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Clinical Pharmacy > Hormonal Contraception > Flashcards

Hormonal Contraception Flashcards

1
Q

What is menarche?

A

the first menstrual cycle - generally happens around 12 years of age

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2
Q

What is menses?

A

the sloughing of the endometrial cells- otherwise known as a period

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3
Q

What is the general length of the menstrual cycle?

A

about 28 dyas

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4
Q

What is menopause?

A

the cessation of the menstrual cycle - a year without the menstrual cycle is when you say that menopause has happened

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5
Q

Menstrual cycles all begin in the _______

A

hypothalamus

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6
Q

In the pulsatile factor, the hypothalamus secretes ____

A

GnRH

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7
Q

GnRH stimulates the anterior pituitary to release _____ or ____

A

FSH or LH

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8
Q

What is the action of the follicle stimulating hormones?

A

stimulates the follicle and this acts in the ovary to recruit follicles

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9
Q

How many follicles are stimulated in each menstrual cycle?

A

several

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10
Q

What happens around day of 5-7 of the menstrual cycle?

A

there is a dominant follicle that forms

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11
Q

What happens when the dominant follicle forms?

A

this means that ovulation will happen in the cycle

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12
Q

The follicle attracts all of the ___ and this is the primary follicle that forms

A

FSH

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13
Q

There is a surge of ____ that occurs 24-36 hours proper to the dominant follicle going through ovulation. There is ovulation once the LH is stimulated

A

LH

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14
Q

What does the follicle become after it is stimulated?

A

oocyte

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15
Q

What happens to the rest of the dominant follicle after ovulation occurs?

A

it forms the corpus luteum

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16
Q

What does the corpus luteum do?

A

this stimulates hormones. and allows the release of estrogen and progesterone

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17
Q

What is day 1 of the menstrual cycle?

A

first day of menses

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18
Q

What hormone is considered the builder of the uterine lining?

A

estrogen - it builds the endometrium lining

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19
Q

Estrogen and progesterone go via negative feedback to stop the production of ____

A

GnRH

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20
Q

What hormone comes in to stop the estrogen from building and building on itself - it makes it more conformable to form?

A

Progesterone

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21
Q

Day 1-14 is what phase?

A

follicular phase

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22
Q

Day 14-28 is what phase?

A

luteal phase

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23
Q

At day 28, what causes the menstrual cycle to form?

A

a fall in the estrogen and progesterone levels

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24
Q

If we count back _____ after the first day of menses, then we know that ovulation occurred

A

14 days

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25
Q

What phase of the cycle is the variable one?

A

the follicular phase

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26
Q

What is the luteal phase based on?

A

the corpus luteum

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27
Q

What is the follicular phase based on?

A

the follicular phase can vary in the amount of GnRH it takes to stimulate the anterior pituitary to release hormones

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28
Q

What is there a spike in in ovulation?

A

body temperature

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29
Q

What is the mechanism of action of oral contraceptives?

A
  1. estrogen and progesterone provide negative feedback mechanism on the hypothalamus
    - suppresses pituitary gonadotropin
    - alters the normal pattern of gonadotropin secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH) by the anterior pituitary
    - midcycle FSH LH surge stop… thereby inhibiting ovulation
  2. creates endometrium that is unreceptive to implantation
  3. production of viscous cervical mucous
  4. possible effect on set secretion and peristalsis in fallopian tubes
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30
Q

What happens when there is a higher level of progesterone given in an OC?

A
  • the estrogen never has time to work on its own and build up the thickness of the uterine wall - this means that the wall of the uterus will be thing. The thinner the wall there is the more hostile the environment for the egg to implant, if one did get released
  • progesterone also thickens the mucous of the cervix- the plug at the cervix can become very thick, preventing the sperm from travelling up the cervix
  • may also have an effect in the secretion process of the fallopian tubes through the peristaltic process. The hormonal contraceptive decreases the peristalsis, meaning that it will not meet tup with the sperm before the lifecycle ends
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31
Q

Most estrogen in birth control is usually what?

A

ethinyl estradiol

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32
Q

What is the highest dose of estrogen that women should be on?

A

35 mcg

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33
Q

How many generations of progesterones are there?

A

3 plus a new one

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34
Q

What is first generation progesterone?

A

binds to estrogen, progesterone and androgen receptors

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35
Q

What is second generation progesterone?

