GYN: Contraception Flashcards
What methods are tier 1?
IUD, implant, male and female sterilization
What is the typical use effectiveness in tier 1?
Less than one pregnancy per 100 method users in 1 year
What methods are tier 2?
COCPs, POPs, Depo, Ring, Patch, Diaphragm
What is typical use effectiveness for tier 2?
6-12 per 100 method users in 1 year
Depo-6
Pill, patch, ring - 9
Diaphragm - 12
What methods are tier 3?
male or female condoms, sponge, withdrawal, spermicides, FAM
What is typical use effectiveness for tier 3?
18+ pregnancies per 100 method users in 1 year
male condom: 18
female condom: 21
withdrawal: 22
sponge: 24 for multips, 12 for nullips
FAM: 24
Spermicide: 28
What is the effectiveness of phexxi?
86% for typical use
What drugs may decrease effectiveness of contraceptives?
Drugs that increase the production of liver enzyme cytochrome P-450
This causes contraceptives to clear more quickly and decrease its effectiveness
rifampin
rifapentine
some anticonvulsants
some retrovirals
griseofulvin
st john’s wort
Also orlistat may decrease absorption of COCs
Which types of contraceptives are decreased by drugs that increase CP-450
all CHC, POPs, implants
NOT depo
What is MEC cat 1?
No restrictions for medical condition
What is MEC cat 2?
advantages or using method generally outweigh theoretical or proven risks
What is MEC cat 3?
condition for which theoretical or proven risks usually outweigh the advantages of the method
IN GENERAL, represents a contraindication for use, if no other more appropriate method is available or acceptable refer to or consult with OBGYN OR MD managing the condition
DOCUMENT
What is MEC cat 4?
Condition that represents an unacceptable health risk if method is used
ABSOLUTE CONTRAINDICATION
MOA of copper IUD
Makes uterus inhospitable to sperm
Foreign Body effect
copper may inhibit sperm capacitation
alters tubal/uterine transport
enzymatic influence on endometrium
Hormonal LNG IUD MOA
thickens cervical mucus
produces atrophic endometrium
slows ovum transport
inhibits sperm motility and function
MEC cat 4 for ALL IUDs (9)
(1) known or suspected pregnancy
(2) postpartum or post-abortion sepsis
(3) Unexplained vaginal bleeding prior to insertion and before evaluation
(4) Gestational trophoblastic disease with persistently elevated hCG levels or malignant disease with evidence or suspicion of intrauterine disease - initiation but not continuation
(5) Cervical cancer prior to insertion and awaiting treatment
(6) Any uterine anatomic abnormalities distorting uterine cavity and incompatible with insertion
(7) Current PID, purulent cervicitis, chlamydia or gonorrhea- initiation but not continuation
(8) Endometrial cancer - initiation but not continuation
(9) known pelvic TB - initiation but not continuation
MEC cat 4 for LNG IUD (1)
Current breast cancer within past 5 years
MEC cat 3 for ALL IUDs (4)
(1) High likelihood of exposure to GC/CT - initiation but not continuation
(2) AIDs, unless clinically well on antiretrovirals - initiation but not continuation
(3) solid organ transplantation with complications - initiation but not continuation
(4) Pelvic tuberculosis - continuation
MEC cat 3 for LNG IUD (4)
(1) Ischemic heart disease occurring after insertion
(2) History of breast cancer with no evidence of disease for 5 years
(3) Severe cirrhosis, benign hepatocellular adenoma, malignant hepatoma
(4) SLE with positive or unknown antiphospholipid antibodies
MEC cat 3 for copper IUD (1)
(1) SLE with severe thrombocytopenia - initiation of copper IUD
Back-up method after insertion of LNG-IUD?
yes: 7 days
Back-up method after insertion of copper IUD?
