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Pharm > Quiz 5: Contraceptives > Flashcards

Quiz 5: Contraceptives Flashcards

1
Q

Mechanisms of contraception

A

sperm⇏vag, egg⇏area, no implant, awareness’s

  • prevent sperm from entering vagina/cervix
    • barrier methods, male sx sterilization
  • prevent egg from entering area of fertilization
    • hormone contraception, female sx sterilization
  • prevent implantation
  • fertility awareness
    • calendar method, cervical mucus viscosity, basal body T
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2
Q

__% not using contraceptive?

reason for __ million pregnancies?

highest rate in __-__yo?

lowest in __-__yo?

A

10% not using

3.1 million pregnancies

highest rate in 15-19yo

lowest in 40-44yo

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3
Q

neary __ of unintended pregnancies result from contraceptive failure?

A

half

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4
Q

__% of pregnancies unintended

__% of live births unintended

A

49% preg

34% birth

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5
Q

nightly… __ million not planning preg have intercourse

__ not using contraceptive

__ condom breaks or slips

A

9.7 million

1 million

31,000

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6
Q

COC background

A

‘60, ↑dose, 75m, 4/5 ‘45

  • intro 1960
  • originally much higher hormone doses
  • >75M women worldwide take coc’s
  • 4 out of 5 women in US born since 1945 have used coc’s
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7
Q

mestranol

A

(prodrug)mestranol estradiol → EE hep met

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8
Q

Progestin component

A
  • varies by drug
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9
Q

Monophasic, Biphasic and Triphasic coc’s

A

vary dose/mixture of estrogen/progestin by day in cycle

  • mono - same days 1-21
  • bi - days 1-10, 11-21 differ
  • tri - days 1-7, 8-14, 15-21
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10
Q

COC effectiveness

A

0.3/8%, 50% newbs miss 3+ pills@3mo, d/c-not replaced

  • First year failure
    • 0.3% perfect use
    • 8% typical
  • Missed pills - 50% first time users missed >=3 pills 3rd cycle
  • Stopping pills and not starting another contraceptive
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11
Q

COC MOA

A
  • Proven:
    • suppression of ovulation (2-7% cycles “escape ovulation”)
    • thickening of cervical mucus
  • Effects not proven to provide contraception
    • slowing tubal motility/progress of ova
    • endometrial atrophy/inhibit implantation
    • localized endometrial edema/inhibit implantation
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12
Q

COC advantages

A
  • effectiveness
  • rapidly reversible - ovulation normally 2 wks after d/c
  • decreased dysmenorrhea
  • reduced PMS symptoms - mastalgia, cramping, pain
  • reduced PMDD
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13
Q

PMDD

A
  • 5 symptoms cyclically pre-menstrual
    • at aleast one of these… significantly…
      • depressed mood
      • swings in emotion
      • anxiety/tension
      • anger/irritability
    • anhedonia
    • difficulty concentrating
    • fatigue
    • sig change in appetite
    • xs sleep/insomnia
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14
Q

COC general health benefits

A

↓ov, end(1/10/20/40/80), BB, acne

  • red ov ca risk
  • red endometrial ca risk
    • 1y - 40%
    • 10y - 80%
    • risk red lasts up to 20y after dc
  • red risk benign breast disease
  • improve acne
    • probably with all COC’s
    • dec test levels
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15
Q

COC disadvantages

A
  • daily
  • prescription
  • cost
  • STI’s
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16
Q

COC - MI risk

A

↑age, ↑dose, ↑↑smoke↘, other RFs

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17
Q

COC - Stroke

A

↑risk+age+dose, ↑↑htn/smoke/>35

  • inc risk - more likely with older, higher dose
  • greatest risk:
    • uncontrolled htn ~25%
    • smoke>10/day ~7%
    • >35y
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18
Q

COC - VTE

A

↑risk+age/dose/hx/sed/bmi, DVT/PE, !30/35

  • inc risk - more likely with older, higher dose
  • other RF’s
    • obesity, hx VTE, sedentary, age
    • CAUTION: BMI>30, >35y
  • types:
    • 2/3 DVT - 6% mort
    • 1/3 PE - 12% mort
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19
Q

COC - HTN

A

poss ↑3-5mmHg, most studies - no ↑htn

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20
Q

COC - DM

A

​not seen with current products

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21
Q

COC - GB dz

A

poss inc risk with pre-existing gallstones

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22
Q

COC - Liver

A

↑hep/neo/aden/ben, rupt-↑intraperitoneal bleed

  • Hepatic Neoplasms
    • inc risk of hepatic adenoma
      • benign liver tumor
      • poss rupture - extensive intraperitoneal bleeds
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23
Q

