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IC17 Contraceptives Flashcards

1
Q

barrier methods

A
  1. male condom
  2. female condom
  3. diaphragm with spermicides
  4. cervical cap
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2
Q

barrier methods: male condom

c/i, adv & disadv

A
  • Allergy to latex/ rubber
  • STI protection
  • High user failure rate
    Poor acceptance
    Possibility of breakage
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3
Q

barrier methods: female condom

c/i, adv & disadv

A
  • Allergy to polyurethane
    Hx of toxic shock syndrome (HSS) if not removed for long time
  • Can be inserted ahead of time
    STI protection if used correctly
  • Very high user failure rate
    Dislike of ring hanging outside vagina
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4
Q

barrier methods: diaphragm with spermicide & cervivcal cap

c/i, adv & disadv

A
  • Allergy to latex, rubber or spermicide
    Recurrent UTIs
    Spermicide causes disturbance in bacteria within region
    Hx of TSS
    Abnormal gynaecological anatomy
  • Low cost
    reusable
  • High user failure rate
    Low protection against STIs
    Increased risk of UTI
    Cervical irritation
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5
Q

COC: role of hormones

progestin & estrogen

A

Progestin
* Thicken cervical mucus
prevent sperm penetration
slows tubal motility → delay sperm transport
Induce endometrial atrophy → even IF egg is fertilised, cannot be implanted
* Blocks LH surge + (oestrogen) suppresses FSH release ⇒ prevents ovulation
LH → stimulates ovulation; blocking of LH = no egg produced
FSH → stimulates follicle production; blocking = no egg

Oestrogen
Stabilises endometrial lining & provide cycle control

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6
Q

COC: SE of progestin

A

acne, oily skin, hirsutism (growth of hair)

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7
Q

COC: possible benefit of progestin

A

Late cycle breakthrough bleeding → to prevent bleeding at end of cycle
Painful menstrual cramps

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8
Q

COC: types of progestin

A

drosperinone & cyproterone

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9
Q

COC: types of progestin
drospirenone

effect, benefits, SE

A

Analogue of spironolactone
may have diuretic effects; to monitor K+ & fluid status
Lesser water retention

Anti-mineralocorticoid + some anti-androgenic action
Lesser acne; ideal for patients with acne/ oily skin

SE: hyperkalemia, thromboembolism & bone loss

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10
Q

COC: types of progestin
Cyproterone

indication, effects, SE

A

treatment of excessive-androgen related conditions (severe acne, hirsutism)

Have anti-androgenic, antigonadotropic effects

SE: high risk of thromboembolism

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11
Q

COC: estrogen

types & doses

A

Types: Ethinyl estradiol (EE), estradiol valerate, esterol, mestranol

Doses:
High: ≥50 μg
moderate/ standard: 30-35 μg
Low: 15-20 μg

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12
Q

COC: estrogen

problem of high doses

A

associated with vascular, embolic events, cancer & significant AE

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13
Q

COC: estrogen (factors favouring lower dose)

A
  • Adolescence
  • Underweight (<50 kg)
  • Age > 35 years ⇒ higher risk of SE
  • Peri-menopausal
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14
Q

COC: estrogen (factors favouring higher dose)

A

obesity/ weight > 70.5kg
* More production of oestrogen; higher dose required to stimulate -ve feedback loop
* EE highly protein bound & enters fatty tissues → will lower plasma conc of oestrogen

Early to mid-cycle breakthrough bleeding/ spotting
Due to cycle not being fully suppressed

Tendency of non-adherence
Can counteract by increasing dose

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15
Q

COC: Types of COC

A
  1. monophasic
  2. multiphasic
  3. conventional
  4. extended-cycle
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16
Q

COC: Types of COC
monophasic

hormones in pills

A

Same amounts of oestrogen & progestin in every pill
Less confusing, less missed-doses instructions

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17
Q

COC: Types of COC
multiphasic

hormones in pills

A
  • Variable amounts of oestrogen & progestin; mimics body cycle
    more oestrogen in early cycle, more progestin in late cycle
  • Tend to have lower progestin overall ⇒ reduced SE
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18
Q

COC: Types of COC
conventional

hormones in pills, benefits for new type

A

21 active pills + 7 days placebo = 28 days

(newer) 24 days active pills + 4 days placebo = 28 days
* 3 additional active pill shortens pill-free interval → reduce hormone fluctuations between cycles
* Overall lesser SE (withdrawal effects; headache & mood swings)

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19
Q

COC: Types of COC
extended cycle

hormones in pills, purpose of placebo

A

84 days active pills + 7 days placebo = 91 days
* Ensures no period for 84 days
* Placebo → to regulate hormones & ensure patient can still produce own hormones

