PR3152 IC17 (main) Flashcards
what are the barrier techniques
male female condoms
diaphragm + spermicide
cervical cap
male condoms
(absolute contraindication, benefits, disadvantage)
absolute contra:
- allergy to latex or rubber
benefits:
- STI protection
disadvantage:
- high failure rate
- poor acceptance
- may break
female condoms
(absolute contraindication, benefits, disadvantage)
absolute contra:
- allergy to polyurethane
- hx of TSS
benefits:
- STI protection (if placed properly)
disadvantage:
- high failure rate
diaphragm with spermicide
AND
cervical cap
(absolute contraindication, benefits, disadvantage)
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
role of progestin and oestrogen in COCs
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
dosing adjustment criteria for oestrogen in COC?
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
Reason for increasing dose of oestrogen in overweight patients?
estrogen highly protein bound
- overweight patients = more tissue distribution = require higher dose
- higher dose to stimulate negative feedback loop
what is the progestin classification
and what are the trends
gen 1: norethindrone, norgestrel, ethynodiol diacetate
gen 2: levonogestrel
gen 3: nogestrimate, desogestrel
gen 4: drospirinone
decreasing androgenic effects with each generation
what are the androgenic side effects?
acne
oily skin
hirsutism
special instructions and counselling points for drospirenone
has antiandrogenic, some antidiuretic effects
but risk of hyperkalemia, venous thromboembolism, bone loss
why do we need higher progesterone dosing?
late cycle breakthrough or spotting
painful menstrual cramp
what are the 4 combinations of COCs?
monophasic
multiphasic
conventional cycle
continuous/extended cycle
describe monophasic COCs (and benefits)
same dose oestrogen and progestin
easy to follow and not complicated if miss dose
describe multiphasic COCs (and benefits)
varying dose oestrogen and progestin depending on the time of cycle
- helps to reduce overall progestin dosing = less SE
describe conventional cycle COCs (and benefits)
21+7 placebo
24+4 placebo
- second regimen helps to regulation hormonal fluctuations more = less SE
describe extended/continuous cycle COCs (and benefits)
84+ 7 placebo
convenient, less periods
when to initiate a COC and counselling for each starting point?
i.e. which day?
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
factors to select COC
adherence
hormonal content required
convenience
androgenic effects
risk factors/medical conditions
how do COCs cause VTE
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
what are the extra contraceptive benefits to using COCs?
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
breast cancer risk with COCs?
increases with age and duration
avoid if
* >40 years old
* current/family history/previous history (<5y)
risk should decrease after stopping
risk factors for VTE?
immobile
age >35yo
cancer
obese
smoker
hereditary
considerations for COC for patients at risk of VTE
low dose estrogen with older progestin
progestin only pills
barrier methods
what are the risk factors for MI/ ischaemic stroke and COC use
more likely due to oestrogen
migraine with aura, smoking, hypertension, dyslipidemia, prothrombotic mutations, age
what are the considerations for administrating COCs in patients at risk of MI/ischaemic stroke?
(relate risk to the type of regimen adjustment)
X migraine with aura = absolute = POP or barrier
X other risk factors = low dose estogen, POP, or barrier
what are the absolute contraindications for COCs
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
what are the common adverse effects of COC and how to manage them?
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
special counselling for COC side effects
should last 3-4 cycle, continue taking for 2-3 months unless serious AE
what are the drug interactions for COCs and explain the interactions (and special instructions)
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
what is the additional counselling for missed dosed (<48h) of COCs?
take the missed dose asap
continue regular dosing
no need for extra contraceptives
what is the additional counselling for missed dosed (>48h) of COCs?
take the missed dose asap
continue regular dosing
not more than 2 per day (discard remainder)
atleast 7 days of extra contraceptives
what is the additional counselling for missed dosed (in the last week e.g., 15-21 days of cycle) of COCs?
take the remainder of the last week
restart next cycle the next day
extra contraceptives at least 7 days
what are the POPs and their indications + contraindications
norethindrone and levonorgestrel
OR
drospirinone
indications: breastfeeding, intolerant to COC e.g. NV, conditions that preclude estrogen
contraindications: patients with breast cancer/risk of -
how to start on POPs
within 5 days of cycle = no backup
any other day = 2 day backup (7 for drospirinone)
what to do for missed doses of POPs
N/L: >3hours, take ASAP, extra contraceptives 2 days
D: <24hours, take asap, extra contraceptives 7 days if ≥ 2 pills missed
What are the dosing frequency for the diff POPs
N/L: continuos dosing 28 days
D: 24+4 placebo
transdermal patch regimen
3 week + 1 week without patch
take weekly
same MOA and ADR w/ COC
not as effective if >90kg
vaginal ring regimen
put for 3 weeks
same MOA and ADR w/ COC
precise placement not required
comparison of transdermal patch and vaginal ring to COCs
higher exposure (duration and percentage) to estrogen - higher risk of VTE compared to COCs
progestin injection regimen
any advantages/disadvantages
intramauscular
- every 12 weeks
- increases adherence but require doctor’s visit
Notable side effects of progestin injections
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
what are the LARCs?
long acting reversible contraceptions
INVASIVE
MOA of IUD
stop sperm migration, fertilised ovum migration, damages the ovum
contraindications of IUD
Should NOT be inserted if pregnant, current STI, undiagnosed vaginal bleeding, malignancy of genital tract, uterine anomalies, or uterine fibroids
risks of IUD
uterine expulsion, perforation,
pelvic infection
levonorgestrel IUD
for patients with menorrhagia (helps to reduce menstrual flow)
5 years
may have breakthrough bleeding
,,,
copper IUD
for patients with amenorrhea
10 years
heavier menstrual bleeding vs levonorgestrel
subdermal progestin implants
include dosing, length of use, ADR
4cm 68mg etonorgestrel
use for 3 years
ADR: irregular bleeding = amenorrhea, prolonged bleeding, spotting, frequent bleeding
failure rates of the different contraceptives
implant: 0.05
IUD (levo): 0.2
IUD (copper): 0.8
Progestin injection: 6%
pill, patch, ring: 9%
diaphragm, condoms, cervical cap: 13-21%
what are the three emergency contraception products?
copper IUD
ulipristal 30mg
levonorgestrel 0.75mg
how to use copper IUD for emergency contraception
insert within 5 days (left for 10 years)
how to use ulipristal/Ella tablet for emergency contraception
include dosing and special considerations
1 tablet ASAP within 120hours (5 days)
do not take if current on progestin contain oral regimen
(take 5 days after)
how to use levonorgestrel for emergency contraception
include dosing and special considerations
2 tablet ASAP best within 12h otherwise 72 hours
less effective if morbidly obese
MOA of Ella tablet/ulipristal for emergency contraception
and % protection
progestin receptor modulator
inhibit GnRH = inhibit ovum production, thin uterine lining, inhibit follicular rupture
60-80% protection
MOA of levonorgestrel for emergency contraception
and % protection
inhibit GnRH = inhibit ovum production, thin uterine lining
lower protection than ulipristal
what are the special counselling points for the two oral emergency contraceptives?
may cause nausea and vomiting
if less than 3hours (and vomitted out), to take another dose
