LECTUREs 43, 44, 45 - contraception / emergency contraception / prescribing Flashcards
1
Q
List progestin-only contraceptive methods
A
implant
levonorgestrel IUD
DMPA (shot)
“mini-pill” (norethindrone / norgestrel POP)
drospirenone POP
2
Q
List combination (estrogen & progestin) contraceptive methods
A
Combination OCs
Disposable vaginal ring
Reusable vaginal ring
Patch
3
Q
List serious side effects of the implant - Nexplanon (etonogestrel)
A
mood changes
headaches
acne
4
Q
List common side effects of the implant - Nexplanon (etonogestrel)
A
pain w/ insertion
irregular bleeding for the first 6-12 months (no bleeding, regular periods, frequent spotting / bleeding)
5
Q
List potential benefits of the implant - Nexplanon (etonogestrel)
A
- long-term protection up to 3 years
- nothing to remember on a regular basis
6
Q
When does fertility return after d/c the implant - Nexplanon (etonogestrel)?
A
may be delayed OR rapid return
(returns within 6 weeks)
7
Q
List non-hormonal IUD options & their duration of use
A
Paragard - copper (up to 10 years)
8
Q
List hormonal (levonorgestrel) IUD options & their duration of use
A
- Mirena (52mg levonorgestrel) - up to 8 years
- Skyla (13.5mg levonorgestrel) - up to 3 years
- Liletta (52mg levonorgestrel) - up to 8 years
- Kyleena (19.5mg levonorgestrel) - up to 5 years
9
Q
List serious side effects of the levonorgestrel IUDs
A
uterine perforation
infection
expulsion (of the device)
10
Q
List common side effects of the levonorgestrel IUDs
A
cramping with insertion
spotting for the first 3-6 months
periods may become lighter/less frequent
11
Q
List the potential benefits of the levonorgestrel IUDs
A
- lighter periods / amenorrhea
- safe to breastfeed
- lower risk of uterine cancer
- long-term protection
12
Q
When does fertility return after d/c levonorgestrel IUDs?
A
immediately
13
Q
List serious side effects of the copper IUD
A
Uterine perforation
Infection
Expulsion
14
Q
List common side effects of the copper IUD
A
- Cramping with insertion
- Spotting for first 3-6 months
- Periods may become heavier / stay about the same
15
Q
List the potential benefits of the copper IUD
A
Lower risk of uterine cancer
Long-term protection
Safe to breastfeed
16
Q
When does fertility return after d/c the copper IUD?
A
immediately
17
Q
List the options for the administration of the DMPA (shot)
A
150 mg IM
104 mg subcut injection
18
Q
List the serious side effects of DMPA (shot)
A
Lower bone density
Heavy bleeding
19
Q
List the common side effects of DMPA (shot)
A
Weight gain
Change in acne, mood, or headaches
Spotting between periods / no period
20
Q
List the potential benefits of DMPA (shot)
A
Lower risk of uterine cancer
Safe to breastfeed
21
Q
When does fertility return after d/c DMPA (shot)?
A
possible delayed return of fertility
22
Q
List the types of combined oral contraceptive (coc) products
A
monophasic (same dose throughout)
biphasic (two strengths throughout)
triphasic (three strengths throughout)
four-phasic (four strengths throughout)
23
Q
List the serious side effects of combined oral contraceptive (coc) products
A
Blood clots (estrogen related)
Stroke
24
Q
List the common side effects of combined oral contraceptive (coc) products
A
Nausea, spotting and/or breast discomfort
Change in mood or headaches
25
List the potential benefits of combined oral contraceptive (coc) products
Improved acne
Lower risk of ovarian/uterine cancer
More regular, lighter, less painful periods
26
When does fertility return after d/c combined oral contraceptive (coc) products?
immediately
27
What does "POP" stand for when referring to oral contraceptives?
