Contraception and Infertility

A normal cycle ranges from:

23-35 days: the average is 28 days

What indicates the next cycle has begun?

the start of bleeding: menses

Phases of the menstrual cycle:

follicular

ovulatory

luteal

Follicular phase:

there is. a surge of estrogen which causes LH and FSH to increase

Ovulatory phase:

LH surge triggers ovulation 24-36 hours later

What predicts the best time for intercourse based on ovulation in order to try to conceive?

ovulation kits

Human chorionic gonadotropin (hCG):

released when fertilized egg attaches to the lining of the uterus

When should you test for pregnancy?

with the 1st morning urine

What is the recommended folate for adults?

400 mcg

What is the recommended amount of folate during pregnancy?

600 mcg

What is recommended for a women who is trying to conceive?

stop smoking, using illicit drugs and drinking excessive amounts of alcohol

keep vaccinations current

avoid NIOSH drugs

consult with healthcare provider to evaluate the teratogenic potential of all current medications

adults recommended to take 400 mcg of dietary folate and 600 mcg when pregnant

Which contraceptive has a delayed return to fertility?

medroxyprogesterone

True/False: both male and female condoms provide protection from STIs

True

What is the MOA of hormonal contraceptives?

inhibit the production of FSH and LH which prevents ovulation.

What are the different types of hormonal contraceptives?

progestin only : pills injectables, implants, IUDs

estrogen/progestin combinations ( pill, patch, and vaginal ring)

combined hormonal contraceptives

combined oral contraceptives

non oral contraceptives (patch, ring)

What are health benefits of hormonal contraceptives?

decrease in menstrual pain

menstrual irregularity

endometriosis pain

acne

decreased risk of ectopic pregnancy

What must be given with all oral contraceptives?

patient package insert (PPI)

Estrogen and progestin combination oral contraceptives:

ethinyl estradiol and progestin: norethindrone, levonorgestrel, drospirenone:

• monophasic: same dose of estrogen and progestin throughout pill pack

• biphasic, triphasic, and quadriphasic: pill packs mimic the estrogen and progesterone levels during menstrual cycle

Drospirenone:

unique progestin that is used in some combined oral contraceptives to reduce adverse effects commonly seen with oral contraceptives.

it is a mild potassium sparing diuretic due to its antimineralcorticoid activity, which decreases bloating

Indications for combined oral contraceptives:

pregnancy prevention

dysmenorrhea

PMS

acne

anemia

1st line treatment for PCOS ( regulate menses)

1st line for endometriosis

Medications used for heavy menstrual bleeding:

natazia

mirena IUD

Prostegin only pills (POP, mini pills);

contain no estrogen and have a 28 days of active pills in each pack

When is POPs primarily used?

in women who are breastfeeding because estrogen can decrease milk production

Which contraceptive can be used as migraine prophylaxis and are safe in women who have migraines with aura?

POPs

Non oral hormal contraceptives:

contraceptive patches

vaginal contraceptive rings

injectable contraceptives

intrauterine devices

True/False: Contraceptive patches have higher systemic estrogen

True

When should contraceptive patches be avoided?

patients at high risk of clotting : patients > 35 years old who smoke, patients with cerebrovascular disease or past blood clots, postpartum patients

women with BMI > 30 kg/m2

Depo-provera:

injectable contraceptive

IM: 150 mg every 3 months

SUBQ: 104 mg every 3 months

What is the schedule for extended cycle combined oral contraceptives?

84 days of active pills followed by 7 days of inactive or very low dose estrogen pills.

