NAPLEX - Contraception & Fertility

A normal menstrual cycle ranges from __ to __ days but on average is __ days.

23-35, 28

What does the start of bleeding (menses) indicate?

the next cycle has begun and is counted as day 1 of the cycle

Follicular phase

Each follicle in an ovary contains an oocyte. FSH spurs follicle development and causes estrogen to surge. Estrogen peaks by the end of the phase. The surge in estrogen causes LH and FSH to increase

Ovulatory phase

the LH surge triggers ovulation 24-36 hours later. ovulation is the release of the egg from the ovary

- LH causes corpus luteum development

Luteal phase

the start of ovulation begins the luteal phase which lasts ~14 days. progesterone is dominant in this phase

For a person wishing to conceive, when should patients have intercouse?

when the LH surge is detected and for the following 2 days (based on sperm survival of 3 days)

When is the hcg level the highest?

in the morning --> an at home urine test can detect pregnancy sooner if the women tests at this time

Adults are recommended to take __ mcg of folic acid daily and the folate requirement increases during pregnancy to __ mcg/day.

400; 600

What is the only reversible contraceptive method that has a delay in return to fertility?

medroxyprogesterone injection

T/F Temperature decreases during ovulation

False, increases (temperature tracking is used to predict ovulation; prior to ovulation temperature is 96-98 but increases to 97-99)

What lubricants should be recommended for condom use?

water or silicone based; never OIL

Hormonal contraceptives MOA

inhibit the production of FSH and LH which prevents ovulation

When dispensing, what should be dispensed with oral contraceptives?

PPI

__ COCs have the same dose of estrogen and progestin throughout the pill pack.

Monophasic

__ pill packs mimic the estrogen and progesterone levels during a menstrual cycle.

Biphasic, triphasic, and quadraphonic

Which progestin is a mild potassium sparing diuretic which decreases bloating, PMS symptoms, and weight gain; this product is also associated with less acne as it has anti-androgenic activity?

drospirenone

Which progestins have low androgenic activity?

norgestimate, desogestrel, and dienogest

What other indications are there for the use of COC?

dysmenorrhea, PMS, acne, anemia, perimenopausal symptoms, menstrual associated migraine ppx

What is the first line for treatment for PCOS? What about for endometriosis?

COCs

Progestin only pills MOA

suppress ovulation, thicken the cervical mucus to inhibit sperm penetration and thinning of the endometrium

What would be a reason to use a POP?

in breastfeeding because estrogen decreases milk production

T/F COCs can be used soon after pregnancy/delivery (approximately 3-6 weeks)

False, this is true for POP --> it is not safe to use estrogen because of the increased risk for thrombosis

POPs require good adherence; the pill must be taken within __ of the scheduled time.

3 hours

What OCs are safe for patients with migraine with aura? Without?

With aura = POP for migraine ppx because estrogen cannot be used due to the risk of storke; without aura = any

T/F Contraceptive patches cause a lower systemic estrogen exposure

False, higher exposure

What BMI precludes patients from using contraceptive patches?

≥ 30 (increased risk of thromboembolism or decreased efficacy)

- Xulane and Zafemy may also be less effective in women who weigh > 198 lbs

How is medroxyprogesterone administered? How often?

IM (150 mg) or SQ (104 mg) every 3 months

Extended cycle COCs involve __ days of active hormonal pills followed by 7 days of inactive or very low dose estrogen pills. With this schedule, bleeding occurs every ___ months.

84, 3 months

T/F Spotting occurs commonly with continuous contraception

True

Spotting occurs commonly with continuous contraception. When should you counsel patients on when this expected to resolve?

typically resolves after 3-6 months

T/F With continuous contraception it is possible to suppress menses altogether

True (amethyst is approved for this but other products can be used like this off label)

What are some SE of estrogen?

nausea, breast tenderness, bloating, weight gain, and increased BP, melasma

Does a low amount of estrogen or progesterone cause breakthrough bleeding?

estrogen --> this is seen especially during the early to mid part of the cycle

What are the severe and rare ADE of estrogen?