progestin-only pill
28
Describe the frequency of administration for POP - norethindrone “mini-pill” & norgestrel (OTC)
Daily within 3 hours of the same time
**No placebo pills**
29
List the serious side effects for POP - norethindrone “mini-pill” & norgestrel (OTC)
Severe headaches
Heavy bleeding
Ectopic pregnancy
30
List the common side effects for POP - norethindrone “mini-pill” & norgestrel (OTC)
spotting & menstrual changes *more common than COC*
31
List the potential benefits for POP - norethindrone “mini-pill” & norgestrel (OTC)
Safe to breast/chest feed
Lack of estrogen-related side effects
32
When does fertility return after d/c POP - norethindrone “mini-pill” & norgestrel (OTC)?
immediately
33
Describe the frequency of administration for POP - drospirenone 4mg (Slynd)
daily
there ARE placebo pills in pack
34
List the serious side effects for POP - drospirenone 4mg (Slynd)
Severe headaches
Hyperkalemia (high blood potassium levels)
35
List the common side effects for POP - drospirenone 4mg (Slynd)
Spotting & menstrual changes more common than COC
36
List the potential benefits for POP - drospirenone 4mg (Slynd)
Safe to breast/chest feed
Lack of estrogen-related side effects
37
When is the return of fertility when d/c POP - drospirenone 4mg (Slynd)?
immediately
38
Describe the frequency of administration for the disposable monthly vaginal ring (etonogestrel & EE | Nuvaring, Eluryng)
Leave in for 3 weeks → remove for 1 week
New ring inserted after 7 days
39
List the serious side effects for the disposable monthly vaginal ring (etonogestrel & EE | Nuvaring, Eluryng)
Blood clots
Stroke
40
List the common side effects for the disposable monthly vaginal ring (etonogestrel & EE | Nuvaring, Eluryng)
Nausea, spotting, breast discomfort
Change in mood or headaches
41
List the potential benefits of the disposable monthly vaginal ring (etonogestrel & EE | Nuvaring, Eluryng)
Improved acne
More regular, lighter, less painful periods
42
When does fertility occur when d/c the disposable monthly vaginal ring (etonogestrel & EE | Nuvaring, Eluryng)?
immediately
43
Describe the frequency of administration for the reusable monthly vaginal ring (segesterone & EE | Annovera)
- Leave in for 3 weeks → remove for 1 week
- Wash with mild soap/warm water, pat dry, & place in case
- Re-insert into vagina (after cleaning)
44
List the common side effects for the reusable monthly vaginal ring (segesterone & EE | Annovera)
Headache / Migraine
N/V
Vulvovaginal infection / Candidiasis
45
List the serious side effects for the reusable monthly vaginal ring (segesterone & EE | Annovera)
Blood clots
Stroke
46
List the potential benefits of the reusable monthly vaginal ring (segesterone & EE | Annovera)
Improved acne
Lower risk of ovarian/uterine cancer
More regular, lighter, les painful periods
Don’t have to remember to use daily
Can use one device up to 13 times
47
When does fertility return when d/c the reusable monthly vaginal ring (segesterone & EE | Annovera)?
immediately
48
Describe how the norelgestromin & EE patch (Xulane, Zafemy) is administered
Transdermal patch applied to upper outer arm, abdomen, buttock, or back
Thin, beige, square plastic with sticky back
49
Describe the frequency of administration for the norelgestromin & EE patch (Xulane, Zafemy)
New patch every week for 3 weeks → patch free for 7 days (4 weeks = 3 patches)
Apply new patch after 7 days
50
List the serious side effects of the reusable norelgestromin & EE patch (Xulane, Zafemy)
Blood clots (more estrogen than most combined pills)
51
List the common side effects of the norelgestromin & EE patch (Xulane, Zafemy)
Nausea, spotting, breast discomfort
Skin irritation
Change in mood or headaches
52
List the potential benefits of the norelgestromin & EE patch (Xulane, Zafemy)
Improved acne
Lower risk of ovarian / uterine cancer
More regular, lighter, less painful periods
Don’t have to remember daily
53
When does fertility return when d/c the norelgestromin & EE patch (Xulane, Zafemy)?
