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PR3152 (cleefy) > PR3152 IC17 (main) > Flashcards

PR3152 IC17 (main) Flashcards

1
Q

what are the barrier techniques

A

male female condoms
diaphragm + spermicide
cervical cap

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2
Q

male condoms
(absolute contraindication, benefits, disadvantage)

A

absolute contra:
- allergy to latex or rubber

benefits:
- STI protection

disadvantage:
- high failure rate
- poor acceptance
- may break

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3
Q

female condoms
(absolute contraindication, benefits, disadvantage)

A

absolute contra:
- allergy to polyurethane
- hx of TSS

benefits:
- STI protection (if placed properly)

disadvantage:
- high failure rate

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4
Q

diaphragm with spermicide
AND
cervical cap
(absolute contraindication, benefits, disadvantage)

A

absolute contra:
- allergy to latex or rubber
- gynaecological structure abnormalities
- hx of uti
- hx of TSS

benefits:
- low cost
- reusable

disadvantage:
- risk of UTI
- high failure rate
- cervical irritation
- low STI protection

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5
Q

role of progestin and oestrogen in COCs

A

progestin
- most of the contraceptive effects
- block LH surge
- thicken cervical mucus to prevent sperm penetration, slow tubal motility, induce endometrial atrophy
- stop ovulation

oestrogen
- help to stabilise the endometrial lining and provide cycle control
- suppress FSH release

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6
Q

dosing adjustment criteria for oestrogen in COC?

A

oestrogen not recommended >50ug = risk of vascular or embolic events, cancers.

lower dose (20-25ug)
- adolescence/>35 years old
- want to minimise side effects
- peri-menopausal
- underweight <50kg

higher dose (30-35ug)
- non adherence
- breakthrough bleeding/spotting
- overweight/obese >70.5

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7
Q

Reason for increasing dose of oestrogen in overweight patients?

A

estrogen highly protein bound
- overweight patients = more tissue distribution = require higher dose
- higher dose to stimulate negative feedback loop

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8
Q

what is the progestin classification
and what are the trends

A

gen 1: norethindrone, norgestrel, ethynodiol diacetate
gen 2: levonogestrel
gen 3: nogestrimate, desogestrel
gen 4: drospirinone

decreasing androgenic effects with each generation

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9
Q

what are the androgenic side effects?

A

acne
oily skin
hirsutism

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10
Q

special instructions and counselling points for drospirenone

A

has antiandrogenic, some antidiuretic effects
but risk of hyperkalemia, venous thromboembolism, bone loss

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11
Q

why do we need higher progesterone dosing?

A

late cycle breakthrough or spotting
painful menstrual cramp

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12
Q

what are the 4 combinations of COCs?

A

monophasic
multiphasic
conventional cycle
continuous/extended cycle

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13
Q

describe monophasic COCs (and benefits)

A

same dose oestrogen and progestin
easy to follow and not complicated if miss dose

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14
Q

describe multiphasic COCs (and benefits)

A

varying dose oestrogen and progestin depending on the time of cycle
- helps to reduce overall progestin dosing = less SE

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15
Q

describe conventional cycle COCs (and benefits)

A

21+7 placebo
24+4 placebo
- second regimen helps to regulation hormonal fluctuations more = less SE

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16
Q

describe extended/continuous cycle COCs (and benefits)

A

84+ 7 placebo
convenient, less periods

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17
Q

when to initiate a COC and counselling for each starting point?

i.e. which day?

A

1) at the start of menstrual cycle

2) on the first Sunday
- require 7 day extra contraceptives
- beneficial if do not want menstruation to occur on weekend

3) quick start (any day)
- require extra contraceptives at least 7 or until start of next menstrual cycle

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17
Q

factors to select COC

A

adherence
hormonal content required
convenience
androgenic effects
risk factors/medical conditions

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18
Q

how do COCs cause VTE

A

progestin: 4th gen ones unknown cause likely due to c protein resistance

estrogen: hepatic production of factor VII, X and fibrinogen = part of the coagulation cascade

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18
Q

what are the extra contraceptive benefits to using COCs?

