Exam 2 DPT V (Brittain)

Nonpharmacologic Contraception

abstinence

basal body temperature (Natural Cycles)

cervical mucus tracking

barrier methods

When are the most fertile days?

those prior to ovulation

Barrier Methods

internal and external condoms

diaphragm

cervical cap

Spermicides

non-oxynol-9 (OTC)

lactic acid/citric acid/potassium bitartrate (Phexxi, lowers pH and sperm motility)

When should spermicides be used?

1 hour before intercourse and each act of intercourse

Adverse effects of non-oxynol-9

vaginal epithelial irritation

Adverse effects of Phexxi

frequent cystitis

What are the hormonal contraceptions?

estrogens and progestins and combined

What can prevent STDs?

condoms

What can be used for menstrual cycle regularity, improvements in certain health conditions, and management of perimenopause?

hormonal contraception

Of the following contraceptive methods, which protects against pregnancy AND STIs?

A. Lamb skin male condoms

B. Nonoxynol-9 spermicidal foam

C. Today Sponge

D. Female condom

D

JR is 30 year old female who is looking for a barrier method that offers both STI and pregnancy prevention. Although STI prevention is important to her, she is primarily concerned with pregnancy prevention. Which form of contraception is the best choice for this patient?

A. Combination of female and male condom for extra pregnancy protection with lubricant to prevent squeaking and friction.

B. Lamb cecum condoms with spermicide foam such as Vaginal Contraceptive Foam 12.5%

C. Male latex condoms with lubricant

D. Contraceptive Sponge

C

A 21 yo female patient routinely purchases emergency contraceptives. She is sexually active, is not in a monogamous relationship, and does not use any other form of contraception. What is the most appropriate recommendation for pregnancy and STI prevention for this patient?

A. Routine use of coitus interruptus ("pull out" method) and continue to use emergency contraception as needed for pregnancy prevention.

B. Routine use of spermicide and referral to primary care provider to discuss prescription contraceptives (oral, patch, ring)

C. Routine use of male condoms and referral to primary care provider to discuss prescription contraceptives (oral, patch, ring)

D. Use a fertility awareness-based method

C

A newly married couple (female/male) needs assistance with condom selection. They are in a monogamous relationship and she have never been pregnant before. They are experiencing irritation with a latex condom + non-oxynol-9. What is the most appropriate, cheapest recommendation?

A. lamb skin condoms with oil-based lubricant

B. latex condoms with water-based lubriccant

C. Today sponge

D. no barrier contraception with emergency contraception when needed

B

Primary role of Estrogens

stabilize endometrial lining and provide cycle control

can suppress FSH release and contribute to blocking LH surge and prevent ovulation

Primary role of Progestins

provide most of the contraceptive effect

thicken cervical mucus to prevent sperm penetration, slow tubal motility, delay sperm transport, induce endometrial atrophy

block LH surge thereby inhibiting ovulation

Which hormone can prevent ovulation the most?

estrogens

What are the active ingredients of estrogen?

ethinyl estradiol (EE)

estradiol valerate

estetrol (E4)

What are the active ingredients androgenic medium-high activity progestins?

levonorgestrel, norgestrel, and norerthindone

What are the active ingredients androgenic low activity progestins?

desogestrel

What are the active ingredients anti-androgenic progestins?

drosperinone

Monophasic Contraceptives

single dose of estrogen + progestin

active 21 days, placebo 7 days

active 24 days, placebo 4 days (may reduce hormone fluctuation between menstrual cycles)

Monophasic Examples

Loestrin-21

Lo Loestrin Fe-24

Yaz

Beyaz

Yasmin

What does Yaz, Beyaz, and Yasmin have in common?

include drospirenone (anti-androgenic progestin)

Which contraceptive do we usually start patients on?

monophasic contraception

due to easier identify and manage side effects

What does Loestrin-21 1/20 mean?

monophasic contraception

active days: 21

Multiphasic

variable dose of estrogen + progestin

active 21 days, placebo 7 days

Multiphasic Examples

Ortho-Novum 7/7/7

Ortho Tri-Cyclen

Ortho Tri-cyclen Lo

What is the difference between Ortho Tri-Cyclen and Ortho Tri-cyclen Lo?

