Reproductive Physiology, Contraception Flashcards
follicular phase
day 0 to day 14
FSH released from P to recruit follicles to grow and develop, one follicle dominates and releases estrogen, estrogen rises until day 14
inc estrogen will increase progesterone to dec FSH and GnRH and cause death of non-dominant follicles, and dec meses flow
day 14
final day of follicualr phase
estrogen reaches threshold to cause LH surge, oocyte release and ovulation
luteal phase
day 14-28 ish
corpus luteum is formed from follicles that didnt make it
if conception has occurred, the corpus luteum releases Progesterone to stop menses in preparation for preggo
if conception didnt occur, the corpus luteum dies off and doesnt release progesterone (sheds) and menstruation occurs again
what is the reset like to connect day 28 to day 1
as E and P decrease, dec - fb to FSH so FSH increases, increases E, LH spikes, progesterone preps but then menses again if not preggo
contraception MOA progestin and estrogen
progestin blocks LH surge to prevent ovulation needed for conception; MOST OF CONTRACEPTIVE EFFECTS; thickens cervical mucus, endometrial atrophy (prevent implantation)
estrogen prevents FSH release to prevent follicular development and maturation; CYCLE CONTROL AND REGULATE ENDOMETRIAL LINING,
how long does a pt have to try a contraceptive before an AE can indicate a medication change
3 months
when are women the most fertile?
24 - 48 hours post-ovulation (LH surge)
physical assessment with contraception
BP before initiating CHC
1pregnancy test when needed
weight measurement for monitoring
omit PELVIC EXAM unless IUD
Which meds are CHCs
pills, patch, ring
CHC tablets
advantages
disadvantages
:) : regulates blood loss, good for anemia, endometriosis, fibrosis, dec cramps , increased spontaneity, dec ovarian, endometrial colorectal cancer, dec benign breast mass (NOT CANCER)
:( : spotting, post pill amenorrhea, mood changes, adherence, expensive, dec libido, cervial and breast cancer, no STD protection,
CHCs AE
common
serious
common: nausea, bloating, breakthrough bleeding (improve after 2-3 mo)
serious: Abdominal pain Chest pain Headaches Eye problems Severe leg pain
ACHES pneumonic
for CHCs Abdominal pain Chest pain Headaches Eye problems Severe leg pain
CHC ring
Nuvaring, Annovera
how to use
insert into vagina and leave for 3 weeks, then 4th week is ring free
**Annovera is insert same ring every four weeks for up to a yr
CHC ring advantages and disadvantages
:) : less spotting than CHC, dec ovarian, colorectal and endometrial cancers like COCs, dec benign breast mass (not cancer), good for adherence, non latex, Nuvaring grace period 35 d, can remove for intercourse for up to 3 hours, can use with tamponor yeast infection
:( : spotting, amenorrhea, insert and removal, discomfort during intercourse, nuvaring requires refrigeration
CHC ring AE
ACHES Abdominal pain Chest pain Headaches Eye problems Severe leg pain
Are CHC rings systemic or local
systemic
CHC patch (Xulane, Twirla) how to use
place patch on dry, harless area of upper arm, shoulder, abdomen or buttox
do NOT place near breast
rotate site qwk
1 patch a week x3 wks then 4th week patch free (like ring but change qwk)
CHC patch advantages and disadvantages
:) : less spotting than COC, good for adherence, dec endometrial, colorectal and ovarian cancers, dec benign breast mass (not cancer), grace period up to 9 days (ok if forgot to change patch week 2 and left it on for an extra 7 days), can swim and bathe with it
:( : spotting possible, amenorrhea, inc risk breast cancer, clot risk, skin irritation, rotating site, patch can detach
CHC patch AE unique
higher risk blood clots, irritation at patch site,
Xulane clinical pearl
less effective in women >198lb/90kg
Twirla patch clinical pearl
CI BMI >30
lower estrogen exposure than Xulane which cn decrease clot risk
Progestin only Contraceptives (POCs)
(norethindrone)
how to use
po qd, no placebo week, continuous
POCs advantages and disadvantages
dec blood loss, dec cramps, inc libido, spontaneity, easy to use, dec endometrial cancer, preferred over CHC bc of CI, reversible and efficacious
:( : irregular menses (E provides cycle control), adherence hard, anxiety, irritability, fewer contraceptive bennies, P- related SE (acne, weight gain)
POCs missed dose management
POP dose needs to be taken at the same time every day
if dose is missed, pt has 3 HOURS to take it
if missed dose occurs, BAM x48h
new POP aporoved in 2019
Drosperinone 14d/4 placebo (Slynd)
24 hour missed pill window
CI women at inc risk hyperkalemia, hepatic impairment and adrenel insufficiency
Progestin only injection (Depo Provera, Depo SQ)
admin
1 mL crystalline susp of Depot medroxyprogesterone acetate (DMPA) in deltoid or buttox
150 mg IM q 11-13 wks
104mg SQ q 11-13 wks
POI Depo Provera
advantages and disadvantages
:) : dec cramping, amenorrhea, dec blood loss, dec endometriosis, inc compliance, dec endometrial cancer, effective
:( : irregular menses, risk of depression, dec BMD, weight gain, slow return to fertility, provider visit needed every time
is depo provera rapidly reversible?