COC - FDA Contraindications

A
  1. thrombophlebitis/thromboembolic disorder
  2. Hx DVT or thromboembolic disorder
  3. cerebrovascular or coronary artery dz
  4. valvular heart dz w/complications
  5. severe htn
  6. dm w/vascular involvement
  7. H/A w/focal neuro sx
  8. Major sx w/prolonged immobilization
  9. BrCa
  10. Endometrial Ca
  11. estrogen dependent neoplasia - known/suspected
  12. undiagnosed abnormal genital bleeding
  13. cholestatic jaundice
  14. hepatic adenomas/carcinomas
  15. preg, or poss
  16. hypersensitivity to any component of product
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24
Q

Quick Start

A

day of visit, bu7, mens w/placebo, WHO, :25% error, preg OK

  • first pill day of visit, 7 days back up cont, menses delayed until placebo started
  • off-label but endorsed by WHO
  • inc likelihood of starting correctly
    • 25% error rate conventional method
  • Early pregnancy risk? Low-dose COC not adversely effect early pregnancy
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25
Q

First-day Start

A

day 1 mens, not preg, no bu, delay-errors

  • first pill on first day of next period
  • insures not preg
  • back up not needed
  • delay between visit and initiation - inc chance not start correctly
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26
Q

Sunday Start

A

bu 1-sun(mon=7), no preg, wkends!, delay, refills

  • first pill first sunday of mens
  • back up req for 7 days if mens starts on monday
  • insures not preg
  • period free weekends
  • delay between visit and start
  • may be harder to get refills on weekends
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27
Q

Perimenopausal Use

A

Caution of thrombosis in obese women over 35y

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28
Q

Use in smokers

A

35>15/40!!!, 35-40!, 20/↑met/tit/bu2-3mos**

  • Don’t:
    • >35y and >15 cig/day
    • >40y and any smoking
  • Caution against use 35-40y w/ reg smoking
  • Start with 20mcg EE to minimize Estrogen dose
    • smoking inc EE met, may need inc dose for efficacy
    • back up for 2-3mos
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29
Q

Postpartum use

A

preg=↗coag + EE ⇒ 3-4wk pp

  • preg = hypercoagulable state
  • Est inc risk of thromboembolism
  • delay COC 3-4wks postpartum
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30
Q

Breastfeeding use

A

EE→milk=adversely, !solo nut

  • est may adversely effect breaskmilk
  • Am Academy Ped’s advises against COC if breastmilk is sole source of nutrition
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31
Q

Interaction with broad spectrum abx

A

fp hep/gi conj →gb→si→li flora unconj→blood, theory/no proof

  • sex steroids abs in si and shunted to liver
    • 60% EE conj in intestinal mucosa and liver
      • excreted through gb to si
    • li bacteria un-conj est metabolites
      • free to be abs to blood
  • despite theoretical risk, bsa’s not shown to dec COC efficacy
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32
Q

“Missed pills” includes

A

v<2h, n/v 2+d

  • vomit <2h after taking
  • severe v/d 2 or more days
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33
Q

Missed pill risk when…

A
  • after 7 pills correctly, little risk of ovulation until 7 consecutive pills missed
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34
Q

Increase risk of escape ovulation (2)

A
  1. missing pills early in packet
  2. lower dose (20mcg EE) pills used
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35
Q

Missed Pills >30mcg EE

A
  • 1-2 pills
    • take active pill ASAP, continue daily pills including today
    • consider EC if 1st week and unprotected intercourse
  • 3 or more pills, wks 1-2
    • as above, plus back up/abs until 7 consecutive active pills
  • 3 or more pills, wk 3
    • finish active pills in current pack
    • start new pack
    • skip placebo
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36
Q

Missed Pills <30mcg EE

A
  • 1 pill
    • take active pill ASAP, continue daily pills including today
    • no back up
    • consider EC if 1st week and unprotected intercourse
  • 2 or more pills, wks 1-2
    • as above, plus back/abs up until 7 consecutive active
  • 2 or more pills, wk 3
    • finish active pills in current pack
    • start new pack
    • skip placebo
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37
Q

Missed Pills - simplified approach

A
  • unprotected sex in last 5 days
    • EC at once
    • 1 COC pill twice next day, continue pack
    • condoms for 7 days of renewed COC use
  • not in last 5 days
    • 2 COC’s ASAP, continue pack
    • condoms for 7 days of renewed COC use
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38
Q

