Test 1 Contraception Flashcards

Question

Considerations for Initiating Combined Oral Contraceptives (COC)

Answer 1

* Concomitant medical conditions * Examinations before initiating Contraceptives * Estrogen and progestin dose * Monophasic vs phasic * Cycle length * Start date

Answer 2

* U.S. Medical Eligibility Criteria for Contraceptive Use – 4 categories * Category 1 – condition for which there is no restriction for the use of the contraceptive method * Perfectly safe – no restrictions * Category 2 – condition for which the advantages of using the method generally outweigh the theoretical or proven risks * Generally considered safe * Category 3 – condition for which the theoretical or proven risks usually outweigh the advantages of using the method * **Don’t recommend** * Category 4 – condition that represents an unacceptable health risk if the contraceptive method is used * **Don’t recommend**

Answer 3

* **Don’t need** PAP Smear * **Don’t need** pregnancy test but you have to be reasonably sure that the patient is not pregnant * **Needs blood pressure taken**

Answer 4

* 30 – 35 mcg estrogen – most women start on this dose * Some women will be started w/ 20 – 25 mcg estrogen dose * younger women and very thin, or \> 35 years old * Progestin – usually start w/ a low androgen activity progestin * norethindrone, norgestimate

Answer 5

* Monophasic = same dose every day, then placebo week * Generally start w/ monophasic – it’s easier to identify SE and adjust * Biphasic = two different doses * Women tend to have more breakthrough bleeding * Triphasic = three separate doses * Good for women who needs less progestin (contain a lower dose overall) * Four-phasic = four separate doses * Only one product available (Natazia)

Answer 6

* The only disadvantages of changing cycle length from traditional is break through bleeding. There are no studies to prove any other disadvantages. * Traditional monthly cycle * 21 active pills + 7 placebo pills * Monthly regimens, shortened placebo * 24 active pills + 4 placebo * 24 active pills + 4 iron only * 24 active pills + 4 folic acid only * 21 active pills + 2 placebo + 5 estrogen only * 22 active pills + 2 placebo + 4 estrogen only * Extended regimen, regular placebo * 84 active pills + 7 placebo * Advantage – no periods * Disadvantage – spotting/breakthrough bleeding in the first few months (give it a few months); it costs more; not having a period may cause anxiety * Continuous regimen, no placebo * 84 active pills + 7 estrogen only * 91 active pills

Answer 7

* First day start = take the first pill on the first day of the next menstrual cycle * No backup protection needed – starting during menses and adequate hormone production will inhibit ovulation * Sunday start = take first pill on Sunday after the next menstrual cycle – most popular in the US * You won’t have bleeding on a weekend * Not necessarily the best method * Must use backup protection for 7 days after starting * Quick start = same day of the office visit - Preference * Must do a pregnancy test to make sure they aren’t currently pregnant * Must use backup protection for 7 days – they could be starting the pack around ovulation and it takes several days to inhibit ovulation * Next menses will be delayed until they reach their placebo week * More likely to continue using it – won’t forget to pick it up from the pharmacy * All methods are appropriate

Answer 8

WHO recommends same day as office visit

Answer 9

* Compliance * Take every day as close to the same time as possible * Common side effects and warning signals * ACHES * Benefits and risks * Patients should understand that COC does not protect against STDs * Drug interactions * Use a high-dose estrogen + backup protection for rifampin use * For most Dis, backup protection is appropriate * When to use backup method * Instructions for missed pills (Don’t have to memorize for test)

Answer 10

* Excess * Nausea * Melasma * Hypertension * Headaches * Breast fullness or tenderness * Weight gain * Deficiency * Early or mid-cycle breakthrough bleeding * Increased spotting

Answer 11

* Excess * Increased appetite * Weight gain * Tiredness, fatigue * Depression * Mood changes * Breast tenderness * Deficiency * Late breakthrough bleeding

Answer 12

* Excess * Acne * Hirsutism * Increased libido * Oily skin and scalp * Rash and pruritus * Weight gain * deficiency * none

Answer 13

Most side effects will be gone at 3 months – if they persist, make changes to the drug

Answer 14

Decrease estrogen component

Answer 15

Decrease progestin component

Answer 16

* Women over 40 * Smoking * Hypertension * Hyperlipidemia * Diabetes * Migraines * Breast Cancer * thromboembolism * Obesity * Postpartum and lactating women

Answer 17

* category 2 but still can use * No increased risk of MI or stroke among healthy, nonsmoking women older than 40 years who use COC with less than 50 mcg EE * May recommend 25 mcg estrogen

Answer 18

* Increases risk of MI and stroke * Cigarettes per day=Times MI risk is increased * Less than 15=1.2 times * 15-24=4.1 times * More than 24=11.3 times * Less than 35 years old * Category 2 – some providers still won’t do it * Over 35 years old – don’t do it * \< 15 cigarettes = category 3 (don’t recommend CHC) * \> 15 cigarettes = category 4 (don’t recommend CHC)