Bleeding occurs every 3 months

spotting can occur ( but resolves after 3-6 months)

Monophasic formulations of combined oral contraceptives:

Junel Fe 1/20

Microgestin Fe 1/20

Sprintec 28

Loestrin 1/28

Yasmin 28

Yaz

Biphasic/triphasic combined oral contraceptives:

tri-sprintec

Quadriphasic combined oral contraceptives:

Natazia

Extended cycle combined oral contraceptives:

Seasonique

Continuous combined oral contraceptives:

amethyst

Drospirenone containing combine oral contraceptives:

Yasmin 28

Yaz

Transdermal estrogen/progestin patch:

Xulane

Progestin/Estrogen vaginal ring:

Nuvaring

POPs: mini pills

Errin

Camila

Nora-BE

Injection progestin only:

depo-provera

Adverse effects of estrogen:

nausea

breast tenderness/fullness

bloating

weight gain

increased blood pressure

What happens if you reduce the estrogen dose?

it will decrease the side effects, but if the dose is too low it can cause breakthrough bleeding

Severe side effects of estrogens: ACHES

Abdominal pain

Chest pain

Headaches

Eye problems

Swelling or sudden leg pain

Boxed warning for all combined hormone contraceptives: pills, ring, patches

do not use in women > 35 years old who smoke due to risk of serious CVD events

Boxed warning for estrogen + progestin transdermal patch:

do not use in women with BMI > 30 kg/m2: due to increase risk of thromboembolism

Boxed warning for Depo-Provera:

loss of bone mineral density with long term use

Contraindications to estrogens:

history of DVT/PE, stroke, CAD

history of breast, ovarian, liver or endometrial cancer

Treatment of breakthrough bleeding if spotting persists:

currently taking < 30 mcg estrogen daily: increase estrogen dose

currently taking > 30 mcg of estrogen daily: try a different progestin

Contraindications to drospirenone:

increased potassium levels

clotting risk

kidney, liver, or adrenal gland disease

Treatment for PMDD:

Product containing drospirenone

SSRI antidepressant

Antibiotics that decrease efficacy of hormonal contraceptives:

rifampin

rifabutin

Anticonvulsants that decrease the efficacy of hormonal contraceptives:

carbamazepine

oxcarbazepine

phenytoin

primidone

topiramate

St. John’s wort, tobacco smoking, and ritonavir can also decrease the effectiveness of :

oral contraceptives

How many days does it take hormonal pills to achieve efficacy?

7 days

Starting birth control: combined oral contraceptives

• 7 days before hormonal pills achieve contraceptive efficacy; so backup method is required for 7 days unless combined oral contraceptives is started within 5 days after the start of a period.

• start today: best practice recommended

• Sunday start: starts Sunday after onset of menstruation

• 1st day start: starts on the 1st day of menses. COCs is started within 5 days after the start of the period, no backup method

Progestin only pill: start date

start anytime

use another method of birth control for the 1st 48 hours of progestin pill use: unless within 5 days of the start of menses

What do you do if the person is late or missed a pill of their contraceptive?

if more than one combined oral contraceptive pill is missed, back up contraception is required x7 days

Emergency contraceptives:

copper IUD : paragard

ulipristal acetate: ella

levonorgestrel: Plan B one-step

Most effective emergency contraceptive:

copper IUD: paragard

When is Copper IUD: paragard given?

within 5 days

When is Ulipristal acetate: ella given?

ASAO, within 5 days

When is levonorgestrel given?

ASAP, within 3 days

Levonorgestrel dosing:

1.5 mg tab started within 72 hours after unprotected sex

MOA of levonorgestrel:

preventing or delaying ovulation and thickens cervical mucus

Side effect of levornorgestrel:

nausea: can take OTC antiemetic

if patient vomits within 2 hours of taking medication, should repeat another dose

MOA of Ulipristal acetate: Ella

prevents or delays ovulation

Counseling points for contraceptive patch:

apply to clean,dry skin of buttocks, stomach, upper arm or upper torso once a week for 21 days out of 28.

start on either day 1 ( no need for back up) or Sunday ( back uop for 7 days if not day 1)

NuvaRing vaginal contraceptive counseling points:

kept in place for 3 weeks and taken out for one week before replacement with new ring.

keep in place for >4 weeks; remove ring , confirm no pregnancy, then insert new ring and use back up contraception until new ting has been in place for 7 continuous days