NO
MOA of the Implant:
Suppresses LH –> inhibits ovulation in most users
produces atrophic endometrium
thickens cervical mucus
MEC cat 4 for implant (1)
Breast cancer within past 5 years
MEC cat 3 for implant (5)
(1) Ischemic heart disease or stroke occurring while using method
(2) Unexplained vaginal bleeding before evaluation
(3) History of breast cancer with no evidence of disease in past 5 years
(4) Severe cirrhosis, benign hepatocellular adenoma, malignant hepatoma
(5) SLE with positive or unknown antiphospholipid antibodies
IMPLANT: need back-up method of birth control?
If inserted on day 1-5 of menses - no backup
If inserted any other time - 7 day back up
COCPs MOA
Progesterone has the most contraceptive effect: inhibits ovulation through the suppression of LH surge, inhibits sperm penetration by thickening of cervical mucus
Estrogen: inhibits ovulation through suppression of FSH, potentiates action of progestin, stabilizes endometrium for less unscheduled bleeding and spotting
First generation progesterone
norethindrone, northindrone acetate, ethynodiol diacetate
- lowest potency
-short half life
-lower doses more likely to have unscheduled bleeding and spotting
Second generation progesterone
norgestrel, levonorgestrel
- more potent and longer half-life
- designed to have less unscheduled bleeding and spotting
- associated with more androgen-related SEs
Third generation progesterone
desogestrel, norgestimate
-designed to maintain potency of second generation but with fewer androgenic SEs
Fourth generation
Drospirenone - analogue of spironolactone, a potassium sparing diuretic
- progestogenic effect
- antiandrogenic properties
- Yaz, Slynd
- early studies found increased risk for VTE, later studies did not find this –> little to no increased risk compared to other progestins
Dienogest: no potasssium-sparing efffect, testosterone derrivative
Mec category 4 for CHC (16)
(1) Smoker 35 years or older, 15 or more cigs/day
(2) Multiple risk factors for arterial cardiovascular dz
(3) Hypertension (160/100) or hypertension with vascular disease
(4) Acute DVT or PE
(5) History of DVT or PE and 1 or more risk factor for recurrence
(6) Major surgery with prolonged immobilization
(7) known thrombogenic mutations
(8) hx or current ischemic heart disease, stroke or complicated valvular heart disease
(9) Migraine with aura at any age
(10) breast cancer within past 5 years
(11) DM with nephropathy, retinopathy, neuropathy, other vascular disease; DM longer than 20 years
(12) Active viral hepatitis, severe cirrhosis, hepatocellular ademona, malignant hepatoma
(13) SLE with positive or unknown antiphospholipid antibodies
(14) peripartum cardiomyopathy - moderately or severely impaired cardiac function or less than 6 months postpartum
(15) Solid organ transplantation with complications
(16) less than 21 days postpartum (breastfeeding and nonbreastfeeding)
MEC category 3 for CHC (13)
(1) 21-42 days pp, non-breastfeeding with other risk factors for VTE
(2) 21 to < 30 days pp, breastfeeding, with or without other risk factors for VTE
(3) 30-42 days pp, breastfeeding with other risk factors for VTE
(4) Smoker35 years or older, fewer than 15 cigs/day
(5) HTN - adequately controlled or less than 160/100 (140-159/90-99)
(6) known hyperlipidemia - consider type, severity and other cardiovascular risk factors
(7) history of breast cancer with no evidence of disease for the past 5 years
(8) Symptomatic gallbladder disease, history of cholestasis related to past COC use
(9) mild cirrhosis
(10) history of bariatric surgery with malabsorptive procedure (like gastric bypass)
(11) History of DVT or PE with no risk factors for recurrence
(12) peripartum cardiomyopathy with normal or mildly impaired cardiac function and 6 or more months post partum
(13) moderate or severe IBS with associated risks for DVT or PE
COCs may potentiate the action of other drugs`
benzos
tricyclic antidepressants
theophylline
What drugs are potassium sparing that can interact with drospirenone-containing COCs that may cause hyperkalemia?