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20
Q

COC: Initiation methods (3)

when to start, need for backup contraceptives

A

First day method
* Start on first day of menstrual cycle
* No backup contraceptive required if pill taken on first day of cycle
Due to ovulation not occurring yet ⇒ new follicle not stimulated

Sunday start method
* Start on first sunday after menstrual cycle begins
* Require backup contraceptive for at least 7 days
* May provide weekends free of menstrual periods

Quick start
Require backup contraceptive for at least 7 days + until next menstrual cycle begins

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21
Q

COC: Initiation methods
purpose of backup contraceptives

A

Due to uncertainty of where the patient is at in the menstrual cycle → might have ovulation already hence still need barrier contraceptive to prevent fertilisation

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22
Q

COC: additional benefits

RAP PIC

A
  • Improvement in menstrual regularity
    Know when bleeding will occur + how much blood will be lost
  • Better for Acne
  • Premenstrual dysphoric disorder
  • Iron-deficiency anaemia
    Some pills contain iron
    Good for patients with heavy flow → risk of anemia
  • Help with management of polycystic ovary syndrome
  • Reduced risk from:
    ovarian & endometrial cancers → but might increase risk of breast cancer
    ovarian cysts, ectopic pregnancy, pelvic inflammatory diseases, endometriosis, uterine fibroids, benign breast disease
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23
Q

COC: risks of taking

A
  1. breast cancer
  2. venous thromboembolism
  3. MI/ Stroke
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24
Q

COC: risks of taking
breast cancer

individuals with higher risks, who should avoid

A
  • In those currently using/ previously used COC
  • Increases risks with duration of use & age >40
  • Healthy & young: benefits of pregnancy prevention > risks of cancer
  • After discontinuation, risks return to same levels as those who never use COC

Patients with following conditions to avoid:
* Age > 40 years old
* Family history/ risk factors of breast cancer
Oestrogen → stimulator of breast cancer; receptor is present throughout body in individuals with breast cancer risks (& breast cancer patients)
* current/ recent history of breast cancer

