Contraceptives Flashcards
MOA of OCPs
suppress ovulation
reduce sperm transfer to fallopian tuves
change endometrium making implantation less likely
thicken cervical mucus (preventing sperm penetration)
health benefits of OCPS
dec in ovarian cancer and endometrial cancer - benefits inscrease w/ longer duration of use
contraception method reccommended for Current or past history of breast cancer:
•Copper IUD preferred
Disease progression may be less with levonorgestrel-releasing IUDs compared to COCs or higher-dose progestin-only contraceptives because breast cancer is a hormonally sensitive tumor
Smoking and OCPs
•Absolute contraindicated in smokers over 35
•Relative contraindication in younger, heavy smokers (>15 cigarettes per day)
Use lowest dose estrogen (10 or 20 mcg)
•Progestin only methods are options
conditions where you should avoid estrogen containing pills
Si/Sx of Estrogen Sensitivity
- History of Migraine
- Heavy menstrual cramps
- Severe nausea and vomiting during pregnancy
- Pregnancy-induced hypertension
Si/Sx Progestin Sensitivity
History of excessive:
weight gain
appetite
tiredness
varicose veins
toxemia during pregnancy
PMS: excessive edema, bloating, headache, depression
Si/Sx of Androgenic Sensitivity
what ocp should we choose ??
History of irregular, heavy, menses
Physical exam may reveal oily skin, hirsutism and acne
Use pill with high progestational activity and low androgenic activity
OCP ideal for acne
pick HIGH estrogen and LOW androgen
what is the most common reason women dc OCPS
what pills is this most commonly seen w/?
when do we see this?
Breakthrough Bleeding and Spotting
- BTB most common with low-dose OCPs and POPs
- Occurs most often during the 1st cycles of OCP use while the endometrium is adjusting to a lower amount of estrogen and progestin
- Bleeding continues to decrease until it reaches a plateau in the 2nd to 4th cycle
when switching OCPs due to BTB we should choose a pill with ??
Choose pill with greater endometrial activity. Higher progestin doses
- More androgenic progestins
- Multiphasic OCPs
- Higher estrogen doses
- Different ratios of estrogen to progestin
when to start OCPs
Sunday?
day 1?
quick start?
backup methods?
- Sunday – start on first Sunday after period begins
- Day 1 – start on first day of period
- Quick Start – start immediately appointment day
- A backup method, should be used for the 1st seven days of the initial cycles if pills are started later than the 5th cycle day.
what to do if menstration does NOT occur?
occurs at incorrect time?
•If menstruation does not occur at the regular time, a pregnancy test must be performed.
If menstruation does occur, OCs should be restarted
- either five days after the onset of menstruation (as for the 1st cycle of OCs)
- or seven days after the last active tablet, which- ever is earlier
MISSED PILLS: 1
take missed pill immediately and next one at regular time
MISSED PILLS: 2
first 2 weeks
3rd week
first 2 weeks:
take 2 pills daily for next 2 days then resume on regular schedule -
use additional contraception for the rest of the cycle
3rd week:
take 2 pills daily until all active pills are taken - restart with one pill daily within 7 days -
use additional contraception until pills are restarted and for first 7 days of pills
MISSED PILLS: 3 or more
stop pills, restart within 7 days with one pill daily
use contraception through first seven days of next pill cycle
Si/Sx of OCPs
- Encourage patients to wait 3 cycles before requesting to change pill - Spontaneously disappear
- Breakthrough bleeding
- Symptoms associated with pregnancy
- especially nausea
- weight gain, breast tenderness
- Other Side effects: Amenorrhea, acne, headache, depression, rash
Pill Danger Signs
undisputed drug intractions w/ OCPS
controversial drug interactions w/ OCPs
- Ethynyl estradiol is conjugated in the liver, excreted in the bile, hydrolyzed by intestinal bacteria and reabsorbed as active drug
- Antibiotics reduce the population of intestinal bacteria, and therefore interrupt the enterohepatic circulation of estrogen resulting in a decreased concentration of estrogen
Return of Fertility After OCP Use
- Average 2 month delay
- Traditionally recommend 3 normal menstrual cycles before attempting pregnancy
Prenatal vitamins for 3 months prior
estrogen and progestin effect on lactation
•Estrogens Inhibit the action of prolactin in breast tissue
- Decreased milk production (quantity)
- Decreased protein content (quality)
- Decrease duration of lactation
•Progestins
- POPs have lesser effect on lactation
- Injectable progestins have no effect or increase milk production
POP are good choice of contraceptives in what pt population
Nursing mothers
Women with reasons to avoid estrogen
Smokers over 35
Can be used by women who have had thrombophlebitis
Less nausea and vomiting than OCPs
instructions and cautions w/ POPs
Take on the first day of menses
Take at the same time of day – SAME HOUR
Use back-up method for first cycle
If 3 hours late or miss one pill use backup for 48 hours (Manufacturer)
Emergency contraception if indicated
Conservative recommendations: 7 days or remainder of the cycle
less effective & greater risk of ectopic pregnancy
MOA of emergency contraception
•High dose estrogen or progestin
- Delays development of follicles
- Prevents ovulation
- Interferes with fertilization
- Prevents implantation of fertilized egg
- Prevents not terminates pregnancy; considered contraceptive not abortifacient (controversial)
name 2 types of emergency contraception
Levonorgestrel 1.5mg X 1 dose (OTC)
Ella (Ulipristal) - Rx
Levonorgestrel instructions
- When taken within 72 hours low failure rate
- Efficacy declines > 72 hours later
preferred in women who are planning on restarting hormonal contraception
Ella (Ulipristal) MOA and instructions
time before restarting hormonal contraception? - backup contraception?