ACE-I
angiotensin II antagonists
potassium-sparing diuretics (spironolactone)
heparin
aldosterone antagonists
chronic daily NSAID use
If taking these meds check potassium levels after first cycle of COC
Back up method needed with COCPs?
Quick start - yes for 7 days
first day of menses - no back up needed
back up if severe vomiting or diarrhea
ACHES
Warning signs:
Abdominal pain (severe)
chest pain (sharp, severe, SOB)
headache (severe, dizziness, unilateral)
Eye problems (scotoma, blurred vision, blind spots)
Severe leg pain (calf or thigh)
What to do if you miss one pill and has been < 48 hours since a pill should have been taken?
Take missed pill ASAP and then take usual pill at same time (may take 2 pills in one day)
No additional contraceptive protection needed
EC is not usually needed, but can be considered (no ella) if hormonal pills were missed earlier in the cycle or in the last week of the previous cycle
If 2 or more consecutive hormonal pills have been missed (=/> 48 hours since a pill should have been taken?
Take most recent missed pill ASAP and discard other missed pills
Continue taking remaining pills at usual time (may take 2 in one day)
Need back-up birth control until hormone pills have been taken for 7 consecutive days
IF pills were missed in the last week of hormonal pills (days 15-28):
- omit hormone-free interval by finishing this pack and then skipping placebo and starting new pack ASAP
- If unable to start new pack immediately, use back-up method of BC until 7 consecutive hormone pills are taken from new pack
Consider EC if hormonal pills missed in first week and unprotected sex in previous 5 days; can consider at other times (not ella)
How to take the contraceptive patch
apply patch to skin, 1 new patch each week x 3 weeks, then no patch x 1 week for withdrawal bleed
Is patch effective for women 90 kg (198 lbs) or more?
yes, but efficacy may be reduced
Back-up method with patch or ring?
Quick start - 7 days
start on 1st day of menses - no back up needed
How to use the ring?
place in vagina x 3 weeks, followed by 1 week without the ring for withdrawal
What to do if patch falls off or delay application of new patch < 48 hours?
Apply new patch ASAP (if old patch has been detached for < 24 hours can try to reapply same patch, can do new too)
Keep same patch change day
No additional protection needed
EC is not usually needed but can be considered if delayed application or detachment occurred earlier in the cycle in the last week of the previous cycle (Not ella)
What to do if patch falls off or delay in application for >/= 48 hours?
Apply new patch ASAP
keep same patch change day
use back up BC until patch has been applied x 7 days
If error occurred in 3rd week - omit the hormone-free week by finishing the 3rd week (keeping same patch change day) and start new patch ASAP
If unable to start new patch ASAP, back up BC until new patch for 7 days
EC (not ella) if delayed application occurred within first patch week and sex in previous 5 days –> can consider other times as well
What to do if delayed insertion of a new ring or reinsertion of current ring for < 48 hours since ring should have been inserted?
Put the new ring in ASAP
keep ring in until scheduled removal day
No additional BC/backup needed
ED is not usually needed but can be considered (no ella) if delayed insertion or reinsertion occurred earlier in the cycle or in last week of previous cycle
What to do if delayed insertion of new ring or delayed reinsertion of current ring for >/= 48 hours?
Insert ring ASAP
keep ring in until scheduled removal day
use back up BC until ring is worn x 7 cont days
If ring removal occurred in 3rd weeK: omit hormone free week by finishing the 3rd week of ring use and start new ring immediately –> if unable to start new ring immediately, use back up BC until ring is worn x 7 cont days
EC considered if delay is in 1st week and unprotected sex in previous 5 days (not ella), can be considered in other instances as well.