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25
COC: risks of taking VTE | causes (E & P), RF, considerations of those with high risk
**Estrogens** increase hepatic production of factor VII, factor X & fibrinogen of coagulation cascade * Distributed to all parts of body * Increase in clotting factors ⇒ more likely for clot formation New generation **progestins** (ie: Drosperinone, Cyproterone & Desogestrel) → unknown MOA, possibly increase protein C resistance * Have antithrombotic activity; resistance ⇒ more thrombotic activity
26
COC: risks of taking VTE | RF, considerations of those with high risk
**Risk factors** >35 year old, obesity, smoking, immobilisation, cancer, hereditary thrombophilia **Considerations** for individuals with clotting risk factors: * Low dose oestrogen with older progestin Ideally to avoid oestrogen in totality * Progestin-only contraceptive * Barrier methods ⇒ general choice, especially if have initial clot & elevated levels of clotting factors
27
COC: risks of taking MI/ Stroke | hormone associated, absolute c/i, considerations for those with risk
oestrogen Migraine with aura (flashing light; blind spots) ⇒ **absolute contraindications** to ALL COC; to use progestin-only/ barrier methods **Considerations** for individuals with risk factors (similar to clotting): * Low dose oestrogen * Progestin-only * Barrier methods
28
COC: absolute contraindications | B3DSM P1ICH (total 15)
* Current **breast cancer**/ recent hx of breast cancer within 5 years * Hx of **deep vein thrombosis [DVT]/ pulmonary edema [PE]**, acute DVT/ PE, DVT/ PE patients on anticoagulant therapy * Major surgery with prolonged **immobilisation** * <21 days **postpartum** with other risk factor * <6 weeks postpartum if **breastfeeding** * Thrombogenic **mutations** * **SLE** with or unknown APLA (antiphospholipid syndrome) * **Migraine** with aura * **BP**: SBP > 160mmHg / DBP > 100mmHg ⇒ stroke risk * **HTN** with vascular disease * Current/ hx of **ischemic heart disease** * **Cardiomyopathy** * **Smoking** ≥ 15 sticks/day AND age ≥ 35yo * Hx of **cerebrovascular** disease * **Diabetes** >20 yrs or w/complications If diabetes recently diagnosed, technically still can use COC
29
COC: AE
1. bleeding breakthrough 2. acne 3. bloating 4. N/V 5. headache 6. menstrual pain 7. breast tenderness/ weight gain
30
COC: AE management | bleeding breakthrough, acne, bloating
**Bleeding breakthrough** → commonly due to oestrogen; will cause build up of fluids * early/ mid cycle ⇒ increase oestrogen * Late cycle ⇒ increase progestin **Acne** * Change to less androgenic progestin * Consider increasing oestrogen * If on progesterone only pills ⇒ change to COC **bloating** * Reduce oestrogen * Change to progestin with mild diuretic effect (ie drospirenone)
31
COC: AE management | N/V, headache, menstrual pain, breast tenderness/ weight gain
**N/V** * Reduce oestrogen * Take pills at night/ change to POP **Headache** * Exclude migraine with aura first ⇒ if present, to stop medications immediately * Usually occurs during pill-free week ⇒ switch to extended cycle/ continuous/ shorter pill interval Due to fluctuation of hormone levels **Menstrual cramps** ⇒ increase progestin/ switch to extended cycle/ continuous **Breast tenderness/ weight gain** ⇒ keep oestrogen & progestin as low as possible
32
COC: AE counselling | when does AE usually occur, how long to persevere
**AE** usually occur during early COC use * Will generally improve by 3rd-4th cycle after body adjust to hormone levels (stabilisation) * Important to check if patient still have any effects → if have, need to change products To **persevere** on COC for 2-3 months before changing products unless have severe AE * VTE, stroke, migraine with aura, MI
33
COC: problems of DDI | What to avoid
Will affect concentration of contraceptives in body ⇒ increase risk of pregnancy Commonly avoid CYP enzyme inducers
34
COC: DDI (drugs involved & how it affects)
**Rifampicin** * (significant interactions) Can alter gut flora → will alter metabolism of COC ⇒ less active COC Same for other ABs but less significant than rifampicin * Use additional contraceptive (barrier method) till rifampin discontinued for ≥7 days Generally recommended if patient given AB **Anti-convulsants** * Reduce free serum concentrations of both oestrogen & progestin * Examples: Phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine, lamotrigine (effects interfered by oestrogen levels in body) **HIV antivirals** Reduces effectiveness of both COC & AV
35
COC: missed dose Missing 1 dose (<48 hours since pill should be taken)
Take missed dose immediately & continue the rest as usual * Aka taking 2 pills on same day * If miss day 15 pill → on day 16, take the day 15 & day 16 pills No additional contraceptive methods required
36
COC: missed dose If ≥2 consecutive dose missed (>48 hours)
Take missed dose immediately & discard the rest of the missed dose Backup contraceptive required for at least 1 week **Example: missing days 10-13 pills (4 days missed)** * Day 14: To take missed day 10 pill AND day 14 pills * Throw away days 11-13 pills * Day 15: continue as per normal
37
COC: missed dose If pills missed during last week of hormonal tablets (days 15-21)
Finish remaining active pills in current pack Skip hormone free-interval (days 21-28) & start a new pack the next day Back up contraceptive required for at least 1 week **Example: missing days 15-19 (5 days) → same idea regardless of number of days missed** * Day 20: To take missed pill from day 15 * Continue taking missed dose of days 16-19 in the time frame of days 21-24 * By right, the hormonal pills should end on day 24 NOW, instead of the usual day 21 (5 days late) * Days 15-19 hormonal pill ⇒ taken during days 20-24 instead * Discard non-hormonal pills from days 21-28 * Day 26: To start on a fresh pack, day 1 of hormonal pills again.
