Hormonal contraceptives: Segars Flashcards
1
Q
what are the pharmacologic effects of HCs
A
- suppress function o hypthalamic pituitary ovarian axis; decrease secretion of GnRH
- Diminish ovarian hormone production
- inhibit maturation/release of dominant ovule
- modify mid-cycle surges of LH and FSH
- increase viscosity of cervical mucus to impede sperm transit
- produce endometrial changes unfavorable for ovum implantation
2
Q
What are the 3 broad categories of HCs
A
- Daily use (oral tablets)
- Non Daily use
- emergency use
3
Q
what are the daily oral HC options
A
- Combination (COC)
- Progestin only (POP
- Extended cycle
4
Q
what are the non daily HC options
A
- patch
- Vaginal ring
- Injectable (LARC): long acting reversible contraceptive
- Implantable (LARC)
- IUS/IUD (LARC)
5
Q
what is the emergancy use contraceptive option
A
progestin only oral tablet
6
Q
what are the different estrogen in COCs (comination oral contraceptives)
A
- Ethinyl estradiol (EE): most common; longer half life and more active than estradiol
- Estradiol valerate: synthetic pro-drug of 17-beta estradiol
- Mestranol: gets metabolized to ethinyl estradiol
7
Q
what are the broad different progestins in COCs
A
- 19-Nortestosterone analogs: Estranes and Gonanes
- Spironolactone-analog
8
Q
what are the Estanes in COCs
A
- Ethynodiol
- Norethindrone
9
Q
what are the Gonanes in COCs
A
- Desogestrel
- Dienogest
- Levonorgestrel
- Norgestrel
- Norgestimate
10
Q
what is the spironolactone analog in COCs
A
Drospirenone
11
Q
What progestins have the most progestinic activity
A
- Desogestrel
- Levonorgestrel
12
Q
What progestins have the most estrogenic activity
A
- Ethynodiol (most)
- Norethindrone (2nd)
13
Q
what progestins have the most androgenic activity
A
-Levonorgestrel
14
Q
Describe a monophasic combination of HCs
A
fixed dose of estrogen and progestin throughout cycle
15
Q
describe Biphasic combination of HCs
A
- fixed dose estrogen throughout cycle
- lower progestin amount in 1st half, allowing endometrial proliferation
- increased amount in 2nd half provides adequate secretory development
16
Q
Describe triphasic HCs
A
increasing dose of estrogen (or progestin and estrogen) 3 times during the cycle
17
Q
Describe Quadriphasic HCs
A
-DECREASING dose of estrogen and increasing dose of progestin 4 times during cycle
18
Q
Describe non oral progestin: Norelgestromin
A
- gonane family: “Gest”
- metabolite of norgestimate
- available in PATCH with EE (ethynyl estradiol)
- 7 day duration *****
19
Q
Describe non oral progestin: Etonogestrel
A
- a vaginal ring with EE (3 weeks duration ***)or
- implantable rod with progestin only (3 YEARS duration)**
20
Q
Describe non oral progestin: mydroxyprogesterone
A
- progestin only
- long acting IM injections (3 month duration)
21
Q
Desribe the non oral progestin: Levonorgestrel
A
- Progestin only IUD
- Kyleena adn Mirena (5 years)
- Skyla and Liletta (3 years)
22
Q
what is the non oral non hormonal contraceptive
A
-copper: non hormonal IUD (10 years)
23
Q
what is the long list of non contraceptive effects of estrogens
A
decrease in:
- cholesterol
- Osteoclastic activity
- Anti-thrombin III
- Bile acid levels
increase in:
- Triglycerides and HDL-C
- clotting factors
- platelet aggregation
- renin/aldosterone activity (Na/fluid retnention)
- thyroid, corticosteroid, sex hormone binding globuline
- Iron/TIBC and prolactin
- Folate metabolism/excretion
24
Q
what are common adverse effects of HCs
A
- irregular bleeding
- breast tenderness
- fluid retention (weight gain)
- mood changes
- headache and GI distress
- Hyperkalemia
- Acne/hirsutism/wt. gain: progestinic and androgenic effect . . . so choose a product without these effects
25
Serious adverse effects of HC's
- systemic thromboembolism: MI/Stroke/DVT/PE/intestinal ischemia -> used copper or progestin only product
- HTN
- Gallbladder disease
26
Do HC's prevent or reduce the risk of STIs and HIV