POP MOA
thickens cervical mucus
produces atrophic endometrium
Inhibits ovulation - inconsistent/variable
POP MEC cat 4 (1)
breast cancer within past 5 years
POP MEC cat 3 (6)
(1) hx of breast cancer with no evidence of disease in past 5 years
(2) severe cirrhosis, benign hepatocellular adenoma, malignant hepatoma
(3) hx of bariatric surgery with malabsorptive procedure (gastric bypass)
(4) SLE and positive or unknown antiphospholipid antibodies
(5)taking ritonavir-boosted protease inhibitors as part of HIV/AIDs tx, some anticonvulsants, rifampin or rifabutin
Back up method with POP
Quick start: back up for 48 hours if > 5 days since LMP
1st pill on first day of menses - no back up needed
IF more than 3 hours late taking pill, use back up for 48 hours
Depo MOA
inhibits ovulation through suppression of FSH and LH
produces atrophic endometrium
thickens cervical mucus
MEC cat 4 for depo (1)
Breast cancer within past 5 years
MEC cat 3 for depo (10)
(1) multiple risk factors for arterial CVD
(2) HTN (160/100) with vascular dz
(3) current/history of ischemic heart disease or stroke
(4) hx of breast cancer with no evidence of disease for 5 years
(5) unexplained vaginal bleeding prior to evaluation
(6) DM with nephropathy, retinopathy, neuropathy, other vascular dz; DM longer than 20 years
(7) severe cirrhosis, benign hepatocellular adenoma, malignant hepatoma
(8) SLE with positive or unknown antiphospholipid antibodies
(9) SLE with severe thrombocytopenia - initiation cat 3, cont cat 2
(10) RA or long-term corticosteroid therapy with history of or risk factors for nontraumatic fractures
Do you need back up with depo?
Quick start x 7 days
first day of LMP, no back up method needed
What to do if late for depo injection?
Need to return q 3 months for injection
Contraceptive efficacy maintained for at least 14 weeks after injection
Can be given up to 2 weeks late (15 weeks from last injection) without needing additional contraceptive protection
If > 2 weeks late (more than 15 weeks from last injection) give injection if reasonable certain patient is NOT pregnant; use back up method x 7 days after injection
Consider use of EC (not ella)
MEC: Adequately controlled HTN
CHC - 3
MEC: BP 140-159/90-99
CHC - 3
MEC: BP >/= 160/100
CHC - 4
DEPO- 3
MEC: Vascular disease
CHC-4
DEPO - 3
MEC: Current and/or history of ischemic heart disease
LNG-IUD - 3 for continuation
Implant - 3 for continuation
Depo - 3
POP - 3 for continuation
CHC - 4
MEC: Known thrombogenic mutations (increased clotting)
CHC -4
MEC: liver tumors: hepatocellular adenoma (begnin), malignant tumor (hepatoma)
CHC - 4
LNG-IUD, Implant, depo, POP - 4
MEC: multiple risk factors for atherosclerotic CVD: older age, smoing, DM, HRN, low HDL, high LDL, or high triglycerides
Depo-3
CHC- 3/4
MEC: Current PID
Cu-IUD - 4 for initiation
LNG-IUD - 4 for initiation
MEC: Peripartum cardiomyopathy - normal or mildly impaired cardiac function for < 6 months
< 6 months: CHC - 4
>/= 6 months: CHC - 4
MEC: Peripartum caridomyopathy with moderately or severely impaired cardiac function
CHC-4
MEC: Immediate postseptic abortion
Copper IUD -4
LNG IUD - 4
MEC: < 21 days postpartum
CHC-4
MEC: 21-42 days pp with risk factors for VTE
CHC - 3
CHC is 2 for no VTE risk factors - it is at level 1 42 days (6 weeks) pp
MEC: Postpartum sepsis
Cu IUD - 4
LNG IUD - 4
MEC: Pregnancy
Cu IUD - 4
LNG IUD - 4
MEC: RA on immunosuppressive therapy
Depo - 3
MEC: Current purulent cervicitis or chlamydial infection
Cu-IUD - 4
LNG-IUD - 4
MEC: Smoking and 35+, < 15 cigs/day
CHC - 3
MEC: Smoking and 35+, >/= 15 cigs/day
CHC - 4
MEC: < 35 and smoking
CHC - 2!
