy to copper; Wilsons disease
- uterus less than 6 cm or greater than 9cm
- Pregnancy
- severe anemia
- unresolved PAP test: Cervical cancer
Advantages and Disadvantages of Copper IUD?
Advantages: efficacy adherence natural sexual activity cost effective patient satisfaction --- Disadvantages: -monthly blood loss increased upto 35% - foreign body - increased risk of infection for 20days after insertion
Advantages and Disadvantages of Progestin IUS?
Advantages: Efficacy adherence spontaneous sexual activity readily reversible ---- disadvantages: a. progestin-related adverse effect b. irregular menses c. high risk of infection after first 20 days - foreign body
Patient counselling point for progestin? IMP**
1) IUD string will be outside the vaginal canal. instruct patient on how and when to check thread to verify IUD is still inserted correctly
- Adverse effects?
PAINS:
Period late
Abdominal pain
Infection
Not feeling well
S tring missing: shorter/longer
components of implant?
Etonogestrel, releases 60–70 mcg/day
during weeks 5–6 and then decreases to
35–45 mcg/day by the end of the first year,
30–40 mcg/day after the second year, and
25–30 mcg/day at the end of 3 years.
implants shouldn’t be given to?
women who weight more than 130% of their ideal body weight
implant MOA?
- INSERTED ROD IN UPPER ARM
- 99% Effective upto 3 yrs
implant adverse effects?
- Bleeding irregularities
- site reaction
- difficulty removing rod after 3 years
“A therapy used to prevent pregnancy after an unprotected or
inadequately protected act of sexual intercourse.”
EMERGENCY CONTRACEPTION
EMERGENCY CONTRACEPTION MOA?
- inhibits ovulation
- prevents fertilization
- increases thickness of cervical mucus
Indications of emergency contraception?
- condom broke
- misused contraceptive
- sexual assault
- exposure to any teratogen
- unprotected intercourse within 120 hours
2 types of emergency contraception?
- IUD/coil
- Emergency contraceptive pill ( aka: morning pill)
__- refer to birth control methods that you use at the time of
intercourse.
Pericoital contraception
Pericoital contraception examples ?
- condoms ( external/internal)
- Diaphragm
- cervical cap
- sponge
- vaginal spermicides
Pericoital methods?
- diaphragm
- cervical cap
- sponge
- spermicides
Barrier method
condom
short-acting hormonal methods?
- patch
- vaginal ring
- estrogen-progestin pill
- progestin-only pill
- shot/injection
Long acting methods?
- IUD with progestin
- IUD copper
- implantable rod
permanent methods?
- Vasectomy
- Tubal ligation
