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PR3152 Immune and Endocrine (NUS Pharmacy) > IC16 Contraception > Flashcards

IC16 Contraception Flashcards

1
Q

What are the methods of barrier techniques, their absolute contraindications, advantages and disadvantages?

A

1) Condoms (Male | Female)
- CI: Allergy - latex, rubber | polyurethane, TSS
- Advantage - STD protection
- Disadvantage - User failure

2) Covers the cervix (Diaphragm with spermicide, cervical cap)
- CI: Allergy to latex, rubber, spermicide, recurrent UTI, TSS, abnormal anatomy
- Advantage - Reusable
- Disadvantage - Cervical irritation, low STD protection, UTI risk

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2
Q

What are the other health benefits of hormonal contraception?

A
  1. Menstrual cycle regularity
  2. Manage perimenopause
  3. Manage polycystic ovary syndrome
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3
Q

What is the MOA of Combined Oral Contraceptives?

A

Progestin - Provide most effect
(1) Cervical mucus thickening - Prevent sperm penetration and slow tubal motility
(2) Induce endometrial atrophy - More unfriendly for implantation
(3) Prevent ovulation - Block LH surge

Estrogen - Stabilize the endometrial lining & provide cycle control
- Prevent ovulation - Suppress FSH

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4
Q

Why is the lower dose estrogenic component (ethinyl estradiol) used by default?

A

High dose is associated with vascular, embolic events, cancer, significant ADR
- Ischemic stroke / MI
- Breast cancer
- Venous thromboembolism

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5
Q

When is a higher dose estrogenic component favored?

A
  • Obesity or weight > 70.5 kg
  • Early to mid cycle breakthrough bleeding/spotting (Random bleed)
  • Tendency to be non-adherent
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6
Q

What is an advantage of fourth generation progestins over the 1st-3rd generations?

A

Anti-androgenic

Drospirenone - Less water retention, less acne

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7
Q

What to take as caution for 4th generation progestin?

A

Drospirenone - Hyperkalemia, thromboembolism (clots), bone loss

Cyproterone - Not to be used solely for contraception as a primary indication, should also treat excessive androgen related conditions like severe acne and hirsutism; also have high thromboembolism risk

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8
Q

When do we need a higher progestational activity?

A

Rarely…
* Late cycle breakthrough bleeding
* Painful menstrual cramps

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9
Q

What are the 2 types of COC based on differences in estrogen and progesterone content? What are their advantages over each other?

A

Monophasic - Same amount of estrogen and progesterone in each pill

Multiphasic - Variable amounts of estrogen and progestin depending on which day, to mimic physiological conditions

Monophasic is less complicated if there is missed dose but multiphasic tend to have lower progestin and thus less side effects

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10
Q

What are the 3 types of COC based on cycle?

A

Conventional cycle
- 21 days (active pill) + 7 days (placebo)
- Newer: 24 days (active) + 4 days (placebo)

Extended cycle (Lesser periods, q3 mths)
- 84 days (active pill) + 7 days placebo

Continuous cycle (No periods)
- No placebo at all

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11
Q

What happens after the first 2 days of placebo COC?

A

Periods get triggered

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12
Q

Why do newer formulations of conventional cycle COC reduce the days of placebo?

A

To shorten the pill free interval to reduce hormone fluctuations between cycles leading to less side effects

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13
Q

What 3 ways can you start your COC?

A

First day method (1st day of menstrual cycle)
- No backup contraceptive needed (By the time the period ends, the patient would already have taken 5-6 active pills)

Sunday start (1st sunday after menstrual cycle start)
- Need backup contraceptive for at least 7 days
- Weekend free of menstrual period

Quick start (Now)
- Need backup contraceptive for at least 7 days and potentially until next menstrual cycle begins

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14
Q

What factors affect selection of COC?

A
  1. Hormone content required (Estrogen & progestin dose - Weight and bleeding)
  2. Convenience (Extended/Continuous)
  3. Adherence (Monophasic)
  4. Tendency for oily skin, acne, hirsutism
  5. Medical conditions (PMS, dysmenorrhea) with bad cramping (Higher doses of progestin or extended/24 day pill to keep the hormone free period shorter)
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15
Q

What are some benefits of COC that are not contraceptive?

A
  • Relief from menstrual related problems
  • Improvement in menstrual regularity
  • Better for Acne
  • Premenstrual dysphoric disorder
  • Iron-deficient anemia
  • Polycystic ovary syndrome (PCOS)
  • Reduced risk from ovarian & endometrial cancers
  • Reduced risk of ovarian cysts, ectopic pregnancy, pelvic inflammatory diseases, endometriosis, uterine fibroids, benign breast disease
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16
Q

COC has breast cancer risk. But what is the bottom line for use? Who can use and who should avoid?

A
  • Healthy & young = benefit > risk
  • Age > 40 = avoid
  • Family history/ risk factors of breast CA = avoid
  • Current/ recent PMH of breast CA (within 5 years) = STOP
17
Q

What components in COC cause venous thromboembolism and how?

A
  • Estrogens increase hepatic production of factor VII, factor X and fibrinogen of coagulation cascade
  • New generation progestins (esp Drospirenone, Cyproterone & Desogestrel) -> unknown MOA
18
Q

What are the risk factors of VTE? How do they contribute?

A
  • > 35 yo
  • Obesity
  • Smoker
  • Family Hx of VTE
  • Immobilization
  • Cancer
19
Q

What components in COC cause Ischemic stroke or MI?