no
can dealy infertility for up to 18 monts (caution in women >35 who are interested in future conception)
Depo Provera AE
progestin related (acne, weight gain) severe depression (rare) BBW Bone Loss due to dec Estrogen production
Depo Provera clinical pearls
do not massage area for a few hrs, irregular spotting in beginning
Take Calcium! 1000-1200mg/d
can be given no longer than 15 wks apart
Progestin Only (LNG) IUD Mirena, Liletta, Kyleena, Skyla
admin
inserted into uterus by healthcare professional and usually stays in place for 3-6 yrs
PO IUDs and length of efficacy
Mirena 6 (maybe 7)
Liletta 6
Kyleena 5
Skyla 3
PO IUDs advantages
amenorrhea, menorrhagia improves, endometriosis improves, adherence, ins spontaneity, dec endometrial cancer, effective, readily reversible
PO IUDs disadvantages
irregular menses for 3-6mo, expulsion (rare), inc risk PID 20 days after insertion
PO IUDs AE
PAINS
Period late, abnormal spotting, inc/dec bleeding
Abdominal pain, pain with intercourse
Infection (STI), abnormal vaginal discharge
Not feeling well, fever, chills
String missing, shorter or longer
PAINS acronym
For IUDs!
Period late, abnormal spotting, inc/dec bleeding
Abdominal pain, pain with intercourse
Infection (STI), abnormal vaginal discharge
Not feeling well, fever, chills
String missing, shorter or longer
Progestin Only (LNG) IUD clinical pearls
LNG causes cervical mucus thickening
string of IUD stays outside cervix
Skyla has metal ring that may interfere with MRI
placement easier with lidocaine spray
Copper IUD (Paragard) admin
inserted into uterus by health care professional and good for 10 years
works primarily as spermicide
Copper IUD (Paragard) advantages
cycle remains regular, adherence, spontaneity, cost effective readily reversible, may be effective for 12 years
Copper IUD (Paragard) disadvantages
dysmenorrhea, spotting, cramping, monthly blood loss inc 50% (use NSAIDs), discomfort during sex, expulsion, PID inc risk for 20 days post-insertion, foreign body
Copper IUD (Paragard) AE
PAINS
Period late, abnormal spotting, inc/dec bleeding
Abdominal pain, pain with sex
Infection (STI), abnormal vaginal discharge
Not feeling well, fever, chills
String missing, shorter or longer
Copper IUD (Paragard) Clinical Pearls
may be used for emergency contraception
Sponge
non latex
non rx
can insert 6 h prior, can remain in place for 24h
must leave in for 6h post intercourse
Diaphragm
latex
rx
can insert 6h prior and remain in place 24h
keep in for 6 hours post intercourse
Cervical Cap
non latex
rx
can insert 6h prior and remain in place 48h
keep in for 6 hours post intercourse
female condom
non latex
non rx
insert up to 8 hours prior
immediate removal
male condom
latex/non latex
non rx
immediately prior and immediately after
periodic abstinence
avoiding sex when ovulating
high pregnancy rates
NaturalCycles.com
Male sterilization
advantages
disadvantages
vasectomy
sterility ~3 mo post op
inc sexual enjoyment, simpler, safer than female sterilization, no further visits once sperm count = 0
:( : fear of op preventing sexual function, regret, short term discomfort, no STI protection
Female sterilization
advantages
disadvantages
Laparoscopic (transabdominal)
- Bipolar cautery (high risk fistulation and ectopic preggo)
- Silastic Band (highest failure rate)
Filshie clip (may apply postpartum)
Postpartum or internal mini-laparotomy
- ligation or excision
:) : no preggo worry, dec ovarian cancer, permanent, v effective
:( : regret, outpt surgery, ectopic preggo, not readily rev, does not prevent HIV/STI
Yuzpe
emergency contraception
WITHIN 3 DAYS
2 doses, N/V, cost high, breast tnederness, HA
Can take w food or meclizine50mg 30-60 min before each dose
Levonorgestrel (po) (Plan B)
1.5mg tav po x1 WITHIN 3 DAYS
v accessible, cost high, N/V, menstrual changes
