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)
