OCSH1 Flashcards
Levels
LH
FSH
Progesterone
Estradiol
Body Temp
LH -Really low after menstruation. Approximately day 14 LH will surge
FSH - a wave
Progesterone - after menstruation progesterone levels are low, after she ovulates, progesterone levels rises and right before menstruation it comes down
Estradiol - slowly increases, and just like LH surges then comes back down
Body temp: increases when ovulating. Also her saliva crystalizes when ovulating
Female cycle
Approximately day 14- ovulation, egg is released, progesterone increases day after ovulation, body temp rises along with elevated progesterone.
-progesterone and body temp remain high throughout rest of the cycle; however, if patient doesn’t get pregnant, both will gradually decrease and ultimately menstruation will day place on cycle day 28
Ovulation tests
Pregnancy tests test for
Checking for LH surge
Preg: beta-HCG level
components of COCs
Estrogens we use:
• ethinyl estradiol ( EE ): 10-50 mcg of estrogen
• Estradiol Valerate ( Tazia )
Estrogen Pharmacology :
- inhibits ovulation by suppressing hypothalamus release of FSH and LH
- inhibits fertilized ovum implantation
- accelerates ovum transport, decreasing fertilization time.
- cycle control
Progesterones
Progestins we use:
• DLNG ( norgestrel )- Ovral, • DSG ( desogestrel ) - Apri , Mircette, Ortho Cept, • ED ( ethynodiol diacetate ) - zovia, demulen
• LNG ( levonorgestrel ) - allese, levlen, triphasil, • NE ( Norethindrone ) - ortho-novum, •NEAC ( norethindrone acetate ) Loestrin, • NGM ( norgestimate ) - ortho tri cyclin
1st gen, 2nd gen, 3rd gen,
Progestin pharmacology :
- cycle control
- thickens cervical mucus that slows sperm transport and ability to penetrate ovum
-causes endometrial transformation
-Drospirenone: is a type of progestin equivalent to 25 mg spironolactone ( aldactone )
Regimens
Monophasic : every active pill are the same
Biphasic: pill change in dose of hormone over cycle. eg) constant estrogen; progestin increase in the late cycle.
Triphasic : 3 different hormones over cycle eg ) progestin /estrogen vary in 3 phase cycle ( q 7 days ) - have Tri in the name. Changing the phase 3 different times.
Qaudriphasic : 4 different phases
Extended cycle: seasonique ( having menstruation once a season. 91 day regimen, not 28 day. Having menstruation 4 times a year instead of 12 times a year.
Noncyclic regimen: librel; no cycle at all.
Progestin only : mini pill…
Monophasic
Eg ) lots of different kinds
Femcon Fe* and minastrin 24 Fe* are both chewable
Fe= iron ( can cause constipation )
Loestrin 1/20 EE= 20 mcg 1 is progesterone ( norethindrone 1 mg )
Ogestrel - EE= 50 mcg
Lybrel
Monophasic but really noncyclic bc no placebo days
20 mcg EE + levonorgestrel 90 mcg
Patient will complain about spotting in the beginning. Worst spotting in 1st 3 months but it will get better
YAZ/ Yasmin
Progestin = Drospirenone = sprinolactone 25 mg ( less water retention but risk of hyperkalemia )
- Drospirenone and desogestrel ; those 2 progestins have increased risk of clot formations vs other choice of progestins
Sprinolactone has antiandrogenic effects. Great choice for patients who have acne, excessive hair growth.
Yasmin - 30 mcg EE = 0.03 mg EE + 3 mg Drospirenone
-21 tabs 3mg Drospirenone & 30 mcg EE , -7 inert white tabs ( placebo days )
YAZ - 20 mcg EE ( 0.02 mg EE ) + 3 mg Drospirenone
- 24 tabs active tabs, - 4 white inert tabs
DDI: Drospirenone is 25 mg of spironolactoen so worry about ddi with ace, arb, Direct renin inhbitor ( tekturna ) so additive
Beyaz is like YAZ ( Drospirenone /EE but difference levomefolate calcium ( increases folic acid ) )
Biphasic
Mircette
Days 1-21 - 0.02 mg EE + 0.15 mg desogestrel
Days 22 -23 2 inactive tabs
Days 24-28 0.01 EE ( low amount ) so biphasic
Lo Loestrin fe
Really low amount of EE.