38
POP: administration time
Need to take everyday at the SAME time for entire cycle
39
POP: indications & reasons
* Patient is breastfeeding Interferes with prolactin production (changes production of milk) Generally avoid oestrogen when breastfeeding * Intolerant to oestrogen (have N/V)
40
POP: c/i
current/ recent hx of breast cancer
41
POP: Types of pills | Number of active pills
* **Norethindrone (norethisterone) or levonorgestrel**→ 28 active pills; continuous Pill only stops ovulation but not follicle stimulation Miss dose = LH increases & ovulation occurs * **Drospirenone** → 24 active pills, 4 inactive Have longer t1/2, hence lesser active pills
42
POP: How to start
* Within 5 days of menstrual cycle/bleeding → no back up contraceptive needed * Any other day → back up contraceptive for 2 days (7 days for drospirenone)
43
POP: Missed dose | N/L & D
**N/L**: If late dose by > 3 hours ⇒ take extra (2 pills total) & continue; backup contraceptive for 2 days * More time sensitive * May cause increased LH, causing follicle to rupture ⇒ ovulation occurs **Drospirenone**: * if <24h, take extra and continue * if ≥2 active pills missed, backup needed for 7 days **Taking extra** Take 1 immediately once discovered dose is missed + other 1 at normal time when usually take the pill the NEXT day (as scheduled)
44
Progestin injections: administration method | things to note
IM injection every 12 weeks Ideal for patients with adherence issues But require regular doctor visit → check if patient willing to do so
45
Progestin injections: impact on fertility
Return to fertility might be delayed
46
Progestin injections: SE
**Will have variable breakthrough bleeding especially the first 9 months (most freq SE)** * 50% become amenorrheic (no period) after 12 months * 70% after 2 years * Note: body will be used to effects & change in hormonal levels in LR ⇒ lesser of such SE **Weight gain** → more than other types of contraceptives **Short term bone loss** → bone mineral density decreases [FDA black box warning] Patients with higher risk (& should avoid): - Older women - Have other osteoporosis risk factors → ie LT steroid use - If require >2 years of use, should evaluate other contraceptives
47
Transdermal contraceptives: components
oestrogen & progestin
48
Transdermal contraceptives: when will effectiveness be reduced
patients >90kg
49
Transdermal contraceptives: application
once weekly every 3 weeks followed by 1 patch-free week Ideal for patients with adherence issues
50
Transdermal contraceptives: SE
similar to COC + application site reactions
51
Vaginal rings: compnent
oestrogen & progestin
52
Vaginal rings: usage
Used for 3 weeks then discarded
53
Vaginal rings: SE
Similar to COC + tissue irritation + risk of expulsion
54
Transdermal patch + Vaginal rings: risk of estrogen
Continuous, higher exposure to oestrogen ⇒ increased risk of VTE
55
LARC: Benefits
* Highly effective: typical-use rates ≈ perfect-use rates ≈ <1% * Easy to use, cheap * Effects quickly reversible upon removal → no long term effects on fertility (within 12 months will return to normal)
56
types of LARC
1. subdermal progestin implant 2. levonogestrol IUD 3. copper IUD
57
subdermal progestin implant | component, how long it lasts, problem with continued use
* Single 4 cm long implant, containing 68 mg of etonogestrel ⇒ long acting * Lasts for 3 years then replaced * Might cause irregular bleeding pattern with continued use Amenorrhea (22%), prolonged bleeding (18%), spotting (34%) & frequent bleeding (7%)
58
IUD: MOA | additional: progestin
* inhibition of sperm migration, damage ovum, damage/disrupt transport of fertilised ovum ⇒ no pregnancy can occur. * If used with progestin → endometrial suppression, thicken mucus Decrease movement of sperm
59
IUD: who should avoid
pregnant, current STI, undiagnosed vaginal bleeding, malignancy of genital tract, uterine anomalies or uterine fibroids
60
IUD: general risks
uterine perforation, expulsion, pelvic infection
61
levonogestrol IUD | effects, ideal users, when to replace
* (progestin) decrease in menstrual flow → usually spotting/ amenorrhea * Ideal if concomitant menorrhagia (bleeding >7 days/ heavy bleeding) * Used for **5 years** then replaced
62
Copper IUD | effects, ideal users, when to replace, additional indication
* Heavier menses/ bleeding (compared to levonorgestrel) ⇒ increase by ~35% average monthly blood loss * Ideal if concomitant amenorrhea * Used for **10 years** then replaced * Can be used as emergency contraceptive ⇒ most effective
63
emergency contraceptives: Options & % pregnancy avoided
1. copper IUD (>99%) 2. ella tablets; ulipristal 30mg (60-80%) 3. prostinor; levonogestrol 0.75 mg
64
emergency contraceptive: copper IUD | How to use after unprotected intercourse; MOA
Insert within 5 days Inhibition of sperm migration, damage ovum, damage/ disrupt transport of fertilised ovum
65
emergency contraceptive: ella tablets | How to use after unprotected intercourse; MOA, additional notes
Take 1 tablet ASAP, within 5 days (120 hours) Progestin receptor modulator * Slows release of GnRH → inhibit ovulation (reduce LH production) * Thins uterine lining * Directly inhibit follicular rupture **AVOID**: * Patients currently taking progestin-containing OC (will reduce effectiveness) Take progestin ONLY 5 days after ella tablet
66
emergency contraceptive: prostinor tablets | How to use after unprotected intercourse; MOA, additional notes
Take 2 tablets ASAP, preferably within 12 hours but not more than 72 hours Progestin: slow release of GnRH inhibiting ovulation & thins uterine lining Less effective in morbidly obese patients
67
emergency contraceptive: ella & prostinor tablets | SE; how to manage
nausea SE is common If patient vomits within 3 hours of taking tablet, to REDOSE

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