Endocrine 1 - Hormonal Contraception

Therapeutics V - Exam 1

what are the different ways to rule out pregnancy (w/o a pregnancy test?) (7)

< 7 days since onset of menses or abortion

no intercourse since onset of latest menses or pregnancy best

correctly and consistently using contraception

no interval > 4-6 hours between feeds when breastfeeding

amenorrhea during breastfeeding

< 6mo postpartum and breastfeeding

w/in 4 weeks postpartum

which contraceptive method takes 6-18mo to return to fertility once stopped?

Depot medroxyprogesterone acetate shot

which contraceptive methods have the worst effectiveness with perfect and typical use?

female condom: perfect - 5%; typical - 21%

male condom: perfect use - 2%; typical - 18%

which contraceptives have the best effectiveness in both perfect and typical use?

IUDs: perfect and typical use - <1%

progestin only implant: perfect and typical use - <1%

what is the MOA of progestins?

thickening of cervical mucus → prevents sperm penetration, slows tubal motility, delaying sperm transport

blocks LH surge → inhibits ovulation

what is the MOA of estrogens?

suppress FSH → block LH surge → inhibit ovulation

stabilizes endometrial lining and provides cycle control

what are the different types of synthetic estrogens?

ethinyl estradiol (most common), mestranol, estradiol valerate

how many different generations of progestins are there?

first-fourth

which progestin generation has the most androgenic SE?

second generation

which progestin has the least androgenic SE?

fourth generation → anti-androgenic, may increase K+

what are the first generation progestins?

norethindrone, norethindrone acetate, ethynodiol diacetate, norethynodrel

what are the second generation progestins?

levonorgestrel, norgestrel

what are the third generation progestins?

desogestrel, etonogestrel, norgestimate

what are the fourth generation progestins?

drospirenone, dienogest, segesterone

what are the androgenic AE?

weight gain, acne, hirsutism, oily skin, increased libido

what are the ADRs of excess estrogen? what are the management options?

ADRs: nausea, breast tenderness, increased BP, HA, edema/bloating

management: decrease estrogen, consider progestin only options

what are the ADRs of estrogen deficiency? what are the management options?

ADRs: early to mid-cycle (days1-9), break through bleeding, increased spotting, dry vaginal mucosa, hypomenorrhea

management: increase estrogen content

what are the ADRs of excess progestin? what are the management options?

ADRs: breast tenderness, depression or irritability, fatigue, constipation

management: decrease progestin

what are the ADRs of progestin deficiency? what are the management options?

ADRs: late cycle BTB, hypomenorrhea, amenorrhea, weight loss

management: increase progestin

what are the serious AE combine hormonal contraceptives (CHC)?

ACHES

abdominal pain, chest pain, HA, eye problems, severe leg pain

what are the CI to CHC?

< 21 days postpartum, anything that increases risk of blood clots, current breast cancer, decompensated cirrhosis, liver tumors

what are the drug interactions to note with CHC?

rifampin

anticonvulsants - phenobarbital, carbamazepine, phenytoin (decrease effectiveness of CHCs)

what are the different types of dosing strategies for oral CHC?

monophasic → same amounts of estrogen and progestin

multiphasic → varying amounts of estrogen and progestin

extended cycle → active pills for 84 days

which initiating methods for oral CHC provide immediate protection? which need back up protection for 7 days?

first day start - immediate protection

Sunday start and quick start - back up protection required for 7 days

what do you do if you’ve missed one oral CHC pill for (<48 hrs)?

take the late or missed pill ASAP and continue taking usual dose afterwards

you do NOT need to use backup contraceptive

what do you do if you missed 2+ oral CHC pills (>/= 48 hrs)?

take the most recent missed pill (only one) ASAP and continue taking usual dose afterwards

use backup contraceptive for 7 days

what are the different patch options?

Twirla

Xulane

when are contraceptive patches not recommended?

Xulane - weight > 90kg

Twirla - BMI > 30 kg/m2

due to decreased absorption at these markers

what is the application regimen for the contraceptive patches?

change the patch weekly, leaving the 4th week patch free (only 3 patches per box)

what is the BBW for contraceptive patches?