A

more potent than first generation, may be better tolerated

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36
Q

What is third generation progesterone?

A

developed to have fewer androgenic effects

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37
Q

What are the newer progesterones considered to be?

A
  • considered to have anti androgenic effects
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38
Q

What are the different androgenic effects of progesterone?

A
  • newer (norgestimate=desogetrel) have minimal androgenic activity
  • older (norgestrel>levonorgestrel>norethindrone) kinds with some androgenic activity
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39
Q

What are the different progestagenic activity effects of progesterone?

A
  • desogestel, levonorgestrel, norgestrel are the most potent

- norethindrone is the least potent

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40
Q

What are the different actions of Yaz? What is it related to?

A
  • Yaz is a derivative of spironolactone
  • it is progestagenic, antiandrogenic, antimineralocorticoid
  • this may be good for PCOS
  • need to watch for K, therefore there are potential risks
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41
Q

What are the advantages of using Yaz?

A
  • less weight gain, useful as an OC, for acne and PMDD
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42
Q

What are the advantages and actions of diane-35?

A
  • cyproterone (anti-androgenic). Indicated for temporary treatment of severe acne. Not to be used in a patient with a history that puts them at risk for blood clots
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43
Q

What are the differences in monophasic, biphasic and triphasic OC pills?

A
  • mono: fixed amount of estrogen and progestin (Alesse, marvelon)
  • bi: 2 phases of progestin
  • tri: 3 phases of progestin (tricyclic)
    • for all of these, estrogen levels are the same throughout**
44
Q

What are the different examples of extended cycles of OC pills?

A

24/26 day cycle (Lolo)

- 84 day cycle (Seasonale, Seasonique)

45
Q

What is the recommendation for OC pills to start off on?

A
  • to use one containing 20 mg of ethinyl estradiol and an older progestin (levonorgestrel or norethindrone)
46
Q

What is the main difference between seasonale and seasonique?

A
  • seasonal (cycle is 84 days, followed by 7 days of sugar pills)
  • seasonique (cycle is 84 days of combined contraception followed by 7 days of low dose estrogen
47
Q

Why can you get breakthrough bleeding when you use two months of hormone containing pills back to back? (biphasic or triphasic)

A

you can get breakthrough bleeding - the drop in progesterone between weeks 3 and week 1 can cause a bit of breakthrough bleeding

48
Q

When starting OC, backup contraception should be used for the first ____ days of OC use when a method is initiated, unless it is on the first day of menses

A

seven

49
Q

When starting a pack of OC on the first day of menses, what happens?

A

there is no need for back up- contraceptive action starts right away

50
Q

To avoid weekend periods, you ned to start on the _______ after the period starts

A

1st sunday

51
Q

What are some absolute contraindications for using BC?

A
  • breastfeeding
  • increased breast cancer
  • increased BVT (blood clots)
  • can cause an increase in hypertension
  • can put you at an increased risk of MI or stroke if you have migraines with an aura at any age
  • should not be used with a bp over 160/100
  • any liver impairment
  • a history of an MI
  • patients that smoke more than 15 cigarettes a day and are over 35- increases the risk of a clot forming
  • if there is a major surgery with prolonged immobilizing
52
Q

What are the conditions that are cautioned, in which the risks could potentially outweigh the benefits?

A
  • first 6 weeks post-pardum
  • if there is a history of a DVT or a pulmonary embolism
  • past breast cancer
  • migraine without an aura over the age of 35
  • hypertension
  • smoking less than 15 cigarettes over the age of 35
53
Q

What are some of the benefits of using a combined oral hormonal contraceptive?

A
  • relief from menstrual issues
    • decreased menstrual cramps, ovulatory paon, menstrual blood loss (decreased iron deficiency anemia)
  • menstrual regularity
  • decreased acne and hirsutism
  • reduced risk of ovarian and endometrial cancer
  • bone density benefits (estrogen)
54
Q

What should be considered in women with a high risk of cardiovascular disease?

A
  • non-estrogen contraceptives (there used to be safety concerns surrounding heart attack and stroke in estrogen levels above 50 mcg)
55
Q

What is the risk of thromboembolism in patients? What is this due to?