lower does of ethynyl estradiol

Extended Cycle

single dose of estrogen + progestin

active 84 days, placebo 7 days (alternative to placebo: estrogen)

Extended Cycle Examples 7 Day placebo phase

quasense

Jolessa

Extended Cycle Examples 7 Day Estrogen-only phase

Seasonique

Lo Seasonique

Continuous Cycle

no placebo phase

Examples: Lybrel

no menses but increased rates of spotting or breakthrough bleeding

Progestin Only

Norethinedrone (Micronor)

Drospirenone (Slynd)

no placebo phase

Micronor

Norethinedrone (progestin only product)

28 active pills

must be taken at same time everyday

if late (> 3 hours) or missed, must use backup for at least 48 hours

When should you use Progestin Only?

estrogen contraindication

> 35 years and smoke

PMH: VTE/PE

> 85 years & MI or stroke risk

Breastfeeding

Do progestin block ovulation?

NO, can just prevent it

can result in an increase ectopic pregnancy

Slynd (Drospirenone)

24 active, 4 placebo pills

start day 1 and no back up needed

more flexibility with dosing and needs to use backup if 24 hours past expected dosing time

What should someone MUST do after initiating contraception?

use second method of contraception (condoms) for at least 7 days for maximum effectiveness

What are some options for initiating therapy of oral contraceptives?

1. first Sunday after menstrual cycle begins

2. first day of bleeding

3. 5th day after menstrual cycle begins

4. quick start

How long should you continue a oral contraceptive before adjustment/changes?

at least 2-3 cycles

Which phase contraceptive is preferred as initiation due to easier manipulation?

monophasic

Who should get lower dose of EE?

adolescent age

underweight

> 35 years

perimenopausal

If someone has no coexisting medical conditions, what should you start in general?

ethinyl estradiol < 35 mcg + norethindrone < 0.5 mg

Who should have antiandrogenics or low androgenics?

oily skin

acne

hirsutism

What should you consider if a patient is difficulty adhering to daily dosing?

consider alternate form: vaginal ring, transdermal patch, DMPA, implants or IUDs

1 tablet missed or late (CHC or drospirenone only)

take it ASAP

acceptable to double up on the same day

2 or more consecutive tablets (CHC or drospirenone only)

take 1 tablet ASAP and discard remaining missed tablets

use additional nonhormonal contraception until tablets have been taken for 7 consecutive days

Norethindrone missed dosing

if a tablet is more than 3 hours late then additional nonhormonal contraception should be used for 48 hours

What antibiotics can decrease efficacy of oral contraceptive?

rifampin

tetracyclines

penicillin

What drug interactions can decrease efficacy of oral contraceptives?

rifampin, tetracyclines, penicillin

phenobarb, carbamazepine, phenytoin

antiretrovirals

drospirenone and potassium sparing antihypertensives

What drug can actually produce a reverse effect where the drug levels can decrease when taken with CHC?

lamotrigine

If a patient is taking lamotrigine or anticonvulsants, what is recommended to use?

DMPA or LARC

Transdermal Patch

apply at beginning of menstrual cycle and replace every 3 weeks (followed by 1 week patch free)

applicated delayed > 48 hours: backup method for 7 days

Where can a patient apply the transdermal patch?

abdomen, buttocks, upper torso, or upper arm

Who would see a reduced efficacy when using a transdermal patch?

weight > 90 kg

DO NOT USE: BMI > 30

What is the risk with using transdermal patch?

higher thromboembolism risk

increased cumulative estrogen exposure

Vaginal ring

insert ring on or before 5th day of menstrual cycle, remain in place for 3 weeks, then 1 week ring free

extended dosing

compress ring to insert

Transdermal Patch Products

Ortho Evra/Xulane (square)

Twirla (circle)

Vaginal Ring Products

Nuvaring

Annovera

Nuvaring

removed/displaced > 3 hours: insert new ring and use backup method for 7 days

discard and replace monthly

Annovera

removed/displaced for > 2 hours

replace ring and use backup method for 7 days

do not discard, remove and reuse up to 13 times

Adverse effects of vaginal rings

potential increased risk of VTE

foreign-body sensation

device expulsion

vaginal symptoms

How should you discard a vaginal ring?

garbage not flush

Depo-Provera (medroxyprogesterone)

administered IM or SubQ within 5 days of onset of menses (every 12 weeks +/- 2 weeks)

requires medical office visit or at pharmacy

How long does it take for return of ovulation using depo-provera?

