IC17 Contraceptives Flashcards
barrier methods
- male condom
- female condom
- diaphragm with spermicides
- cervical cap
barrier methods: male condom
c/i, adv & disadv
- Allergy to latex/ rubber
- STI protection
- High user failure rate
Poor acceptance
Possibility of breakage
barrier methods: female condom
c/i, adv & disadv
- 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
barrier methods: diaphragm with spermicide & cervivcal cap
c/i, adv & disadv
- 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
COC: role of hormones
progestin & estrogen
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
COC: SE of progestin
acne, oily skin, hirsutism (growth of hair)
COC: possible benefit of progestin
Late cycle breakthrough bleeding → to prevent bleeding at end of cycle
Painful menstrual cramps
COC: types of progestin
drosperinone & cyproterone
COC: types of progestin
drospirenone
effect, benefits, SE
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
COC: types of progestin
Cyproterone
indication, effects, SE
treatment of excessive-androgen related conditions (severe acne, hirsutism)
Have anti-androgenic, antigonadotropic effects
SE: high risk of thromboembolism
COC: estrogen
types & doses
Types: Ethinyl estradiol (EE), estradiol valerate, esterol, mestranol
Doses:
High: ≥50 μg
moderate/ standard: 30-35 μg
Low: 15-20 μg
COC: estrogen
problem of high doses
associated with vascular, embolic events, cancer & significant AE
COC: estrogen (factors favouring lower dose)
- Adolescence
- Underweight (<50 kg)
- Age > 35 years ⇒ higher risk of SE
- Peri-menopausal
COC: estrogen (factors favouring higher dose)
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
COC: Types of COC
- monophasic
- multiphasic
- conventional
- extended-cycle
COC: Types of COC
monophasic
hormones in pills
Same amounts of oestrogen & progestin in every pill
Less confusing, less missed-doses instructions
COC: Types of COC
multiphasic
hormones in pills
- 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
COC: Types of COC
conventional
hormones in pills, benefits for new type
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)
COC: Types of COC
extended cycle
hormones in pills, purpose of placebo
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
COC: Initiation methods (3)
when to start, need for backup contraceptives
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
COC: Initiation methods
purpose of backup contraceptives
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
COC: additional benefits
RAP PIC
- 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
COC: risks of taking
- breast cancer
- venous thromboembolism
- MI/ Stroke
COC: risks of taking
breast cancer
individuals with higher risks, who should avoid
- 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
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
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
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
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
COC: AE
- bleeding breakthrough
- acne
- bloating
- N/V
- headache
- menstrual pain
- breast tenderness/ weight gain
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)
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
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
COC: problems of DDI
What to avoid
Will affect concentration of contraceptives in body ⇒ increase risk of pregnancy
Commonly avoid CYP enzyme inducers
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
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
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
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.
POP: administration time
Need to take everyday at the SAME time for entire cycle
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)
POP: c/i
current/ recent hx of breast cancer
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
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)
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)
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
Progestin injections: impact on fertility
Return to fertility might be delayed
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
Transdermal contraceptives: components
oestrogen & progestin
Transdermal contraceptives: when will effectiveness be reduced
patients >90kg
Transdermal contraceptives: application
once weekly every 3 weeks followed by 1 patch-free week
Ideal for patients with adherence issues
Transdermal contraceptives: SE
similar to COC + application site reactions
Vaginal rings: compnent
oestrogen & progestin
Vaginal rings: usage
Used for 3 weeks then discarded
Vaginal rings: SE
Similar to COC + tissue irritation + risk of expulsion
Transdermal patch + Vaginal rings: risk of estrogen
Continuous, higher exposure to oestrogen ⇒ increased risk of VTE
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)
types of LARC
- subdermal progestin implant
- levonogestrol IUD
- copper IUD
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%)
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
IUD: who should avoid
pregnant, current STI, undiagnosed vaginal bleeding, malignancy of genital tract, uterine anomalies or uterine fibroids
IUD: general risks
uterine perforation, expulsion, pelvic infection
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
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
emergency contraceptives: Options & % pregnancy avoided
- copper IUD (>99%)
- ella tablets; ulipristal 30mg (60-80%)
- prostinor; levonogestrol 0.75 mg
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
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
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
emergency contraceptive: ella & prostinor tablets
SE; how to manage
nausea SE is common
If patient vomits within 3 hours of taking tablet, to REDOSE
