Lecture 11: Contraception Flashcards
What are the three types of contraceptive methods?
- Non-hormonal
- Combined hormonal
- Progestin Only
What are the non-hormonal contraceptive methods available?
- Natural family planning/fertility awareness
- IUD
- Spermicides
- Barriers
- emergency contraception (EC) with copper
What are the types of combined hormonal methods available?
- Pills
- Patch
- Vaginal Ring
What are the progestin only methods?
- Pills
- Injectable
- Implant
- IUS(intrauterine SYSTEM aka Mirena)
- EC (emergency contraceptive) Plan B
What are advantages of barrier methods?
- some methods offer protection against STD
- Preferred by occasional intercourse
- alternatives for hormonal methods
- most methods available without prescription
What are the disadvantages of barrier methods
- not effective as hormonal methods/implants
- efficacy is dependent on consistent and correct use
- needs use of concomitant spermicide
What are types of barrier methods?
- condom
- latex
- polyurethane
- sheep membrane
- Fertility awareness based methods
- no side effects and exogenous hormones
- cycles can be variable
- Male sterilization, vasectomy, safe, easy, reversible
- spermicide/diaphragm
- female condoms (can be inserted well before intercourse, can be used by latex allergies)
- Copper intrauterine device
- contraception for 12 years
- can be emergency contraception if inserted up to 5 days after intercourse
- however must be inserted by healthcare professional and can have bleeding changes
- Female sterilization
What are the different methods of female tubal occlusion?
- ligating
- blocking with clips or rings
- cauterizing
NONSURGICAL TUBAL OCCLUSION - Essure
-micro-inserts placed into proximal fallopian tubes
What are the characteristics of spermicides?
Chemical barrier that women can use by themselves
Most common is N-9
How do emergency contraceptives work?
Exogenous Progesterone (progestin) inhibits LH production Exogenous estrogen inhibits FSH production
What are progestins?
Synthetically made progesterone
What are progestin effects of OCs?
- inhibits LH surge and subsequent ovulation
- Thickens Cervical mucus (sperm cant penetrate)
- Decreases estrogen-driven cell proliferation (e.g. in endometrium)
- Converts reproductive tissues from proliferative modes to functional modes
What are estrogen effects of OCs?
- Inhibits FSH surge and subsequent follicle development
- MAY inhibit ovulation
- thins cervical mucus…
- Increases endometrial proliferation
What is synthetic estrogen?
Estradiol
What is ethyline estradiol?
A synthetically made estrogen
What are the different types of synthetic progestins?
- Testosterone derivatives (19 C)
- estranes
- gonanes
- Progesterone derivatives (21 C)
- pregnanes
- Spirolactones
- Anti-progestins (Ella)
What is Medroxyprogesterone acetate?
Progesterone ONLY
Injectable
Seen as DepoProvera
The ONLY progestin that is derived specifically from progesterone
What are advantages and disadvantages of Depot Medorxyprogesterone acetate?
DepoProvera
Highly effective, decreases endometrial changes
Discontinuation due to spotting/irregular bleeding
-amenorrhea and prolonged menses
-menstrual changes
-WEIGHT GAIN
-injection every 3 months!
If someone is predisposed to obesity, which contraception do you want to avoid?
DepoProvera
Medroxyprogesterone acetate
What is Drosperinone?
Derived from 17alpha spirolactone
Seen in Yaz and Yasmin
What are the effects of progestins in combination OCs?
- modify mid-cycle surges of LH/FSH
- inhibit ovulation by suppressing HPO
- diminish ovarian hormone production
- produce endometrial change unfavorable to implantation
- thickens cervical mucus to impede sperm travel
- inhibit sperm action
What is the significance of all the different types of progestins?
There are different bioavailabilities after oral intake
Gestodene has over 90%
Levonorgestrel has around 90%
Norgestimate = 22%
Higher bioavailability = higher mg required
What is the clinical relevance of bioavailability?
Comparing mg to mg requirement from OC to OC does not matter
Because mg is dosed based on bioavailability
What are the examples of gonanes?