Answer 19

o Increases BP 6 – 8 mmHg o Monitor BP – check before and after starting o If BP goes up, stop CHC and it will go down (takes 3 – 6 months) o Contraindicated in \> 160/100 mmHg (category 4)

Answer 20

* Controlled – may give * Pick a CHC that has low androgenic activity * High – may not recommend * Estrogen increases triglycerides even more * Puts patient at risk for pancreatitis

Answer 21

* Pick a progestin with low androgenic activity * Diabetes for 20 years or complications from diabetes – high risk of having microvascular complications * Do not recommend

Answer 22

o Higher risk of stroke in women who have migraines with aura than in those who have migraine without aura (blurred vision, halos, unusual smells) o Adding estrogen can add complications – do not recommend o Over 35 + migraines with aura = category 4 (don’t recommend) o Over 35 + migraines without aura = category 2 o Develop migraine after starting CHC à discontinue use

Answer 23

o No link between breast cancer and CHC in women who take lower dose CHC o Localized, non-metastatic breast cancer can be seen in women who take high-dose CHC o Do not recommend for a woman who has had breast cancer (category 3 or 4)

Answer 24

o Estrogen increases hepatic production of Factors VII, X, and fibrinogen o Risk increased in women with underlying hypercoagulable states, obesity, pregnancy, surgery, air travel, certain malignancies, age, estrogen dose o Estrogen increases the risk of thrombosis (less than in pregnancy) o Some progestins also increase the risk of thrombosis (3rd generations but risk is still lower than pregnancy clots)

Answer 25

o Higher risk of contraceptive failure – efficacy decreases o Higher risk of venous thromboembolism (VTE)

Answer 26

o Hypercoagulable o Avoid in the first 6 weeks – category 4 o Do not give in breastfeeding women – decreases milk supply o Give mini pills (progestin only pills)

Answer 27

Transdermal contraception Vaginal ring

Answer 28

* Xulane patch * 20 mcg EE + 150 mcg norelgestromin released daily * Due to no first-pass metabolism, women are exposed to approximately 60% more estrogen than from a COC containing 35 mcg of EE * Exposed to more estrogen – does this increase the risk of DVT? Controversial studies * Apply to abdomen, buttocks, upper torso, or upper arm once weekly x 3 weeks, followed by 1 patch-free week * May skip the patch-free week, but may increase the risk of DVT * Use backup method if: * If the patch is not replaced after 9 days * If it comes off partially, they should take it off and apply a new patch

Answer 29

* NuvaRing * 15 mcg EE + 120 mcg etonogestrel released daily * Inserted by patient and left in place for 3 weeks, followed by 1 ring-free week * Use backup method if: * It gets expelled and is out for more than 3 hours * Women should not douche, but may use a topical therapy

Answer 30

* Also known as minipills * 28 active pills, no placebo – the same dose the whole time * Effectiveness – less than CHC * Some women still ovulate (40%) * Concerns * It increases cervical mucus (effects only last 24 hours) – taking this form of BC at the same time is very important * If they are \> 3 hours late in taking their medication, they must use a backup form of birth control * Patient counseling * Timing (recommend taking at noon if they have sex during the night or morning usuall) * They may have irregular bleeding (they may or may not ovulate) * Return to fertility * Immediate (3 hour window)

Answer 31

· 150 mg medroxyprogesterone actetate – IM · 104 mg medroxyprogesterone acetate – SQ

Answer 32

* Black box warning: If used \>2 years, significantly reduced bone mineral density of lumbar spine and femoral neck * However, most professionals believe it can still be used beyond 2 years * When it is stopped, bone mass increases (maybe not back to baseline) * No link to fractures and bone loss * Recommend women take Ca++ * Amenorrhea (most after 1 year) * Weight gain * Average: 5lbs in 1st year, 16 lb at 5 years * Can counsel on diet and exercise * May increase glucose, increase LDL, decrease HDL (effects of high-dose progestin)

Answer 33

* Counseling * IM injection (deltoid or gluteus maximus) or SQ Injection (anterior thigh or abdominal wall) * Patient should return every 3 months * If they are more than 1 week late, they must take a pregnancy test * Return to fertility * Delayed – average is 10 months

Answer 34

* Implanon, Nexplanon (radiopaque) * Considered a LARC (long acting reversible contraception) * Good for 3 years:super effective (better than sterilization) * 68 mg etonogestrel released at 60 mcg/day initially and decreasing to 25-30 mcg/day by end of year 3 * Inhibits ovulation, makes the endometrium very thin * Concerns * Insertion complications * Efficacy may be reduced in women weighing more than 130% of their ideal body weight * Patient counseling * Patients may have very unpredictable irregular bleeding that can persist * Return to fertility * Immediate * Cost ~$500 to $800