Reason biphasic day 25,26 no progesterone but EE 10 mcg continuing
Triphasic
7/7/7 = Triphasic
It either affects estrogen or progesterone.
7/7/7 - this has progesterone increase slowly over 3 phases
Tri- progesterone is changing
Enpresse, Levonest, - progesterone is changing but also estrogen is changing
Estrostep Fe - in the name. Affecting estrogen over 3 phases.
20 to 30 to 35 mcg
4 phases
Natazia ( estradiol valerate and dienogest )
All other contraceptives ( say they start on first day of menstruation ) ( or first Sunday after menstruation ) - have to use backup for 7 days,
For natazia - patient needs to use back for 9 days
extended cycle regimen
Seasonique
LoSeasonique
Quartette
Seasonique / LoSeasonique
Difference is amount EE
LoSeasonique has lower EE
91 tabs total, start on first day of menstruation or after fist Sunday after menstruation
84 tabs are active tabs
In placebo tabs on last 7 days you still get low dose of estrogen in them - ( sudden drop in estrogen can cause bleeding, migraines due to menstruation )
Quartette
91 tabs
84 active
7 inactive
Not true placebo days bc you get 10 mcg of EE in inactive pills
Progesterone stays the same except in placebo - 84 days
And estrogen changes in 4 phases - 91 days
Adverse effects of OC
Risk of CLOTs
- thickens blood 3-6 x so increase in risk of DVT and MI
- additional risk factors are smoking and &35 y/o
- low dose < 50 mcg poses less risk than older / higher dose formulations
You’d give smokers mini pill
Progesterone adverse effects
Androgenic effects: acne oily skin, increased appetite, weight gain, depression, fatigue, lethargy
Absolute contraindications
1) thrombo- embolic disorder or history ( DVT , CVA )
2) history of breast/uterus neoplasia
3) undiagnosed vaginal bleeding
4) liver issues
5) pregnant
Contraindications from WHO: lactation < 6 weeks postpartum ( progesterone increases breast milk but estrogen decreases production of breast milk ) - give mini pill
> 35 & smoke >15 cigs/day. HTN/ migraines, / diabetes with end organ disease, / chest pain
Physical exam before OC
BP , breast exam ( cancer? ), pelvic examination ( uterus cancer ? ) , Pap smear ( cervical cancer? ) , liver function ( abnormal? )
Family history of clotting issues? , social hx ( smoking? ) hypercoagulable?
When to start?
1) very first day of menstruation or Sunday after menstruation bleeding begins
Sunday start benefit: package will have days with Sunday starting
If you start on Sunday wont get menstruation on a weekend. Let’s say patient doesn’t want menstruation on Tuesdays and Wednesday, then start on Wednesday
SE will decrease with consistent use after 3 months
T
SE: spotting
DDI
ABX : reality is it doesn’t really affect oral contraception
- Griseofulvin has mixed data : clinically tell patients you worry about decrease of EE
Watch out for inducers:
CYP3a4 ( strongest inducer : rifampin )
Anticonvulsants: phenytoin, phenobarbital, carbamazepine, oxcarbazepine
Inhibitors DDI
Grapefruit juice: will increase estrogen —> SE: headache nausea,
Choose progesterone only if on inducers
Progestin Only
Micronor
Nor-QD,
Aygestin
Camila
Errin
Jolivette
Nora-BE
-norethindrone =0.35 mg
Initiated on the first day of menses
Use back up for 2 days if > 3 hours late on dose
Estrogen decreases milk production and postpartum women are in hyper coagulable state - give minipill
Alternative progestin forms
Medroxyprogesterone acetate
-Depo-provera ( 150 mg IM ) q 3 months
- Depo SubQ provera 104 q3 months
- Provera ( 2. 5 mg, 5 mg , 10 mg )
Candidates for use :
Can’t tolerate estrogen
Does patient have seizures ( estrogen is a more excitatory hormone and progesterone is more calming hormone)
Avoid in patients with depression and migraine headaches
SE:
Progesterone
Irregular bleeding and spotting for up to 7 days during 1st few months of therapy
Amenorrhea - no period at all
Weight gain
Delayed fertility upon D/C ( 9 months to 1 year )
Headache, nervousness, depression
Risk of bone loss with prolonged administration, may be irreversible
Depo provera
Deep IM injection Q3 months 150 mg ( given day 1-5 of cycle or after ruling out pregnancy )
-depoSubQ provera 104: SubQ
104 mg every 3 months ( every 12 to 14 weeks
Advantages :
No estrogen side effects ( no increased risk of blood clots)
Decrease seizure frequency - ok with anticonvulsants
Increase quantity of protein content in breast milk
Low failure rate 0.3%
Nexplanon
Implanted by physician ( inserted / removed minor procedure )
Subdermal ethonogestrel rod implant (
Released over 3 years -great long term option
Effect reduced by inducers
SE:
Risk of clots
Implantation site tenderness
Ortho- evra / Xulane patch
Apply to butt, ab, or upper outer arm or back
Change once a week, last week is placebo
Never put on breast area.