immediately
54
Describe how the levonorgestrel & EE patch (Twirla) is administered
Transdermal patch applied to abdomen, buttock, or upper torso (excluding breasts)
Thin, beige, round plastic with sticky back (larger than others)
55
Describe the frequency of administration for the levonorgestrel & EE patch (Twirla)
New patch every week for 3 weeks → patch free for 7 days (4 weeks = 3 patches)
Apply new patch after 7 days
56
List the serious side effects of the reusable levonorgestrel & EE patch (Twirla)
Blood clots
57
List the common side effects of the reusable levonorgestrel & EE patch (Twirla)
Nausea, spotting, increased weight
Skin irritation
Change in mood or headaches
58
List the potential benefits of the reusable levonorgestrel & EE patch (Twirla)
Improved acne
Lower risk of ovarian / uterine cancer
More regular, lighter, less painful periods
Don’t have to remember daily
59
When does fertility return when d/c the levonorgestrel & EE patch (Twirla)?
immediately
60
Name the acronym to remember serious side effects of combined contraceptive methods
A.C.H.E.S.
61
What does the acronym A.C.H.E.S. stand for? What does is describe?
A.C.H.E.S. is an acronym to help remember serious side effects of combined contraceptive methods
Abdominal pain
Chest pain (shortness of breath, coughing)
Headache
Eye problems (double vision, blurry vision)
Severe leg pain
62
Describe how the patient should manage late / missed doses of the drospirenone oral pill
If ONE late/missed dose → take late/missed pill ASAP & take next dose as normal, *no backup needed*
If 2+ missed doses → take only most recent missed pill ASAP, continue taking remaining pills as normal, *backup for 7 days*
63
Describe how the patient should manage late / missed doses of the norethindrone or norgestrel oral pill
If any number of pills is > 3 hours late:
Take late/missed pill ASAP, *backup needed for 2 days*
64
Describe how the patient should manage late / missed doses of the progestin-only injection
2 weeks late (>15 weeks): receive injection if reasonably certain person is not pregnant, *backup for 7 days, consider emergency contraception*
65
List the 3 options for when to start contraception
Quick start
Next period
Sunday start
66
Describe the "quick start" method for starting contraception
Start anytime it is reasonably certain that the patient is not pregnant
If more than 1-6 days after period start, use backup method for 2-7 days
67
Describe the "next period" method for starting contraception
Start w/in 1-6 days of period start
No backup method required
68
Describe the "Sunday start" method for starting contraception
Start on Sunday after period starts
If more than 1-6 days after period start, use backup method for 2-7 days
69
Describe how contraception should be started when changing hormonal methods
Switch method at any time OR when due for next injection
No backup needed IF no gaps in treatment
70
Describe how contraception should be restarted after using emergency contraception
Levonorgestrel —> start/resume method immediately
*Backup method for SEVEN DAYS*
Ulipristal acetate → start/resume method FIVE DAYS after use
*Backup method for UNTIL SEVEN DAYS of use*
71
List all possible uses for "contraception"
- Contraception
- Acne, Hirsutism, Alopecia
- Regulation of cycle
- Menorrhagia
- PMS / PMDD
- Endometriosis
- Dysmenorrhea
72
List the general potential health benefits of using contraception
- Decreased risk of endometrial & ovarian cancer
- Decreased risk of menstrual-related headaches
- Improvement in perimenopausal symptoms
73
Describe recommendations for addressing irregular bleeding as a side effect of contraception
- Ensure the patient is taking pills at the same time every day
- May improve with continued use (if contraceptive recently started)
OTHERWISE...