restarting POP? - backup?
- Selective progesterone receptor modulator (blocks progesterone receptors)
- As effective as levonorgestrel when given within 3 days; but unlike levo, effective for 5 days
- Requires a prescription
- If hormonal contraception is to be restarted, levonorgestrel is preferred
- wait 5 days before restarting hormonal contraception.
- Backup contraception is required for the first 5 days after taking and for the first 7 days after starting hormonal contraception (i.e., when ulipristal is used and hormonal contraception is restarted, backup contraception is required for a total of 12 days after ulipristal)
- restart the POP 5 days after taking ulipristal and use backup contraception for 14 days.
Xulane (generic Evra Patch) instructions and placement
norelgestromin and 0.75mg of ethinyl estradiol
Worn for 3 weeks, removed for the 4th week
Placed on chest, buttocks, abdomen, upper outer arms, upper torso
•Not placed on the breast or on irritated skin
Xulane backup method needed:
day 1 start
sunday start
- Day 1 start: no backup method needed
- Sunday start: backup method x 7days
- Special directions if forgot to change the patch, or if it falls off (on BB)
Enzyme inducers may _______concentrations of Xulane
DECREASE
NuvaRing instrcutions
when to insert?
etonogestrel (active form of desogestrel) and 15mcg of ethinyl estradiol over 3 weeks
Stays in place 3 weeks, removed the 4th
Inserted during the first 5 days of menstruation
- Back up method for the first 7 days
- One size fits all; 2.1 in diameter
Extra stored in refrigerator
nuvaring si/sx
what to doif it slips out??
vaginal discharge, irritation, infection
If it slips out for more than 3 hours use back up for 7 days
Annovera instructions
when is it inserted?
ethinyl estradiol 13mcg and segesterone 150mcg
REUSABLE vaginal ring that’s inserted for 21 days…removed for 7…then reinserted for up to 13 cycles, or 1 year
•Inserted between day 2 and 5 of menstruation – no back up; otherwise use backup for 7 days
Advise cleaning Annovera and patting it dry before each insertion AND after each removal…and storing it in its case for the “out” week. So far, there’s not a significant concern about higher infection risk.
what to do if annovera falls out
how to store?
If it is out of the vagina for more than 2 hours at one time or at different times that add up to more than 2 hours over the first 21 days of the cycle, then another method of birth control, such as condoms or spermicide is needed for 7 days
Keep Annovera at room temp…not in the fridge like NuvaRing.
T/F women can skip annovera out week and therefore skip their periods
FALSE
Don’t advise skipping Annovera’s “out” week. Suggest a different contraceptive if women want to avoid menses
T/F
Annovera’s efficacy may be reduced by oil- or silicone based vaginal products, such as some lubricants
TRUE
Long-acting Injectable Progestin instructions
when to inject?
si/sx
return of fertility ??
Injected within 5 days after the onset of menstrual bleeding -> inhibits ovulation for over 3 months
Can be used in women who need to avoid estrogen; including breast-feeding
menstrual irregularities
Return of fertility; 6 months
Nexplanon (Etonogestrel 68mg)
when can it be inserted where NO backup contraception is needed?
- Single rod, progestin only, implantable contraception
- Protects for 3 years
- No back up method needed if implanted days 1-5 of menstruation; Otherwise use back up for 7 days
Si/Sx of nexplanaon
DDIs?
menstrual irregularities
DIs:
enzyme inducers(rifampin, antifungals, anticonvulsants)
inhibitors (intraconazole, ketoconazole)
name the types of IUDs and their components
- Copper – Paraguard™
- Progestin filled – Mirena™, Skyla™, Liletta™, Kyleena™
how do Levonorgestrel containing IUDs work?
works by causing suppression of the endometrium
increasing the amount and viscosity of cervical mucus
and reducing tubal motility.