Unscheduled spotting/bleeding

A
  • 30-50% in first few months
  • 70-90% none by 3rd pack
  • management of bleeding…
    • before completing active pills
      • endometrial support - inc prog content
    • continued after withdrawal bleed
      • more E or less P
    • mid-cycle - etiology unk
      • try tri-phasic, inc E+P in middle pills
39
Q

COC’s and weight

A
  • insufficient data to determine effects
  • no large effect evident
40
Q

COC’s and H/A

A

new/↑: eval RFs, usually<3mo :no proof △ pills

41
Q

Yasmin/Yas

A
  • 7/4 placebo pills/cycle (4 shorter period)
  • EE + drosperinone (steroidal prog of spirolactone group)
    • antimineralocorticoid activity
      • mild diuretic = less water wt gain
        • dec bloating if caused by h2o ret, not nec cause
      • inc risk hyper K with (snak)
        • Spironolactone/eplerenone
        • chronic NSAID
        • ACE/ARB
        • K supp/salt subs
42
Q

Season- pills

A
  • = levonorgestrel + EE, #84 + #7 pills
  • Seasonale - 30+placebos
    • 1st COC for extened cycles (q3mo)
    • ↑spotting v #28
  • Seasonique - 30+10
  • LoSeasonique - 20+10
    • 10s v placebo marketed: ↓spotting, shorter/lighter period
43
Q

Lybrel

A

levo+20, 1st contin/atro-endo, 41% spot>6m

  • levonorgestrel + 20mcg EE
  • 1st COC continuous use - no menses
    • atrophic endometrium - no need to slough
  • still many report spotting/bleeding
  • mfg reports 59% stopped bleeding after 6mo
    • 41% bleed beyond 6mo
44
Q

NuvaRing

A

120eto+15 qd, ~PO-fp, 21/7

  • soft, transparent, flexible copolymer ring, 2” dia
  • releases 120mcg etonorgestrel + 15mcg EE daily
    • abs rate sim to PO, no first pass effect
  • 21 day vag insert, discard and place new one 7 days later
    • expect menses during 7 days
45
Q

NuvaRing failure rate/AE’s

A

same

  • 0.3% perfect use, 8% typical - both same as COC
  • AE’s = COC
46
Q

NuvaRing advantages

A

ease, no spike/↓bl abn, fast+/- next cycle

  • easy to use
  • slow, steady release of hormones (v. daily spike w/pills)
    • low levels of bleeding abnormalities
  • rapidly effective/reversible - most ovulate next cycle after stopping
47
Q

NuvaRing disadvantages

A

=coc risk, fall out, foreign body

  • same risk as coc for mi, stroke, vte
  • ring expulsion “fall out”
  • “foreign body” sensation
48
Q

NuvaRing expulsion

A

<3 re, >3 bu7 re/EC12 or new3

  • <3h - rinse lukewarm h2o, reinsert
  • >3h wk 1 or 2
    • rinse/reinsert
    • back up for 7d
    • EC if unprotected sex
  • >3h wk 3
    • discard, insert new ring
    • back up for 7d
49
Q

3 methods to start NuvaRing

A

day 1 alone, 1-5/visit bu7

  1. insert 1st day of bleeding, no additional contraception
  2. insert day 1-5 of bleeding, back up 7d (not diaphragm)
    • this is from package insert, very conservative, would probably be ok
  3. insert day of office visit, back up 7d
50
Q

Xulane

A

patch, 150 norelgestromin + 20 qd

  • transdermal patch - thin, 3 layer, flexible, 20cm2
  • releases 150mcg norelgestromin and 20mcg EE daily
51
Q

Xulane failure rate/AEs

A

same

  • 0.3% perfect use, 8% typical - both same as COC
  • AE’s = COC
52
Q

Xulane disadvantages

A

risk=coc, ↑60/Black Box, skin, Br sx

  • same risk mi, stroke, vte as coc
    • 60% higher systemic hormone levels v. coc (no 1st pass)
    • Black Box Warning - poss inc vte risk, not conclusive
  • skin rxns
    • irritation, redness, rash - 3% d/c
    • rotate sites, do not apply over irritated/broken skin
  • breast sx
    • discomfort, engorgement, pain in cycles 1+2
    • more common w/patch v. coc
53
Q

Starting Xulane

A

day 1, sun bu7

  1. apply 1st day of bleeding
  2. apply 1st sunday, back up 7d
54
Q

Xulane dislodged/detached

A

re < 24h < new/bu7/EC

  • <24h
    • try to re-adhere with pressure, not adhesive or wrap
    • if no seal, replace
  • >24h
    • start new patch cycle immediately – new change date
    • back up 7d
    • offer EC if had unprotected sex
55
Q

POP’s

A
  • prog=norethindrone
  • “minipills”
  • Nor-QD, Micronor, Ovrette
  • prog dose<coc>
    </coc><li>active pill same time every day - mission critical d/t lower dose</li>

</coc>

56
Q

POP failure rates/reasons

A

same, ↓dose→timing!