- Ibuprofen 800mg TID x 5 days
74
Describe recommendations for addressing headaches as a side effect of contraception
- Use OTC pain relievers
- Consider continuous products if headaches occur during placebo week
- d/c products if headaches get WORSE
75
Describe recommendations for addressing nausea as a side effect of contraception
- Try taking pills with food or at bedtime
- May improve with continued use (if contraceptive recently started)
- Consider continuous products if nausea at start of cycle
76
Describe recommendations for addressing breast tenderness as a side effect of contraception
- Advise the patient to try a more supportive bra
- OTC pain relievers
- Consider switching to product with less estrogen
77
Describe recommendations for addressing acne as a side effect of contraception
- Topical acne treatments
- Consider different pill formulation (less androgenic)
- Change to a combined product (if applicable / able)
78
List the types of contraception that pharmacists can prescribe in Indiana
oral
patch
ring
IUD
79
Describe the procedure that a pharmacist must follow when prescribing contraception in Indiana
- Birth Control screening
(self-screening for risk assessment)
- Pharmacist Review
- Screen for pregnancy
- Check blood pressure
- General counseling
- Identify different methods pt is eligible for
- Assess preferences
- Method counseling
AFTER PRESCRIBING
- Provide initial prescription for up to 6 months
- Can renew for an additional 6 months
- Provide a written record of method prescribed
- Refer the patient to a PCP or women’s health provider
(or notify provider if they have one (optional))
- Assess BP at least once every 6 months
80
Describe the stroke risk based on the dosage of EE in a contraceptive
>/= 50 mcg EE has highest risk for strokes
*In the case that CHCs are considered independent risk factor for stroke
81
Describe the potential benefits / issues of using contraception with patients that experience migranes WITHOUT aura
Steady level of hormones → potential benefit
Low dose & monophasic
Can ALSO make then more frequent & severe
Sign to STOP COC therapy
82
Describe the potential benefits / issues of using contraception with patients that experience migranes WITH aura
Slightly higher risk for strokes
Mechanism of increased risk possibly due to temporarily narrowed blood vessels
NO USE OF CHC !!!
Progestin-only contraception recommended
83
Describe the guidelines & options for progestin-only contraceptive use for transgender men (F → M)
Do not interfere w/ testosterone risk
Reversible
Options
- POP pills (norethindrone & drospirenone)
- LARCs - Implants, IUDs, progestin-only injectable
84
Describe the guidelines & options for COC use for transgender men (F → M)
- CONTROVERSIAL due to the presence of estrogen in pts on testosterone during transitioning phase
- No contraindications to current use
Low-dose or estradiol alone can be used to stop menses
85
Describe the guidelines & options for non-hormonal contraceptive use for transgender men (F → M)
Copper IUDs may increase existing menstrual bleeding
Great for patients that wish to avoid progestin & estrogen products due to existing amenorrhea
86
Describe the guidelines & options for irreversible contraceptives for transgender men (F → M)
- Tubal ligation → fallopian tubes are cut or “tied”
- Excision of fallopian tubes → removal of the fallopian tubes
87
List the options for emergency contraception
- Copper IUD
- Levonorgestrel emergency contraception (LNG EC)
- Ulipristal acetate EC
88
Describe the frequency of administration for the copper IUD when used as an emergency contraceptive
1 insertion
89
Describe the frequency of administration for Ulipristal acetate (Ella)
1 prescription per cycle
90
Describe the frequency of administration for the levonorgestrel EC pill
one dose OTC as needed (prn)
91
How soon should LNG EC / Copper IUD be used after unprotected intercourse (UPI)
within 5 days
(LNG EC labelled for 72 hours)
92
How soon should Ulipristal acetate (Ella) be used after unprotected intercourse (UPI)
within 5 days
(wait 5 days to re-start hormonal birth control if used)
93
List common side effects of emergecy contraception
- N/V, HA, dizziness, breast pain, stomach pain
- *If the patient vomits w/in 2 hours of taking, consider repeating dose*
- Next period may start early or late, may have spotting
94
How soon does fertility return after the patient is finished taking emergency contraception?
immediately
95
Describe the mechanism of action for the copper IUD
- Interferes w/ sperm viability & function
- *Most effective EC across all BMIs / weights*
- In-office procedure
96
Describe the mechanism of action for Ulipristal acetate (Ella)
- Inhibits ovulation & leads to follicular rupture
- Effective up to 5 days
- Better efficacy than LNG up to 194 lbs
- Effective AFTER LH surge have begun
Interacts w/ hormonal contraceptives
Rx only
97
Describe the mechanism of action for the LNG EC pill
- Inhibits ovulation
- May be less effective > 165 lbs (BMI of 25)
- Labelled for 72 hours
OTC
No interaction with other methods
98
When can medication abortion be administered?