The prefertilization and postfertilization effects occur before implantation.
hoq do copper IUDs work?
not known, it is thought that the copper may have an effect during prefertilization such as affecting sperm migration or altering the viability or speed of the ovum.
Other theories suggest that the copper IUD affects postfertilization (but prior to implantation) such as by damaging the fertilized ovum
Reusable dome-shaped silicone cup with a flexible rim is called??
health risks and benefits??
diaphragm
Health benefits
- Lower incidence of cervical neoplasia
- Decreased incidence of STDs
Health Risks
•Associated with an increased risk of UTIs and yeast infections
diaohragm instructions
Inserted vaginally to fit over the cervix -> May need to be fitted- different size/types
• Must use spermicidal jelly* for it to be effective
Prevents sperm from gaining access to the uterus
- May be inserted up to 6 hours before intercourse
- Must be left in place at least 6 hours after intercourse (max 24 hours)
- If intercourse occurs more often than once within 6 hours; do NOT remove the diaphragm, insert more spermicide vaginally . The diaphragm must remain for 6 additional hours.
Soft, deep, rubber cup with a firm round rim that Fits over the cervix like a thimble
cervical cap
Spermicide is used to fill cap 1/3 full prior to insertion
Cap is effective for more than one episode, up to 48 hours without adding more spermicide
Must remain in place at least 6 hours (max 48 hours)
compare/contrast diaphragm vs cervical cap vs sponge
ALL - add spermicidal jelly for effectiveness , must remain in place for 6 hours after intercourse
diaphragm - left in place for MAX 24 hours, if another round of intercourse must insert more spermicidal jelly
Cervical cap- can leave in for 48 hrs, do not need to add more spermicidal jelly if more intercourse
sponge - do not leave in longer then 30 hours, portection lasts for 24 hours even w repeated intercourse
sponge instructions
Contains spermicide nonoxynol-9
Wet the sponge thoroughly with clean water, squeeze gently until sponge is very sudsy.
With the dimple side inside, fold sponge. With string loop on the bottom end, insert the sponge deep into the vagina
Protection begins right away and lasts for 24 hours even with repeated acts of intercourse.
• Wait 6 hours after last intercourse before removing sponge.
Do not leave sponge in vagina for more longer than 30 hours.
T/F
- Mineral oil based lotions or lubricants can decrease the strength of latex by 90% in just 60 seconds
- Poly condoms: NOT OK for latex allergy
TRUE
FALSE - •Poly condoms: OK for latex allergy
T/F
Female condom is more effective in preventing transmission of diseases than the male condom
&
CAN use with a male condom
true
CANNOT USE w/ MALE CONDOM
spermcide MOA and Si/Sx
Chemicals usually nonoxynol-9
• Cause the sperm cell membrane to break, which DEC sperm movement and their ability to fertilize the egg
Essential to the effectiveness of several barrier methods
May cause local irritation in M & F
What is/are the most effective form(s) of birth control?
- Implant
- IUD
- Vasectomy
- Tubal methods
What are the factors that determine effectiveness of birth control?
- Motivation to prevent pregnancy
- Inherent biologic capacity to conceive
- Frequency of intercourse
- Following directions
What are the estrogen components of an OCP?
- Ethinyl estradiol
- Mestranol
- Estradiol valerate
Multiphasic
Duplicate the pattern of the ovulatory menstrual cycle and doses change accordingly
What CV complications may be a/w OCP use?
- MI
- CVA
- Thromboembolism
Recall C/I for OCPs
- Smoking >35
- Uncontrolled HTN
- Undiagnosed abnormal vaginal bleeding
- DM
- DVT/PE history or risk
- HA/stroke
- Current or past Hx of BC
- Hepatitis/cirrhosis
- Breast-feeding exclusively
- Family Hx of thrombosis
Why would an extended or continuous OCP regimen be preferred?
- Improves menstruation problems & endometriosis related menstrual pain
- No periods
What are appropriate counseling points in a patient initiating OCPs?
- When to start
- When to take the pill
- When to expect her period
- What to do if she missed a pill
- No barrier to STDs
What is the only indication for 50 mcg OCP use?
IF the patient is also taking anticonvulsants
What is the mechanism of action of emergency contraception?
- Delayed development of follicles
- Prevents ovulation
- Interferes w/ fertilization
- Prevents implantation
Describe Sunday start
Start first Sunday after bleeding starts
If started within first 5 days, no back up needed
Describe day 1 start
Start on first day of period, no back up needed
Describe quick start OCP use
Start OCP on day of appointment
If started within first 5 days of menstrual cycle, no back up needed
What are the options for progestin only contraception?
- Depo-provera
- POPs
What adverse side effect is a/w depo?
Osteoporosis (decrease in bone growth)