  • 0.3% perfect use, 8% typical
  • d/t lower prog dose = shorter duration of action
    • late pill can compromise efficacy
57
Q

POP MOA (4)

A
  1. ovulation inhibited in variable proportion of cycles
  2. cervical mucus thickened, may prevent sperm penetration
  3. reduced ovum transport through fallopian tube
  4. altered endometrium, may inhibit implantation
58
Q

POP advantages

A
  • Safety - no EE, lower prog (no comparative data)
  • few contraindications
  • simple, fixed daily regimen - same pill every day
  • immediate reversibility
59
Q

POP disadvantages

A

bleeding △’s, timing/efficacy

  • menstrual cycle disturbances
    • bleeding changes in many/most users
      • short cycles, irregular periods, spotting most common
  • vulnerable efficacy
    • must be taken same time each day
60
Q

POP contraindications

A
  • known/suspected preg
  • known/suspected BrCa
  • undiagnosed abnormal vaginal bleeding
  • hypersensitivity to any component
  • benign or malignant liver tumors
  • acute liver dz
61
Q

Starting POP’s

A

no bu - 1-5d, 6-6pp, 21pp, next day : bu2

  • may be started immediately w/o back up if:
    1. during 1st 5 days of cycle
    2. 6wk-6mo pp if fully breastfeeding and amenhrrheic
    3. w/i 21d pp (not br.feed)
    4. day after stopping another hormonal method
  • under any other circumstances must use back up 2 days
62
Q

POP user instructions

A

no off days, 3h late - imm+bu48

  • start next pack day after last pack is finished
    • no days off
  • 3hr late taking pill -
    • take immediately
    • back up 48h
63
Q

Prog-only injection

A
  • Depot medroxyprogesterone acetate (DMPA-IM)
  • 150mg deep IM injection
  • q3m
64
Q

Prog-only injection first year failure rates

A

0.3 - 3​%

  • 0.3% perfect use, 3% typical
65
Q

Prog-only injection disadvantages

A

d/c delay - 10/50, q3m, BB min/WHO

  • cannot d/c immediately
    • 10mos for 50% conception rate
    • 20mos to approach 100%
  • q3m return visits required
  • Black Box Warning -
    • Depo-Provera may cause sig loss in bone mineral density
    • increases with duration
    • may not be completely reversible
    • should only be used long term (2y) if no other adequate
    • WHO studies show it is reversible
66
Q

Implanon/Nexplanon

A

68mg eto, match SQ, 3y, most eff hormonal

  • single matchstick sized soft medical polymer rod
  • contains 68mg etonorgestrel
  • inserted just under skin in arm
  • provides effective contraception for 3y
  • most effective hormonal method
67
Q

Implanon first year failure

A

0.05/0.05% - most effective hormonal method

68
Q

Implanon advantages

A

same + ease, discrete, rev 6w/2cy

  • same as other prog only methods
  • ease of use - no regular user activity
  • discreet
  • reversibility - upon removal, ovulation for most returns within 6 wks, 2 cycles
69
Q

Implanon disadvantages

A

=POP, insertion issues, 1-5d : bu7

  • same as other prog only methods
  • insertion complications
    • swelling, redness, bruising, pain (3.6%)
    • incorrect technique
  • clinician dependent - must be inserted by skilled, trained practitioner
  • immediately effective if inserted in 1st 5 days of bleeding
    • otherwise backup 7 days
70
Q

IUDs available in US (2)

A
  • ParaGard - polyethylene with barium for X-ray visibility, wound with fine Cu wire
  • Mirena/Skyla/Liletta - levonorgestrel intrauterine systems
71
Q

IUD first year failure rates

A

ParaGard 0.6/0.8%

Mirena 0.2/0.2%

72
Q

IUDs MOA

A

prevent fert….