no
27
HCs can improve what hormone related events
- irregular menstrual cycles
- Dysmenorrhea
- Menorrhagia
- Functional ovarian cysts
- Acne
- Anemia
- PMDD
- Peri-menopausal symptoms
- Hirsutism
28
HCs can reduce risk of what cancers
- ovary
- endometrium
- Colon/Rectum
29
what # category of medical eligibility criteria for contraceptive use whould you NOT give therapy
4
30
Contraindications for COC use
- known/suspected pregnancy or <21-d post partum
- vascular related disease
- complications to valvular heart disease
- Peripartum cardiomyopathy
- rheumatic heart disease, especially if + for antiphospholipid antibody
- Hepatic adenoma or malignant hepatoma
- severe decompensated cirrhosis
- acute/chronic solid organ transplant rejection or organ failure
- Major surgery w/ prolonged immobilization
- uncontrolled sever HTN (>160/>100)
- Diabetes > 20 years
- Migraine headaches with aura
- acute/Flare viral hepatitis (initiation of therapy only)
- SMOKING > 15/day in patients > 35 years old . . . ABSOLUTE CONTRAINDICATION
31
contraindication for IUD use
- known/suspected pregnancy
- postpartum sepsis
- immediate post sepsis abortion
- Distorted uterine cavity
- unexplained vaginal bleeding (initiation only)
- Cervical cancer (initiation)
- Current PID (initiation)
- Pelvic TB (initiaion)
- current purulent cervicitis (initiation)
- confirmed gestation trophoblastic disease w/persistently elevated Beta-hCG levels (initiation)
- Malignant gestational trophoblastic disease w/ evidence/suspicion of intrauterine disease (initiation)
32
Drug interactions of HCs
-inducers of CYP3A4: antimicrobials, antivirals, anti seizure
33
Describe the therapeutics of giving HCs
- the timing is not that fast
- need backup contraception while trying to reestablish new levels to blunt LH/FSH
- exam/tests required to initiate therapy
- need follow ups
- 1 year of refills
- manage bleeding irregularities
- management of PID in IUD users
34
How can a health care provider be reasonably certain that a female isn't pregnant and can therefore give HCs
- less than or equal to 7 days after start of normal menses
- no intercourse since start of last menses
- has been correctly and consistently using a reliable method of contraception
- is less than or equal to 7 days after a spontaneous or induced abortion
- is within 4 weeks postpartum
- is fully or nearly fully breastfeeding, amenorrheic, and less than 6 months postpartum
35
most effective form of contraception
-implant then IUD
36
when can you start a patient on contraception
anytime as long as not pregnant
37
Which contraceptive methods do you need to do bimanual exam and cervical inspection prior
- copper IUD
| - Levonorgestrel IUD
38
Which contraceptive method do you need to measure blood pressure prior
combined hormonal contraceptive
39
what backup answer should I never pick on the test
backup for 30 days
40
which contraception method requires ongoing evaluation of BP
combined hormonal contraception . . all others follow ups are not REQUIRED but encouraged
41
what if a patients misses a day or 2 of pills?
-take late or missed pill asap and continue therapy
42
what if a patient goes over 48 hours or misses 2 pills
stop and start over
43
management of PID in IUD and IUS users
- treat the PID
| - don't have to remove the IUD
44
What is the MOA of Progestin emergency contraception
(Levonorgestrel)
| -inhibition of ovulation
45
Describe 2 dose emergency contraception
- first dose within 72 hours
| - 2nd dose 12 hours after first dose
46
Describe 1 dose emergency contraception
-take within 72 hours
47
Describe Ulipristal (non progestin) emergency contraceptionn
- 1 dose
- within 120 hours
- a progesterone receptor modulator
- delays follicular rupture by 5-9 days
48
Describe the initiation of COCs after emergency contraception
-start NO SOONER THAN 5 DAYS of ulipristal use and use barrier method until the next menstrual cycle