ongoing need for contraception, check for STI, need medical F/U, BUM x7d, can use multiple times per cyc;e
Ulipristal (Ella)
emergency contraceptive 30mg po x1 WITHIN 5 DAYS more effective than po LNG (Plan B) Rx :/, CYP3A4 substrate, N/V, HA, abdominal pain, menses changes, dysmenorrhea
only ONCE per cycle
BUM x14d or until end of cycle
Copper IUD emergency contraceptive
place WITHIN 5 DAYS PAINS Period late, abnormal spotting, inc/dec bleeding Abdominal pain Infection (STI), vaginal discharge Not feeling well, fever, chills String missing, shorter or longer
most effective, need office visit
LNG IUD emergency contraception
WITHIN 5 DAYS PAINS Period late, abnormal spotting, inc/dec bleeding Abdominal pain Infection (STI), vaginal discharge Not feeling well, fever, chills String missing, shorter or longer
off-label, need office visit
which emergency contraception options are needed within 5 days or 3 days
Yuzpe and LNG (Plan B) are within 3 days
Ulipristal/Ella, Copper IUD, and LNG IUD are within 5 days
which contraceptives dec endometrial cancer
CHCs (po, patch, ring), POCs, IUDs
which barrier contraceptives are latex
diaphragm and male condom
which contraceptives are rapidly reversible?
CHC patch, POI (progestin only implant) Nexplanon, IUDs
POI (progestin only implant) Nexplanon, Implanon
admin
rod inserted SQ in upper arm
POI nexplanon advantages and disadvantages
:) : amenorrhea, menorrhagia improve; adherence, readily reversible, effective for 3 years, MRI safe, varying BMIs ok
:( : irregular meses first 6 mo, expulsion, inc risk infection first 20d, progestin-related AE
POI Nexplanon AE
progestin related (weight gain, acne) bleeding irregularities, inflammatoin, hematoma, pain, redness, difficulty removing rod, rod breaks, fibrosis
Which IUD contraceptives are good for 6 years
Mirena, Liletta
Which IUD contraceptive is good for 5 years
Kyleena
Which IUD contraceptive is good for 3 years
Skyla
which contraceptives are CHCs
which are POCs
CHCs are COCs, Patch, Ring
POCs are Depo-Provera, Nexplanon, PO (LNG) IUDs
When to start a contraceptive?
all of them can be started any time as long as pateint is certainly not pregnant
how long is additional contraception needed for copper IUD
none
how long is additional contraception needed for LNG IUDs
BUM x7d if starting >7d post menses
how long is additional contraception needed for implant
BUM x7d if >5d post menses
how long is additional contraception needed for injectable
BUM x7d if starting >7d post menses
how long is additional contraception needed for CHC
BUM x7d if >5d post menses
how long is additional contraception needed for POP
BUM x2d if >5d post menses
what if pt misses dose of COC?
<24h (late) or 24-48h (missed 1 dose): take dose ASAP, continue taking at usual time, no contraception needed
if >48h (2+ pills missed): take most recent ASAP, discard missed, BAM x7d
- if doses were missed in week 3, finish the hormone pills in current pack even if it omits week 4, start new pack immediately after
- consider EC if missed in week 1 and had intercourse <5d prior
What if patch application is delayed or detached?
<48h: apply new one ASAP, keep same patch change day, EC not needed
> 48h: apply new patch ASAP, use BAM x7d, if occurred in third patch week, omit week 4 by finishing third week and starting new patch immediately
*EC considered if delay was in week 1 and unprotected intercourse occurred within the last 5d
What if delayed insertion/reinsertion of ring?
<48h: insert ring ASAP, keep in until scheduled ring day, no BUM needed, EC not needed
> 48h: insert ASAP, keep in until scheduled ring removal day, use BUM until its been in for 7d, omit week 4 by finishing up week 3 and inserting new ring right after
*EC considered if delay was in week 1 and unprotected intercourse occurred within the last 5d