Up to 70 days (10 weeks) gestation
(gestational age → first day of last menses)
99
List the contraindications for medication abortion
- Current IUD
- Long-term systemic corticosteroids
- Chronic adrenal failure
- Coagulopathy / anticoagulant therapy
- Inherited porphyria
- Intolerance / allergy
100
Which drugs are used for medication abortion?
Mifepristone (Mifeprex)
Misoprostol (Cytotec)
101
Describe misoprostol (Cytotec)
Prostaglandin EI analogue
Cervical softening
Uterine contractions
102
Describe mifepristone (Mifeprex)
Selective progesterone receptor modulator (SPRM)
- Antiprogesterone (competitively inhibits the actions of progesterone at the progesterone-receptor sites)
- Decidual necrosis, cervical softening, increased uterine contractility, prostaglandin sensitivity
103
Describe the dosing regimen for medication abortion
Mifepristone (200mg PO x1 dose)
THEN Misoprostol
800 mcg buccally 24-48 hours later (4 pills)
[2x 200 mcg tablets in each (2) cheek (30 min)]
104
What are the TWO indications for the mifepristone / misoprostol regimen?
medication abortion
natural early pregnancy loss (spontaneous abortion, miscarriage)
105
Describe what bleeding could occur for a patient who used the mifepristone / misoprostol regimen & if they should be concerned
Bleeding & cramping are expected
Bleeding will be heavier than menses
106
List serious side effects that may occur after / during the mifepristone / misoprostol regimen
HEAVY BLEEDING
> 2 pads/hour x 2 consecutive hours
Blood clot larger than a lemon
Chill & any fever > 101 / 100.4 for > 4 hours
107
List common ADRs for the mifepristone / misoprostol regimen
N/V, diarrhea
Headache, dizziness
Hot flushes, chills
108
Describe what pain could occur for a patient who used the mifepristone / misoprostol regimen & how patient can treat it
Pain is most severe ~2.5 - 4 hours after misoprostol
NSAIDS recommended
109
What is the impact of properly counseling patients on contraceptives?
Patient satisfaction
Use of preventative care
Medication adherence !!!
Respectful relationships
110
List different types of communication/resources that can be used with people seeking contraception
- directive
- consumerist
- shared decision making
- one key question
- PHI-CARE model
- MyPath
& more!
111
Describe the directive approach to contraceptive counseling
“First-line”
- Tiered effectiveness
- Literally just showing a chart of how effective each medication is
- Not recommended to be only counseling method / only way info is provided
112
Describe the consumerist approach to contraceptive counseling
Informed choice of patient
Foreclosed
113
Describe the "one key question" approach to contraceptive counseling
“Would you like to become pregnant in the next year?”
YES
Assessment and care based on core pre-conception factors
Folic acid supplementation
IDK / okay either way
Pregnancy ambivalence → more likely to not be using contraception or d/c use
Determine appropriate intervention
Folic acid supplementation if potential for pregnancy
NO
Discussion about current method, satisfaction, and accurate use
Discuss all available options
114
Describe the PHI-CARE model approach to contraceptive counseling
Past Experience
What methods have been used in the past, like, dislikes
Health history
Review history to evaluate safe options
Importance
Find out what is important for the pt about their contraceptive method
Counsel
Share what options match the preferred methods
Autonomy
Give the patient a chance to ask questions, discuss when they would like to start the method, etc.
Review
Share information the patient needs to know to use the contraceptive method
Experience
Open the lines of communication for the patient to follow up after they begin using the contraceptive method
115
Describe the shared decision making approach to contraceptive counseling
“Best” option identified based on preferences
- Collaborative
- Choice Talk & Information Sharing
(inform that reasonable options are available)
- Option Talk & Deliberation
(provide more detailed information about options)
- Decision Talk & Decision Making
(support consideration of preferences & decision)
116
Describe MyPath and how it can be used for contraceptive counseling
MyPath is an online tool to help patients make informed decisions - useful pre-appointment or if a person is waiting to be seen
PA → Parenting / Pregnancy attitudes
“Do you think that you might like to have (more) children at some point?”
T → Timing
“When do you think that might be?”
H →How important delaying pregnancy is
“How important is it to you to prevent pregnancy (until then)?”