Answer 35

* LARCs * T380A Intrauterine Copper IUD * Levonorgestrel Intrauterine System

Answer 36

* Paragard – good for 10 years * Non-hormonal method of contraception * Mechanism of action * Copper ions inhibit sperm motility and acrosomal enzyme activation so that sperm rarely reach fallopian tube * Sterile inflammatory reaction in endometrium phagocytizes sperm * Concerns * Bleeding increases (only with this IUD) * Copper increases prostaglandins à increases bleeding * Patients with copper problems (Wilson’s disease) * Uterine perforation * Return to fertility * Immediate

Answer 37

* Liletta, Mirena, Skyla * Mirena 52 mg (5 years) releases 20 mcg/day of levonorgestrel initially (decreases to 50% by end) * Indicated for heavy menstrual bleeding * Skyla 13.5 mg (3 years) Releases 14 mcg/day of levonorgestrel initially and decreasing to 5 mcg/day * Lower dose, smaller size * Have a small uterus * Liletta 52mg (3 years) Releases 18.6 mcg/day of levonorgestrel initially and decreasing to 12.6 mcg/day * Similar to Mirena, but is only good for 3 years and is much cheaper (~$50 at some clinics) * Kyleena 19.5mg 5 years Releases 17.5 mcg/day of levonorgestrel initially and decreasing to 7.4 mcg/day * Similar to Mirena, newest one. * Concerns * Amenorrhea – 60% of women * Uterine perforation on insertion * Return to fertility * Immediate

Answer 38

o P = period being late OR pregnancy (must be removed right away) o A = abdominal pain OR pain with intercourse (IUD may have moved or become lodged where it shouldn’t be) o I = infection (avoid in women who have been exposed to several STDs) o N = not feeling well (fever, chills – concerned with infection) o S = string (the woman can check to make sure the strings are still there and are the same length – should check once a month)

Answer 39

· Contraceptive Patch (because it contains estrogen)

Answer 40

* For Unplanned or inadequate protection * High-dose progestin * Yuzpe method * Copper IUD * Selective progesterone receptor modulator

Answer 41

* The most common form of emergency contraception is high-dose progestin (Plan B) * Yuzpe method – use multiple CHC pills * Primary mechanism – inhibits ovulation by inhibiting the LH surge (may delay or push it back instead of inhibiting it – important counseling point) * Only good for one incidence of unprotected sex * Will alter their next menses – may be heavier, longer * If they don’t have menses w/in 3 weeks, they should take a pregnancy test – not 100% effective

Answer 42

* PlanB One-step, next choice * Levonorgestrel 1.5 mg x 1 dose or 0.75 mg q12hr x 2 doses * May take both tablets at the same time – equally as effective, same SE profile * Most effective if taken within 72 hours after intercourse * The sooner the better – efficacy declines with time * Has been studied up to 120 hours – still works, but efficacy is decreased – may be better options for her * Effectiveness * 1.1% failure rate * 1000 acts results in 12 pregnancies * 89% average reduction of pregnancy * Decreases in obese women (more than Ella) * Side effects * Nausea (probably won’t need an anti-emetic) * OTC access * Available to anyone of any age – sold in the isle, not behind the counter

Answer 43

* Combined estrogen and progestin oral contraceptives * Website Tells how many pills/packs of birth control to use * Always 2 doses (4 – 5 tablets per dose) 12 hours apart * Effectiveness * 2-3.2% failure rate * 1000 acts results in 25 pregnancies * 74% average reduction of pregnancy rate * Side effects * Nausea, vomiting (give an anti-emetic) * Give dose again if vomiting occurs within 1 hour of taking

Answer 44

o The most effective emergency contraceptive available o Approved for insertion up to 5 days after unprotected intercourse (7 days in Canada) o Functions as a spermicide, creates a hostile environment in the uterus – may inhibit implantation) o Good for 10 years after placement

Answer 45

* Ulipristal 30 mg x 1 dose (Ella) * Effectiveness * Use up to 120 hours after unprotected sex (same efficacy for the whole time) * Pregnancy rate reported at 2% * Stable over 5 days * More efficacious at day 4 & 5 compared to Plan B * Not available OTC * Decreases in obese women, but not as much as levonorgestrel * Side effects * Headache, abdominal pain, nausea, dysmenorrheal, fatigue, dizziness * Must repeat dose if vomiting occurs within 3 hours of taking * MOA – prevents/delays ovulation by inhibiting development of the follicle * May also have an effect on the thickness of the endometrium (may inhibit implantation) * Counseling * May alter next menses – heavier, longer * If menses is delayed more than 1 week from the expected date, take a pregnancy test * **Decreases the effectiveness of BC pills** – she should use a backup method for the rest of the cycle