A

help with acne, PMDD, PCOS, iron deficient anemia
control menstrual symptoms and irregularities.
reduce risk of endometrial and ovarian cancer.
reduce risk of ovarian cysts, PID, ectopic pregnancy, endometriosis, uterine fibroids, benign breast disease

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19
Q

breast cancer risk with COCs?

A

increases with age and duration

avoid if
* >40 years old
* current/family history/previous history (<5y)

risk should decrease after stopping

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20
Q

risk factors for VTE?

A

immobile
age >35yo
cancer
obese
smoker
hereditary

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20
Q

considerations for COC for patients at risk of VTE

A

low dose estrogen with older progestin
progestin only pills
barrier methods

21
Q

what are the risk factors for MI/ ischaemic stroke and COC use

A

more likely due to oestrogen

migraine with aura, smoking, hypertension, dyslipidemia, prothrombotic mutations, age

21
Q

what are the considerations for administrating COCs in patients at risk of MI/ischaemic stroke?

(relate risk to the type of regimen adjustment)

A

X migraine with aura = absolute = POP or barrier
X other risk factors = low dose estogen, POP, or barrier

21
Q

what are the absolute contraindications for COCs

A

Cancer conditions
* Current breast CA/ recent history of
breast CA within 5 years

Heart conditions:
* SBP > 160mmHg / DBP > 100mmHg
* HTN with vascular disease
* Current/History of ischemia heart disease
* Cardiomyopathy
* History of cerebrovascular disease

Stroke conditions
* Hx of DVT/PE, acute DVT/PE and pts with DVT/PE and on anticoagulant therapy
* Major surgery with prolonged immobilization
* Thrombogenic mutations
* Migraine with aura

Pregnancy conditions
* < 21 days postpartum with other risk factor
* <6 weeks postpartum if breastfeeding

Autoimmune conditions
* SLE with + or unknown APLA

Lifestyle factors
* Smoking ≥ 15 sticks/day AND age ≥ 35yo

Diabetes
* Diabetes >20 yrs or w/complications

22
Q

what are the common adverse effects of COC and how to manage them?

A

Changing to extended/continuous cycle:
1) headache
- to exclude migraine with aura
- occurs usually during placebo

2) menstrual cramps
- can also increase progestin

Increasing oestrogen dose:
1) acne
- can also consider antiandrogenic gen 4 progestin
- increase oestrogen if on POP > COC

Decreasing oestrogen dose:
1) nausea/vomiting
- can also consider taking at night/change to POP

2) bloating
- can also consider using drospirinone for mild diuretic effect

**Lower both oestrogen and progestin: **
1) breast tenderness/weight gain

23
Q

special counselling for COC side effects

A

should last 3-4 cycle, continue taking for 2-3 months unless serious AE

24
Q

what are the drug interactions for COCs and explain the interactions (and special instructions)

A

antibiotics (more specific to rifampin)
- affects the GI flora = alter metabolism = decrease effect of COCs
- do not take for 7 days and use extra contraceptives

anticonvulsants
- decrease free serum conc of COC (cyp inducer)
- Phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine, lamotrigine

HIV antivirals eg protease inhibitor
- decrease effectiveness of COC and antiviral

24
Q

what is the additional counselling for missed dosed (<48h) of COCs?

A

take the missed dose asap
continue regular dosing
no need for extra contraceptives

25
Q

what is the additional counselling for missed dosed (>48h) of COCs?

A

take the missed dose asap
continue regular dosing
not more than 2 per day (discard remainder)
atleast 7 days of extra contraceptives

26
Q

what is the additional counselling for missed dosed (in the last week e.g., 15-21 days of cycle) of COCs?