ACHES --> abdominal pain that is severe, chest pain (heart attack, PE), headache (stroke), eye problems (blurry vision can indicate a blood clot in the eye), swelling or sudden leg pain (DVT)

What patients should NOT receive drospirenone?

in women with clotting risk because it has a slighter higher risk of clotting, kidney, liver, or adrenal gland disease because it can increase potassium

Which contraceptive can lead to loss in bone mineral density?

injectable medroxyprogesterone

- take adequate calcium and vitamin D

If spotting persists what steps should be taken?

1. currently taking < 30 mcg of estrogen daily = increase estrogen dose

2. currently taking > 30 mcg of estrogen daily = try a different progestin

For a patient with fluid retention/bloating which contraceptive (hormonal) would you use?

one containing drospirenone

Which contraceptives are indicated for heavy menstrual bleeding?

Natazia and Mirena IUD

Which hormonal contraceptive would you use for patients with mood changes/disorder?

monophasic COC, extended cycle or continuous with drospirenone

T/F DMPA can help with weight loss

False, this product should be avoided if trying to avoid weight gain

If early or mid cycle spotting occur the __ dose may need to be __. If later in the cycle, the __ dose may need to be __.

estrogen, increase; progestin increased

How long must patients use a back up method while being on birth control + rifampin?

6 weeks after rifampin has been dc'd

What Hep C drug cannot be used with ethinyl estradiol? Why?

Mavyret; liver toxicity

In general, it take __ days of hormonal pills to achieve contraceptive efficacy.

7

Start today method

literally start today, best practice bc it maximizes time protected from unintended pregnancy, requires back up for seven days

Sunday start method

starts the sunday after menstruation, requires contraception back up for seven days

COCs can be started on the first day of menses. If started within __ days after the start of the period then no back up is needed. If not within __ days then use back up for seven.

5

When should a patient start a POP?

start at any time and use another method of BC for the first 2 days of POP use

If more than __ COC pill is missed, back up contraception is required.

1

What should you do if you take POP > 3 hours past the scheduled time?

take pill ASAp and take next dose on schedule !!! back up is required for two days!!!

What hormone does IUD Mirena, Skyla, Kyleena, and Liletta contain?

levonorgestrel (lasts 3-8 years)

What long acting reversible contraceptive can be used for emergency contraception and or regular BC? How long can it be used? What are its drawbacks?

copped IUD (paragard), used for up to 10 years but causes heavy menstrual bleeding and cramps

Nexplanon

plastic rod placed subdermally in the arm and releases etonogestrel for three years

What is the most effective form of emergency contraception?

copper IUD within 5 dats

Ella

ulipristal, EC for use within 5 days; prescription required

- more effective than Plan B, less effective if > 195 lbs or BMI > 30 (consider IUD)

Plan B

levonorgestrel EC, use within 3 days

- less effective if > 165 lbs or BMI > 25 (consider Ella or IUD)

MOA of Plan B

preventing or delaying ovulation and thicken cervical mucus

What is the dose of Plan B?

1.5 mg tab one dose (levonorgestrel)

What is the primary SE of levonorgestrel?

nausea --> if patient vomits within 2 hours of taking the medication she should consider repeating

Infertility

defined as not being able ot get pregnant after one year or longer of unprotected sex

Which agents for infertility are used to induce ovulation?

clomiphene and letrozole

Clomiphene MOA

SERM to increase ovulation

- causes LH and FSH to surge which triggers ovulation (like estrogen essentially)

Letrozole MOA

aromatase inhibitor

- suppress estrogen to increase FSH = ovulation

Gonadotropin drugs

act as LH, FSH, or hCG to cause ovulation

T/F Fertility drugs causes risk of multiple births

True