Hormonal Contraceptives

Question 1

Pharmacologic Effects of HCs

Answer 1

• suppress fxn of hypothalamic-pit-ovarian axis- dec secretion of GnRH
• diminish ovarian H prod
• inhibit maturation/release of dominant ovule
• modify mid-cycle surges of LH and FSH
• inc viscosity of cervical mucus to impede sperm transit
• produce endometrial changes unfavorable or ovum implantation

Question 2

Hormonal Contraceptive Choices

Answer 2

• daily use
• non-daily use
• emergency use

Question 3

Hormonal Contraceptive Choices- daily use

Answer 3

oral tablets

• combination (COC)
• progestin-only (POP)
• extended cycle

Question 4

Hormonal Contraceptive Choices- non-daily use

Answer 4

• patch
• vaginal ring
• injectable- LARC (long-acting reversible contraceptive)
• implantable- LARC
• IUS (intrauterine device)- LARC

Question 5

Hormonal Contraceptive Choices- emergency use

Answer 5

-oral tablets- progestin-only

Question 6

estrogens in COCs

Answer 6

• ethinyl estradiol (EE)- most common
• estradiol valerate
• mestranol

Question 7

progestins in COCs

Answer 7

19-Nortestosterone analog
-Estranes
-Gonanes
Spironolactone-analog
-Drospirenone

Question 8

progestins in COCs- 19-Nortestosterone analog

Answer 8

• Estranes- Ethynodiol, Norethindrone

- Gonanes- desogestrel, dienogest, levonorgestrel, norgestrel, norgestimate

Question 9

Phasic Combination of COC’s- monophasic

Answer 9

(H’s taken for 21 days)

-fixed dose of estrogen and progestin thruout cycle

Question 10

Phasic Combination of COC’s- biphasic

Answer 10

• fixed dose of estrogen thruout,
• lower progestin amt in 1st half allowing endometrial prolif, inc amt in 2nd half provides adequate secretory development

Question 11

Phasic Combination of COC’s- triphasic

Answer 11

inc dose of estrogen 3 times during cycle

Question 12

Phasic Combination of COC’s- quadriphasic

Answer 12

dec dose of estrogen and inc dose of progestin 4x during cycle

Question 13

Non-Oral Progestins

Answer 13

-Norelgestromin
-Etonogestrel
-Medroxyprogesterone
-Levonorgestrel
(NEML)

Question 14

Norelgestromin

Answer 14

patch with EE- 7 day duration

Question 15

Etonogestrel

Answer 15

• vaginal ring with EE- 3 wks

- available in progestin-only implantable rods- 3 yrs

Question 16

Medroxyprogesterone

Answer 16

-progestin-only long acting IM or SQ injections- 3 months

Question 17

Levonorgestrel

Answer 17

-progestin-only IUS- 5 yrs or 3 yrs

Question 18

Non-Oral Non-Hormonal

Answer 18

Copper- non-hormonal IUD- 10 yrs

Question 19

Estradiol and progesterone effects- cellular moa impacting SE’s

Answer 19

-bind to Rs in various tissues- transferred into nucleus resulting in gene and protein expression

Question 20

Non-contraceptive effects of estrogens- dec what?

Answer 20

• chol
• osteoclastic activity
• anti-thrombin III
• bile acid levels

Question 21

Non-contraceptive effects of estrogens- inc what?

Answer 21

• triglycerides, HDL-C
• clotting factors
• platelet aggregation
• renin/aldosterone secretion/activity (Na/fluid retention)
• thyroid, corticosteroid, sex-hormone binding globulins
• iron/TIBC, prolactin
• folate metabolism/excretion

Question 22

estrogens- adverse effects

Answer 22

• irregular bleeding
• breast tenderness
• fluid retention (wt gain)
• mood changes
• headaches, GI distress
• hyperkalemia (drospirenone-containing agents)

Question 23

estrogens- serious adverse effects

Answer 23

• systemic thromboembolism
• HTN
• gallbladder dz

Question 24

Non-contraceptive benefits of combination HCs (COCs)

Answer 24

Improvement in H-related events
-irregular menstrual cycles
-dysmenorrhea
-fxnal ovarian cysts
-acne
-anemia
-PMDD
-peri-menopausal sx's
-hirsutism
REduction in some cancers
-ovary, endometrium, colon/rectum
*HCs do NOT prevent/reduce risk of STIs and HIV!!!!!

Question 25

COC- contraindications

Answer 25

• pregnancy or < 21 d postpartum
• vascular-related dz
• valvular HD
• peripartum cardiomyopathy
• rheumatic HD
• hepatic adenoma or malignant hepatoma
• decompensated cirrhosis
• solid organ transplant rejection or organ failure
• major surgery with prolonged immobilization
• uncontrolled severe HTN
• diabetes > 20 yrs with pathy’s
• migraine HA’s with aura
• acute/flare viral hepatitis
• smoking > 15 cigs/day and > 35 yo

Question 26

IUD- contraindications

Answer 26

• pregnancy
• postpartum sepsis
• immediate post-sepsis abortion
• distorted uterine cavity
• unexplained vaginal bleeding
• cervical cancer
• current PID
• pelvic TB
• current purulent cervicitis
• current STI
• gestational trophoblastic dz with persistently elevated B-HCG
• malignant gestational trophoblastic dz with intrauterine dz

Question 27

Drug interactions- inducers

Answer 27

• antimicrobial agents
• antiviral agents
• anti-seizure agents

Question 28

how to be certain a woman is not pregnant

Answer 28

• < 7 days after start of normal menses
• not had sex since start of last normal menses
• uses a method of contraceptive (correctly, consistently)
• <7 days after spontaneous or induced AB
• within 4 wks postpartum
• fully or nearly bresat feeding

Question 29

emergency contraception- can be admin:

Answer 29

• after unprotected intercouse (up to 72 hrs)
• concern of contraceptive failure
• sexual assault/rape
• exposure to teratogens

Question 30

emergency contraception- moa of progestin

Answer 30

(levonorgestrel)

• inhibition of ovulation (primary)!!!
• available in 1 and 2-dose tx’s

Question 31

Levonorgestrel-Only, 2-dose- emergency contraception

Answer 31

Plan B

• first dose- take 1 (0.75 mg) tablet ASAP (within 72 hrs of unprotected sex!!!)
• second dose- take 0.75 mg 12 hrs after 1st dose

Question 32

Levonorgestrel-Only, 1-dose- emergency contraception

Answer 32

take tablet (1.5 mg) ASAP (within 72 hrs!!!)

Question 33

Ulipristal (non-pregestin), 1-dose- emergency contraception

Answer 33

• only dose- take tablet ASAP (within 72 hrs)
• progesterone-R modulator: main action is inhibition of ovulation!!!
• initiation of COC’s after EC: start COC no sooner than 5 days of ulipristal use AND use barrier method until next menstrual cycle