A
  • is it s risk due to both estrogen and progesterone
  • risk of venous thromboembolism such as: DVT and PE
    • non-uses: 2 to 3 per 10,000 women per year
    • low dose older agents: 6 per 10,000 women per year
    • pregnancy: 17 per 10,000 per year
  • recommend other contraceptives in women at high risk of DVT/PE (>35 years old and smoker, history of clots)
  • educate all women of risk and to watch for signs and symptoms: leg pain or swollen, severe chest pain or shortness of breath
56
Q

What are the oral contraceptives early signs of danger? (ACHES)

A

A: Abdominal pain that is severe: can be gallbladder disease, pancreatitis
C: Chest pain: pulmonary embolism or acute MI
H: Headaches: stroke, hypertension, migraine
E: Eye problems (blurred vision, flashing lights, blindness): stroke, hypertension, vascular insufficiency
S: Severe leg pain: deep vein thrombosis

57
Q

What are some common problems faced with too much estrogen?

A
  • PMS like symptoms: nauseas, bloating, breast tenderness, melanoma, irritability, headache (cyclic) and weight gain (cyclic)
58
Q

What are the common problems faced with too little estrogen?

A
  • early or mid-cycle spotting (early cycle BTB), hypomenorrhea, vasomotor symptoms, headaches, depression, nervousness
59
Q

What are the common problems faced with too much progestin?

A
  • breast tenderness, headache, fatigue, changes in mood, increased appetite and weight gain (noncyclic), decreased libido
60
Q

What are the common problems faced with too little progestin?

A
  • late breakthrough bleeding (late cycle BTB), dysmenorrhea, heavy flow
61
Q

What are the common problems associated with too much androgen?

A
  • increased appetite, weight gain (non-cyclic), oily skin/scalp, acne. hirtutism, increased libido, rash, increased LDL
62
Q

What is the common management of breakthrough bleeding?

A
  • may occur during the first three months of use and then resolve. After three months, if it does not resolve need to consider to changing to another OC treatment with increased estrogen and progestin (depending on when the bleeding occurs)
63
Q

What is the common management of breast tenderness?

A

if it continues after the first 3 months, investigate, then consider changing to an option with less estrogen

64
Q

What is the common management of weight gain?

A
  • may increase appetite in the first month, but overall not associated with weight gain
65
Q

What is the common management of nausea with OC pills?

A
  • generally resolves within the first 3 months, may take at bedtime or with food. Can consider to changing to an option with less estrogen
66
Q

What is the common management of headaches associated with OC pills?

A
  • contraceptives should be avoided
67
Q

What is the common management of acne associated with OC pills?

A
  • initially may worsen, but generally there is an improvement with long-term. If not, change to less androgenic progesterone
68
Q

If the hormone free period is longer than 7 days, you should treat it as a _____

A

missed pill

69
Q

What are the acceptable changes in generics that allow for the products to be considered interchangeable?

A

80-125%

70
Q

What are some of the drugs that will decrease the OC effectiveness?

A
  • carbamazepine
  • oxycarbazepine
  • phenytoin
  • primidone
  • phenobarb
  • topiramate
  • rifampin
  • griseofulvin
  • ritonavir
  • St. John’s wort
71
Q

What antibiotic will affect the way that OC pills are metabolized? What should be done?

A
  • penicillin

- recommend to use a back-up contraceptive

72
Q

What are the medicinal ingredients in the era patch?

A
  • norelgestromin 150 mcg and EE 20 mcg daily

it is a metabolite or norgestimate- minimal androgenic activity

73
Q

How should evra patches be used?

A

apply 1 patch weekly for 3 weeks (buttocks, upper outer arm, lower abdomen, upper torso), with 1 patch free week

  • this should be started on the first day of menses
    • never put on breast tissue- there is too much estrogen**
74
Q

The effectiveness of evra may be decreased in women over what weight?

A

90 kg

75
Q

What are the two side effects that are greater in evra patches compared to OC?

A
  • greater spotting, breast tenderness in the first 2 cycles than the OC
    • can use up to 9 patches in a row
76
Q

What are the medicinal ingredients in the nuvaring?

A

120 mcg etonorgestrel and 15 mcg EE

77
Q

When should the nuvaring be started?

A

start on day 1-5 of menses

  • day 1 means that there is no backup needed
  • there may be lower estrogen exposure (therefore, may have less estrogen related SE)
78
Q

There is less ______ than OC in a nuvaring?