Levonorgestrel family
-anything with “gestrel” or “mate” as end name
Plan B, Alesse, Orthcyclin, Mircete
What are examples of Estranes?
Norethindrone family
Anything that ends in “drone”
Ovcon 35, loestrin, orthonovum brand names
What contraceptive progestin has longest half-life? Shortest?
Drospirenone (spirolactone)
Norethindrone
How does combination OCs affect androgen pathways?
- Estrogen and progestin metabolism in liver INCREASES sex hormone binding globulin (SHBG)
- Increased SHBG binds testosterone, thereby DECREASING testosterone floating around
- suppression of LH and FSH which leads to less testosterone production
- Inhibition of 5alpha-reductase so less DHT formation
What is the clinical effect of OCs?
Less testosterone
So less facial hair
Less acne
What are other clinical effects of hormonal contraception?
- decreased menstrual flow
- improved anemia (because less blood loss)
- suppressed functional ovarian cysts (because suppression of FSH)
- Decreased acne/hirsutism
- Cancer protection
What are the characteristics of cyclic OCs and bleeding?
Artificial and nonovulatory
Withdrawal from hormones
Placebo bleedings allows for withdrawal bleeding
What does LNG stand for?
Levonorgestrel
What is Yuzpe Regimen?
Two doses of estrogen 0.1 mg with norgestrel 1.0mg
12 hours apart
First dose within 120 hours of unprotected sex (5 days)
What are the advantages of EC combination pill?
75% of unintended prengancies prevented
-increased incidence of side effects due to high estrogen component
Nausea and vomiting
What is levonorgestrel?
Plan B
Single dose
Nausea
What is Ella?
Ulipristal Acetate A progesterone receptor modulator whose likely main effect is to INHIBIT or DELAY ovulation Taken as single dose 120 hours after sex -nausea, requires prescription
How do you dose oral contraceptives?
Dose started high for efficacy
Lower does of EE (ethinyl estradiol) and progestin have synergistic effects on pituitary inhibition
Lowered to improve safety and decreased side effects
What is EE?
Ethinyl estradiol
Orally bioactive estrogen used in oral contraceptive pills
Synthetic estrogen
What are symptoms with traditional oral contraceptive?
- Pelvic pain
- headaches
- breast tenderness
- bloating/swelling
- use of pain meds
Symptoms felt during the hormone free days
What are recent innovations of hormonal contraception?
- Contraceptive Patch
- Vaginal Ring
- Levonorgestrel Intrauterine System
- IUS
- Mirena
- Implanon
What are the characteristics of contraceptive patch?
Norgestimate + 20 mcg EE
Weekly application and comparable to OCPs
Application site reactions
Higher risk of breast pain, not effective with obese and visible on skin
What are the characteristics of vaginal ring?
Efficacy comparable to OCPs Etonogestrel + 15 mcg EE -3 weeks -coital problem may lead to discontinuation -lower rate of breakthrough bleeding
What are the characteristics of the Levonorgestrel Intrauterine System?
EXTREMELY effective 20 mcg of Levonorgestrel/24 hours Stays in place to 5 years -increases thickness of cervical mucus -requires professional insertion and can change bleeding pattern Progestin only Mirena T-shaped device
What are the characteristics of Implanon/Explanon?
Extremely effective Use of Etonogestrel Effective immediately and rapid return to fertility 3 years of protection Contains NO estrogen Goes into skin in upper arm
What are LARC methods?
Long-Acting REVERSIBLE Contraceptive methods
Examples: Mirena, IUS, Implanon, Levonorgestrel Intrauterine System
What are risks of birth control?
Increased death
Increased CVD mortality
Thromboembolism
Why does lecturer not give a shit about oral contraceptive side effects?
Because she argues that pregnancy is much riskier
Doesn’t address the fact that we can just use barrier methods….
If woman has preexisting medical conditions, what should we do for contraception?
We should use LARC because pregnancy is more dangerous to OCP
What is the association between OCPs and endometrial cancer?
OCPs decrease risk of endometrial cancer