MEC: Complicated solid organ transplant
Cu-IUD - initiation 3
LNG-IUD - initiation 3
CHC - 4
MEC: History of CVA (stroke)
Implant: 3 for continuation, 2 for initiation
Depo - 3
POP - 3 for continuation, 2 for initiation
CHC - 4
MEC: Superficial venous thrombosis (acute or history)
CHC -3
NOTE: varicose veins are level 1 for all
MEC: Systemic Lupus Erythematosus with positive or unkown phospholipid antibodies
LNG IUD: 3
Implant: 3
Depo: 3
POP: 3
CHC: 4
MEC: SLE with severe thrombocytopenia
Cu-IUD: 3
Depo: 3
MEC: Pelvic TB
Cu-IUD: 4 for I, 3 for C
LNG-IUD: 4 for I, 3 FOR C
MEC: Unexplained vaginal bleeding (suspicious for condition) prior to eval
Cu-IUD: 4 for I
LNG IUD: 4 for I
Implant: 3
Depo 3
MEC: Complicated valvular heart disease
CHC - 4
MEC: Acute viral hepatitis or viral hepatitis flare
CHC: 4 for initiation
Drug interactions: Antiretrovirals: Fosamprenavir (FPV)
CHC -3
Anticonvulsant therapy: phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine
POP-3
CHC-3
Anticonvulsant therapy: lamotrigine
CHC - 3
Antimicrobial therapy: rigampin or rifabutin therapy
CHC - 3
POP - 3
ALL OTHER abx, antifungals, antiparasitics are OK!
MEC: distorted uterine cavity
cu IUD: 3
LNG IUD: 3
MEC: Current breast cancer, breast cancer in the last 5 years
LNG IUD 4
Implant: 4
Depo: 4
POP: 4
CHC:4
MEC: Past breast cancer with no evidence of current disease
LNG IUD - 3
Impant: 3
Depo: 3
POP: 3
CHC: 3
MEC: Breastfeeding < 21 days pp
CHC 4
MEC: Breastfeeding 21 to < 30 days pp with or without risk factors for VTE
CHC 3
MEC: Breastfeeding 30-42 days pp with other risk factors for VTE
CHC 3
MEC: cervical cancer awaiting treatment
Cu-IUD: 4 for initiation
LNG- IUD: 4 for initiation
MEC: Severe cirrhosis
CHC 4
LNG IUD: 3
Implant: 3
Depo: 3
POP: 3
MEC: History of DVT/PE NOT getting anticoag therapy with high risk for recurrent DVT/PE
CHC: 4
MEC: History of DVT/PE NOT getting anticoag therapy with LOW risk for recurrent DVT/PE
CHC: 3
MEC: Acute DVT or PE
CHC: 4
MEC: DVT/PE and established anticoagulant therapy for at least 3 months with high risk for recurrent DVT/PE
CHC: 4
MEC: DVT/PE and established anticoagulant therapy for at least 3 months with low risk for recurrentl DVT/PE
CHC 3
MEC: Major surgery with prolonged immobilization
CHC: 4
MEC: DM with nephropathy/retinophathy/neuropathy or other vascular disease OR DM > 20 years
Depo: 3
CHC: 4
MEC endometrial cancer
Cu IUD: 4 for I
LNG IUD: 4 for I
MEC: symptomatic call bladder disease both current and medically treated
CHC: 3
MEC: Gestational trophoblastic disease persistently elevated bHCG levels or malignant disease with evidence or suspicion of INTRAUTERINE DISEASE
Cu-IUD: 4 for I
LNG IUD: 4 for I
MEC: Migraine with AURA
CHC: 4
MEC: History of bariatric surgery - Malabsorptive procedures like gastric bypass
POP: 3
COCP: 3
CHC patch/ring: 1
Restrictive procedures like a sleeve are 1 for all
MEC History of cholestasis past COC related (NOT pregnancy)
CHC: 3
Hx of pregnancy related cholestasis is a 2