What is the bottom line for use of COC in this regard?

What are the risk factors synergistic with COC?

A

Estrogen > Progestins

  • Migraine with aura -> absolute contraindication to all COC -> progestin-only/ barrier instead
  • Rest are risk factors to which to consider low dose estrogen/ progestin-only / barrier instead

Risk factors such as age, hypertension, migraine headache with aura, obesity, dyslipidemia, smoking, and prothrombotic mutations

20
Q

What are 12 absolute contraindications for use of COC?

A
  • Current breast CA/ recent history of breast CA within 5 years
  • Hx of DVT/PE, acute DVT/PE and pts with DVT/PE and on anticoagulant therapy
  • Major surgery with prolonged immobilization
  • < 21 days postpartum
  • Thrombogenic mutations
  • Migraine with aura
  • SBP > 160mmHg / DBP > 100mmHg
  • HTN with vascular disease
  • Current/History of ischemia heart disease
  • Cardiomyopathy
  • Smoking ≥ 15 sticks/day AND age ≥ 35yo
  • History of cerebrovascular disease
21
Q

When do ADRs of COC tend to occur? What counseling point to take note?

A

During early COC use, may improve by 3rd-4th cycle after adjusting to hormone levels

Encourage to persevere for 2-3 months before changing the product because side effects should go away unless it is seriou (VTE, MI, migraine with aura, stroke)

22
Q

What are 7 ADRs of COC? What steps to do to alleviate ADRs?

A

Breakthrough bleeding:
- If early/mid cycle -> increase estrogen
- If late cycle -> increase progestin

Acne:
- Change to less androgenic progestin
- Can consider increase estrogen. If on progesterone only pills (POP), change to COC

Bloating:
- Reduce estrogen
- Change to progestin with mild diuretic effect (Drospirenone)

Nausea/Vomiting:
- Reduce estrogen
- Take pills at night / change to POP

Headache:
- Exclude migraine with aura first!
- Usually occurs in pill-free week -> switch to extended cycle/continuous/shorter pill-free interval

Menstrual cramps:
- Increase progestin / switch to extended cycle or continuous

Breast tenderness/weight gain:
- Keep both estrogen/progestin as low dose as possible

23
Q

Which drugs have interactions with COC and how?

A

Rifampin
* Theoretical interaction with antibiotics as alter gut flora, alter metabolism, less active drug.
* Use additional contraception till rifampin discontinued for at least 7 days.
* Some providers might still recommend additional contraception when on antibiotics in general

Anticonvulsants
* Reduces free serum concentrations of both estrogens and progestin
* Phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine, lamotrigine

HIV antiretrovirals
* Reduces both effectiveness of COC & antiretrovirals
* Protease inhibitor like ritonavir, darunavir

24
Q

What should you do if you missed one dose of COC less than 48h?

A
  • Take the missed dose immediately and continue the rest as usual
  • This may mean 2 pills on the same day
  • No additional contraceptive methods required
25
Q

What should you do if you missed two or more doses of COC more than 48h?

A
  • Take the missed dose immediately and discard the rest of the missed doses
  • Continue the rest as usual (may have 2 pills on the same day)
  • Backup contraceptive required for at least 1 week
26
Q

What should you do if you missed pills during the last week of hormonal tablets (Day 15-21)?

A
  • Finish the remaining active pills in the current pack
  • SKIP the hormone-free interval and start a new pack the next day
  • Backup contraceptive for at least 7 days
27
Q

When is POP good to use?

A

Breast feeding, intolerant to estrogen (eg N/V), conditions that preclude estrogen

28
Q

When is POP truly contraindicated?

A

Current or recent history of breast cancer

29
Q

When to initiate and duration of POP?

A

Norethisterone - 28 active pills (continuous)

Initiation:
- Within 5 days of menstrual cycle/bleeding (No need back up)
- Any other day (Need 2 day back up)

Missed dose:
- Late by > 3h needs 2 day backup

30
Q

What other hormonal contraceptive options are there besides oral formulation? How about their efficacy and safety?

A

COCs:
1. Transdermal - Not effective in weight > 90 kg
- Once weekly: 3 wk active, 1 wk free

  1. Vaginal ring - Precise placement is not an issue compared to diaphragm and cervical caps

Both patch and rings have higher continuous estrogen exposure, increasing the VTE risk

Progestin Injection (DMPA) IM q12wks
- Adherence is good but need regular doctor visit
- Delayed return to fertility
- Variable breakthrough bleeding in the 1st nine months
- Weight gain
- Short term bone loss (Bone mineral density)

31
Q

What are long acting reversible contraception and their examples?

A

Category of hormonal and non-hormonal contraceptive (Invasive method)

Intrauterine Devices (IUD)
- Levonorgestrel IUD (Progestin)
- Copper IUD (No progestin)

Subdermal progestin implants (4cm, contain etonogestrel)

32
Q

What is the MOA of IUDs?

A

Inhibition of sperm migration, damage ovum, damage/disrupt transport of fertilized ovum.

If with progestin -> endometrial suppression, thicken mucus

33
Q

When should IUDs not be inserted?

A

Pregnant, current STI, undiagnosed vaginal bleeding, malignancy of genital tract, uterine anomalies or uterine fibroids

PR3152 Immune and Endocrine (NUS Pharmacy) (10 decks)

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