CV risk associated w/ smoking, risk of venous thromboembolism, and PK profile of ethinyl estradiol

women 35 yo + who smoke should not use contraceptive patches

what are the clinical pearls for contraceptive patches?

check daily, avoid creams and lotions, rotate patch site

when should the contraceptive patches be applied?

during the first 24 hours of starting period

considered that “patch change day'“

what is the protocol if the contraceptive patch falls off for < 48 hrs?

apply a new patch ASAP or reapply patch if it has been < 24 hours

keep the same patch change day

do NOT need backup contraception

what is the protocol if the contraceptive patch falls off for > 48 hours?

apply new patch ASAP

keep the same patch change day

use backup contraception for 7 days

what are the contraceptive ring options?

Nuvaring

Annovera

what is the advantage of Nuvaring over oral CHCs?

better adherence

what is the dosing regimen for Nuvaring?

insert and leave in for 3 weeks and remove for one week

when should the Nuvaring be inserted?

initiate on first day of menstrual period

what is the protocol if the Nuvaring falls out?

w/in 3 hours - rinse and re-insert

> 3 hours - weeks 1-2: re-insert ASAP and use backup for 7 days; week 3: insert new ring and start a new cycle OR insert w/in 7 days and use backup for 7 days

what is the dosing regimen for Annovera?

insert for 3 weeks, remove for one week (ring is reusable, one ring lasts for a year)

when should backup contraceptives be used when initiating Annovera?

if initiating (after no hormonal contraceptive use) when menstrual cycles are irregular or it has been 5+ days from menstrual bleeding

initiating after using progestin-only contraceptives (pills, injections, or IUDs)

if Annovera has been out for 2 or more hours

how do you initiate Annovera after never using hormonal contraceptives prior?

insert between days 2 and 5 of bleeding, no backup

if menstrual cycles are irregular or 5+ days from menstrual bleeding, use backup for 7 days

what is the protocol if Annovera falls out?

reinsert w/in 2 hours

if out for more than 2 hours, use backup for 7 days

what are the advantages of progestin only contraceptives?

can be used if estrogen is CI, no estrogenic AE, decreased risk for MI and stroke if > 35 yo, safe for breastfeeding pts

what are the disadvantages of progestin only pills?

not as effective as CHCs, require strict compliance, no hormone free interval

when is the depot-medroxyprogesterone acetate (DMPA) injection given?

every 3 mo

IM in gluteal or deltoid muscle

SC in abdomen or thigh

within 5 days of onset of menstrual bleeding

what is an advantage of the DMPA shot?

no interaction w/ seizure meds

what is the BBW for the DMPA shot?

can lose significant bone mineral density with increased duration and may or may not be reversible

note: most clinicians don’t find this clinically relevant

what can you do to treat prolonged menstrual bleeding caused by DMPA injection or Nexplanon?

short course NSAIDs (5-7 days)

10-20 days of estrogen

what are the long-acting reversible contraceptives (LARC)

implant - Nexplanon

intrauterine devices (IUDs)

how long is Nexplanon implanted for?

3 years

when should Nexplanon be inserted?

between days 1 and 5 of menstrual cycle

anytime but use backup method for 7 days

when may Nexplanon have decreased effectiveness?

>130% above IBW - may not be clinically relevant

what are the types of IUDs available?

copper - ParaGard

levonorgestrel - Mirena, Skyla, Liletta, Kyleena

how do IUDs work?

inhibits sperm migration, damages ovum or disrupts transport, possibly damaging fertilized ovum before implantation of egg

when are IUDs CI?

pregnancy, pelvic inflammatory disease, current STD, undiagnosed abnormal vaginal bleeding, malignancy of genital tract, uterine abnormalities, Wilson’s disease (Copper IUD)

how long does the copper IUD last?

10 years

how long does each LNG-IUDs last?

Mirena - 5 or 7 years

Liletta - 6 years

Skyla - 3 years

Kyleena - 5 years

what are the warning signs that there is something wrong with someone’s IUD?

PAINS

period - late, abnormal spotting or bleeding

abdominal pain, pain with intercourse

Infection - abnormal vaginal discharge

Not feeling well, fever, chills

String missing, shorter, or longer

how often should pts check for IUD strings?

once a month

what are the different emergency contraceptive options?

morning after pill, Yuzpe method, copper IUD

what are the differences between the 2 emergency contraceptive pills?

levonorgestrel - use w/in 72 hours, available OTC

Ulipristal - use w/in 5 days, Rx only

what is the Yuzpe method of emergency contraception?

2 doses of oral CHCs (ethinyl estradiol + levonorgestrel) 12 hours apart

most effective w/in 72 hours

how is the copper IUD used for emergency contraceptive?

placed up to 7

most effective

what is the OTC hormonal contraceptive option?

norgestrel aka Opill