10 months average, up to 18 months

Nexplanon (Etonogestrel)

dermal implant

placed under the skin

potential decreased efficiacy in overweight/obese patients

inserted between days 1 and 5 in menstrual cycle

Intrauterine Device examples

Skyla

Kyleena

Liletta and Mirena

Emergency Contraception examples

Levonorgestrel

Ulipristal (ellaOne)

Yuzpe method (CHC)

Copper IUD

Emergency Contraception is used for...

used to prevent pregnancy

prevent ovulation (inhibits, delays)

prevent implantation

NOT AN ABORTIFACIENT

Levonorgestrel

emergency contraception

1.5 mg tablet x 1 dose

administered within 72 hours of unprotected intercourse (earlier the better)

Ulipristal (ellaOne)

SERM

30 mg x 1 dose

prescription only

administer within 120 hours of unprotected intercourse

When should you start or resume HC after taking ellaOne?

after 5 days

What is the newly approved OTC contraception that is PROGESTIN only?

Norgestrel (OPill)

Who should NOT use OTC contraception?

patients who have or had breast cancer

with other hormonal contraceptives

for emergency contraception

Signs and symptoms of estrogen excess

decreased lactation

stroke

HTN

MI

Thrombophlebitis

Sign and symptoms of progestin excess

decreased menstrual bleeding length

HTN

Signs and symptoms of estrogen deficiency

early to mid-cycle breakthrough bleeding/spotting

Signs and symptoms of progestin deficiency

heavy menstrual bleeding

late-cycle breakthrough bleeding/spotting

delayed onset of menstrual bleeding

Signs/Symptoms of Amenorrhea

cessation or absence of menses

infertility, vaginal dryness, or decreased libido

Levonorgestrel (IUD)

replaced on 3-8 year cycle

decreased menstrual blood flow

first 6 months: increased spotting

Paragard (IUD)

copper

replace every 10 years

increased menstrual blood flow and dysmenorrhea

Mirena dose

dose can wean after implantation

Who is contraindicated to get an IUD?

pregnancy

current PID

STD/STI

Possible MOA of IUD

inhibition of sperm migration

damaging ovum or disrupting transport

possibly damaging fertilized ovum

endometrial suppression

thickening cervical mucus

What are some early use side effects of hormonal contraceptives?

nausea, bloating, breakthrough bleeding

(improve by third cycle)

What are some common adverse effects of hormonal contraceptives?

irregular bleeding

commonly seen with extended cycle products

estrogen/progestin content may need to be adjusted

What are some serious severe side effects that you should discontinue? (ACHES)

Abdominal Pain

Chest Pain

Headaches

Eye problems

Severe leg pain

What are some CHC contraindications?

breastfeeding

current breast cancer

history/higher risk of DVT/PE

migraines with aura

Smoking

How many days post-partum should you NOT initiate estrogen?

first 21 days

Patients who are breastfeeding, what hormonal option could you consider?

progestin only

Patients w/ current or past history of breast cancer should or should not use CHC

should not

With those having risk of thromboembolism, what is the recommendation?

low-dose oral estrogen contraceptives containing older progestins or progestin-only contraceptive methods

In migraines, who is contraindicated to receive CHC therapy?

any age with migraine + aura

> 35 years with any type of migraine (with or without aura)

In those with HTN, who is contraindicated to receive CHC therapy?

SBP > 160 and/or DBP > 100

due to CHC increasing BP by 6-8 mmHg

When is it acceptable to use a low dose CHC in those with HTN?

< 35 years, well controlled and frequently monitored BP

When are CHC contraindicated in those that smoke?

> 15 cigarettes/day

For those that do smoke, what type of CHC should you give them?

progestin only or non-hormonal contraceptive

When should you not use CHC in patients with diabetes?

those with vascular disease or diabetes > 20 years

Primary Amenorrhea

by age 15, never menstruated