Releases about 60% more estrogen than oral OC
Xulane has less EE than orthoevra
Start on 1st day of menstrual cycle or 1st Sunday after patients period starts
If patch off for <24 hours- put patch back on
If patch off for > 24 hours - apply new patch asap, start, use back up for 7 days
Nuvaring Vaaginal ring
Used for 21 days q month ( 3 weeks )
Very low daily dose of EE and ethonogestrel
Refrigerate
- can store at room temp for up to 4 months
- if you refrigerate can be used until exp date on box
IUD/ IUS
Copper ( paragrad) - ( good for 10 years )
- cannot give if patient has Wilson’s disease or copper allergy
- sometimes used as emergency contraception. ( not FDA approved ) used with 5 days of UPI
Levonorgestrel - Mirena 5 years
( Skyla ) 3 years
( liletta ) - 3 years
Watching out for PID for first 20 days then after that it is rare.
If period is late make sure youre not pregnant
Benefit: highly efficacious, long acting, safe , rapidly reversible, avoidance of exogenous estrogen
Diaphragms
Caya ( no size )
Miles wide seal arching
All diaphragm are to be used with spermicide : ( nonoxynol 9)
Leave in 6 hours after sex but take out afterward ( dont want infection/ toxic shock syndrome )
Washing with mild soap and water
Dont use oil based products ( like petroleum jelly can break condom and thing out silicone gel )
Replace every 2 years. If you gain or lose weight need to resize
Spermicide
Nonoxynol- 9
MOA: immolizes sperm
How to chose OC?
Acne: ortho tri-cyclen, estrostep, and YAZ are all approved for acne.
Most COC are helpful bc estrogen decreases testosterone levels
-YAZ = 25 mg spironolacone which is an androgen receptor blocker
Weight gain: estrogen initially cause weight gain due to water and sodium retention but long term weight not likely
Pill with androgenic activity stimulate appetite, if this is suspected suggest less androgenic pill
PMS or dysmenorrhea: sx may improve with extended or continuous cycle pills : seasonique, Lybrel
Bloating: Yasmin or yaz
Menstrual migraine: if migraine from drop of estrogen then recommend something continuous ( seasonique etc)
If patient has migraine with auras - avoid EE bc increased risk of stroke.
Now if migraine & >35 years old -with or without aura we don’t recommended combined oral contraception bc fear of stroke
OC and medical conditions
If patient <35 y/o and controlled HTN can start COC with low estrogen ( <35 mcg ) Mircette, Loestrin,
If not controlled HTN then no EE
Diabetes : if non smoker, <35 y/o, without HTN, rentinopathy, or other vascular dz then you may be give COC, if diabetes plus one condition then no COC
Women with Hx of DVT, PE, CAD, CHF, or CVA : NO Estrogen products
-use mini pill
Breakthrough bleeding
- if bleeding early in cycle then maybe not enough EE ( now this is after patient on contraception for a couple of months )
If bleeding later in cycle it could be progesterone so ∆ progesterone