A

estrogen exposure - also less irregular bleeding than OC, more vaginal symptoms including vaginitis

79
Q

Can store nuvaring at room temperature for ___ months

A

4

80
Q

What is the benefit go progestin only pills?

A
  • safe in lactation, also used in women with contraindications to estrogen or cannot tolerate it
  • dose is 35 mug of norethindrone daily
  • – there is NO pill free interval
  • – it is very important to take the tablet at the same time each day (within 3 hours)
  • mechanism - increased cervical mucus viscosity and endometrial atrophy, sperm motility is reduced (40% continue to ovulate)
81
Q

What is the hormone that is responsible for thickening the cervical mucous viscosity?

A

progesterone

82
Q

Why does ovulation occur in a progesterone only pill?

A
  • estrogen will not be produced in a level that will block the GnRH
83
Q

More than 3 hours variation in taking the tablet needs to be treated as what?

A
  • the cervical mucous will not be thick enough and is considered a missed pill
    • this is typically used in breastfeeding women - does not have an effect on breast milk
84
Q

What are the main adverse effects of progesterone only pills?

A
  • irregular bleeding, hormonal side effects such as bloating, headache, breast tenderness
85
Q

What should the patient do if they are taking the pill more than 3 hours after the time they are supposed to?

A
  • take the pill ASAP and continue taking the pack
  • backup must be used for 48 hours in all cases and EC may be needed to be considered if there is unprotected intercourse in the last 5 days
86
Q

What is the dose of depo-provera?

A

medroxyprogesterone acetate injection 150 mg IM every 3 months

87
Q

What s the mechanism of medroxyprogesterone acetate?

A

inhibits secretion of gonadotropins, and inhibits ovulation, increases cervical mucous viscosity and endometrial atrophy

88
Q

What natural state does depo-provera replicate?

A

the menopausal state

89
Q

What are the indications of depo-provera?

A

for women that desire 3 months of contraception, have contraindications or intolerance to who may have side effects from estrogen (more than 35, migraine sufferers, smokers, breastfeeding, endometriosis, sickle cell disease, taking anticonvulsants, high risk of stroke)

90
Q

What are the contraindications of depo-provera?

A
  • pregnancy, unexplained vaginal bleeding, current diagnosis of breast cancer, caution with liver disorders
91
Q

What are the benefits of depo-provera?

A

amenorrhea, decreased risk of endometrial cancer, decreased symptoms of endometriosis

92
Q

What are the adverse effects associated with depo-provera?

A
  • menstrual cycle disturbance, hormonal (headaches decreased libido, nausea, breast tenderness), weight gain, decreased mood
  • decreased bone mineral density, which may not be completely reversible. Increased bone mineral density with greater duration of use
93
Q

How long does it take to term to fertility after depo-provera?

A
  • average of 9-12 months, decreased bone mineral density
94
Q

What is a LARC?

A

a long acting reversible contraceptive

95
Q

What is a SARC?

A

a short acting reversible contraceptive

96
Q

What are the 2 kinds of IUS’s

A

copper IUD

levonorgestrel IUS

97
Q

When can IUDs not be used?

A

a current pregnancy, current pelvic inflammatory disease, current STI, undiagnosed abnormal vaginal bleeding, uterine abnormalities

98
Q

What are the risks of IUDs?

A

uterine perforation with insertion of expulsion of the IUS

99
Q

What is the mechanism of action of a copper IUD?

A
  • creates a hostile environment for sperm through an immune response
  • reduces formation of mature eggs
100
Q

What are some of the side effects of a copper IUD?

A
  • increase in menstrual cramping and bleeding
101
Q

How long does the IUS stay in place for?

A

maximum of 30 months

102
Q

What is the mechanism of action of a levonorgestrel IUS?

A
  • creates a hostile environment for sperm
  • reduces formation fo mature eggs
  • has additional mechanism of endometrial suppression and thickening of the cervical mucous (mucous plug)
103
Q

What are the common side effects of the levonorgestrel IUS?

A
  • breast tenderness, headache and acne
104
Q

If the IUS has not been inserted within the first 7 days of menses, what should be recommended?

A
  • use a backup contraception within the first 7 days
105
Q

What is the difference between mirena and jaydess?

A

Mirena is used mostly for women that have had children, while jaydess is commonly used in women that are nulliparous or adolescents

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