A

take the remainder of the last week
restart next cycle the next day
extra contraceptives at least 7 days

26
Q

what are the POPs and their indications + contraindications

A

norethindrone and levonorgestrel
OR
drospirinone

indications: breastfeeding, intolerant to COC e.g. NV, conditions that preclude estrogen
contraindications: patients with breast cancer/risk of -

27
Q

how to start on POPs

A

within 5 days of cycle = no backup
any other day = 2 day backup (7 for drospirinone)

27
Q

what to do for missed doses of POPs

A

N/L: >3hours, take ASAP, extra contraceptives 2 days
D: <24hours, take asap, extra contraceptives 7 days if ≥ 2 pills missed

28
Q

What are the dosing frequency for the diff POPs

A

N/L: continuos dosing 28 days
D: 24+4 placebo

29
Q

transdermal patch regimen

A

3 week + 1 week without patch
take weekly

same MOA and ADR w/ COC

not as effective if >90kg

29
Q

vaginal ring regimen

A

put for 3 weeks

same MOA and ADR w/ COC

precise placement not required

30
Q

comparison of transdermal patch and vaginal ring to COCs

A

higher exposure (duration and percentage) to estrogen - higher risk of VTE compared to COCs

31
Q

progestin injection regimen

any advantages/disadvantages

A

intramauscular
- every 12 weeks
- increases adherence but require doctor’s visit

32
Q

Notable side effects of progestin injections

A

will have variable breakthrough bleeding in the first 9 months

50% of patients become amenorrheic after 12 months > 70 after 2 years

more weight gain

short term bone loss = decrease bone mineral density
- X older women
- X osteoporosis risk factors e.g., steroids
- X more than 2 years of use

33
Q

what are the LARCs?

A

long acting reversible contraceptions

INVASIVE

34
Q

MOA of IUD

A

stop sperm migration, fertilised ovum migration, damages the ovum

35
Q

contraindications of IUD

A

Should NOT be inserted if pregnant, current STI, undiagnosed vaginal bleeding, malignancy of genital tract, uterine anomalies, or uterine fibroids

36
Q

risks of IUD

A

uterine expulsion, perforation,
pelvic infection

37
Q

levonorgestrel IUD

A

for patients with menorrhagia (helps to reduce menstrual flow)
5 years
may have breakthrough bleeding
,,,

38
Q

copper IUD

A

for patients with amenorrhea
10 years
heavier menstrual bleeding vs levonorgestrel

39
Q

subdermal progestin implants
include dosing, length of use, ADR

A

4cm 68mg etonorgestrel

use for 3 years

ADR: irregular bleeding = amenorrhea, prolonged bleeding, spotting, frequent bleeding

40
Q

failure rates of the different contraceptives

A

implant: 0.05
IUD (levo): 0.2
IUD (copper): 0.8
Progestin injection: 6%
pill, patch, ring: 9%
diaphragm, condoms, cervical cap: 13-21%

41
Q

what are the three emergency contraception products?

A

copper IUD
ulipristal 30mg
levonorgestrel 0.75mg

42
Q

how to use copper IUD for emergency contraception

A

insert within 5 days (left for 10 years)

43
Q

how to use ulipristal/Ella tablet for emergency contraception

include dosing and special considerations

A

1 tablet ASAP within 120hours (5 days)

do not take if current on progestin contain oral regimen
(take 5 days after)

44
Q

how to use levonorgestrel for emergency contraception

include dosing and special considerations

A

2 tablet ASAP best within 12h otherwise 72 hours

less effective if morbidly obese

45
Q

MOA of Ella tablet/ulipristal for emergency contraception

and % protection

A

progestin receptor modulator

inhibit GnRH = inhibit ovum production, thin uterine lining, inhibit follicular rupture

60-80% protection

46
Q

MOA of levonorgestrel for emergency contraception

and % protection

A

inhibit GnRH = inhibit ovum production, thin uterine lining

lower protection than ulipristal

47
Q

what are the special counselling points for the two oral emergency contraceptives?

A

may cause nausea and vomiting

if less than 3hours (and vomitted out), to take another dose

PR3152 (cleefy) (13 decks)

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