  • ParaGard - imair sperm fx - Cu spermicidal?
  • Mirena
    • thickening cervical mucus
    • inhibit sperm survival
    • suppress endometrium
    • suppress ovulation in some women
73
Q

IUDs advantages

A

eff, ect, dur, $$

  • highly effective
  • protect against ectopic preg
  • long-lasting
  • cost-effective
74
Q

IUDs disadvantages

A

irr mens early, insertion/pain/cramp/perf/null, expulsion2-10/null, strings

  • menstrual disturbances - irregular bleeding common in early months
  • insertion cramping and pain
  • spontaneous expulsion - 2-10% in 1st year
  • perforation at insertion
  • string problems - missing strings may signal perforation or expulsion
  • w/o hx pregnancy
    • more difficult insertion
    • more risk expulsion
75
Q

Spermicide

A

​

nonoxynol-9, surf/cm, solo/barrier

76
Q

Spermicide formulations

A
  • gels, creams, foams
    • useful immediately
    • with barrier, foam alone because if filles vaginal vault
  • suppositories, tablets - “inserts” –names can lead to errors
    • 10-15min to dissolve/disperse
  • film - inserted near cervix 15 min before intercourse
77
Q

Spermicide first year failure rates

A

18/29%

78
Q

Spermicide advantages

A

OTC, imm eff, lube, no sys sfx

  • no rx
  • effective immediately (some)
  • lubricating
  • no systemic sfx
79
Q

Spermicide disadvantages

A

timing(15m/1-3h), irritation, messy, ↑lube

  • timing intercourse
    • may be too early with suppositories, tablets and film
    • too late 1-3h
  • vaginal/penal irritation
  • messy
  • excessive lubrication
80
Q

Diphragm and Cervical Cap

A

6-8 > 24/48, “jelly”

  • dome-shaped latex cup inserted before intercourse
  • covers cervix
  • typically used with spermicide “jelly” (name issue)
  • timing concerns:
    • leave in place 6-8h after intercourse
    • no longer than
      • 24h diaphragm
      • 48h cervical cap
81
Q

Diaphragm and Cervical Cap first year failure rates

A
  • diaphragm 6/16%
  • cervical cap
    • null 10/16%
    • parous 26/36%
82
Q

Condoms - types

A
  • latex - natural rubber
  • synthetic - polyurethane, polyisoprene
  • natural - lamb cecum - larger pores inc vuln to STI
83
Q

Condoms - breakage/slippage

A

polyurethane > latex

84
Q

Condoms first year failure rates

A

2/18%

85
Q

Condoms - differences

A
  • Size - no standard
  • Thickness - no standard
  • Spermicide - not recommended d/t
    • no increased protection
    • increased irritation - poss inc vuln STI
  • Novelty Ingredients - some warn “not shown to decrease STI or pregnancy”
86
Q

Condoms - advantages

A

STI, access, $$, port, no sys, ↘prej

  • STI protection - best point
  • accessibility
  • $$
  • portability
  • no sys sfx
  • may ↘prej
87
Q

Condoms - disadvantages

A

↘sens↘spont, allergies

88
Q

Female Condom - advantages/disadvantages

A
  • advantages
    • latex-free
    • protects outside vagina
    • can be inserted 8h before intercourse
  • disadvantages
    • dislike ring outside vagina
    • cumbersome
    • expensive v. male condoms
89
Q

Emergency Contraception - definition + efficacy

A

post fluid exchange, preg 8↘0.5-2%

  • contraception implemented after unprotected intercourse
  • efficacy: drops pregnancy rate following unprotected intercourse from 8% to 0.5-2% if utilized appropriately
90
Q

EC - E/P

dosing + ADRs

A

Yuzpe since ‘74, coc(50EE/250lev), 2 now, 2 @12h

N/V d/t EE, Br tend, Irr bleed, HA

91
Q

EC - Prog only - MOA, time window, ADRs

A

ovulytic/↓sperm tx, 72h, fat/nau/ha/↑bleed/low abd pain

  • MOA: prevent ovulation (primary) and impair sperm transport
    • not abortifacient
  • Time window: up to 72h after unprotected intercourse
  • ADRs:
    • Fatigue
    • Nausea
    • HA
    • Heavier menstrual bleeding
    • Lower abdominal pain
92
Q

OTC ECs

A

Plan B One-Step, 1.5mg levo

no age rest, “17+”, no ID/proof

93
Q

EC - Ulipristal

A

Ella - sel PROG R mod/ag/ant props

30mg <120h, >PROG only for BMI 26+

HA, Abd pain, Nausea, Dysmenorrhea

94
Q

EC - Copper-T IUD

A

5d window, **99%**, !PID/gon/chlam

Pharm (7 decks)

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