L3: Hormonal Contraception Kaczmarski

T/F: Are progestins in hormonal contraception equivalent to progesterone?

FALSE

estrogen MOA

inhibits ovulation by suppressing release of FSH and LH

progestin MOA

• Inhibits ovulation by suppressing LH surge
• Inhibits implantation by producing an atrophic endometrium
• Mediates production of thickened cervical mucus

also slows ovum transport through fallopian tubes

return to ovulation after estrogen/progestin

2-3 months aka readily reversible

estrogen excess side effects

-nausea
-edema, bloating
-headaches during active pills
-breast tenderness
-increase breast size

progestin excess side effects

-moodiness
-headaches between pill packs
-vaginal candidiasis

androgen excess side effects

-increased appetite
-noncyclic weight gain
-hirsutism
-acne

estrogen deficiency side effects

-hot flashes, vasomotor symptoms
-early & midcycle spotting and BTB
-decreased libido

progestin deficiency side effects

-weight loss
-heavy menstrual flow
-late BTB/spotting
-delayed onset of menses

severe warning signs/ ACHES

abdominal pain
chest pain
headache
eye problems
severe leg pain

if 1 monophasic OC dose is missed at anytime in cycle what should you tell the patient? backup needed?

take missed OC immediately and at next regularly scheduled time

no backup needed

if 2+ monophasic OC doses are missed within first 2 weeks of cycle what should you tell the patient? backup needed?

Take most recent missed OC immediately and at next

regularly scheduled time (ok if two on same day), then

continue per package

- Discard all unused missed pills

- Use back-up method x 7 days + consider EC if appropriate

if 2+ OC doses are missed in the third week of cycle what should you tell the patient? backup needed?

Take most recent missed OC immediately and at next

regularly scheduled time (ok if two on same day), then

continue until end of pack, SKIP PLACEBO WEEK, start new

pack immediately.

- Discard all unused missed pills

- Use back-up method x 7 days + consider EC if appropriate

28 pill progestin only pills API options and strength

norethindrone 0.35 mg (Rx)

norgestrel 0.075 mg (OTC)

POP 28 active pack dosing schedule

norethindrone or norgestrel

take every day AT SAME TIME within 3 hour window

if 28 active pill POP is taken outside of 3 hour window , how long is backup contraception recommended?

48 hours

24 active pill POP option

Drospirenone

if 1 dose of drospirenone is missed, what should patient do? backup needed?

take missed dose ASAP,

no backup method if <24 hrs

if 2+ drospirenone doses are missed, what should patient do? backup needed?

take missed dose ASAP, then take next dose at regularly scheduled time and continue as such

Backup contraception for 7 DAYS

what age patients are best candidates for POPs

>35

Xulane should be avoided at what BMI and weight?

BMI >30 or >90 kg

Xulane API

Ethinyl estradiol 35 mcg/day and norelgestromin 150 mcg/day

Twirla API

Ethinyl estradiol 30 mcg/day and levonorgestrel 120

mcg/day

Twirla should be avoided at what BMI

>30

Disadvantages of CHC patches

skin irritation
patch detachment
VTE/PE risk significantly higher

if CHC patch detaches and its been less than 48 hours what should pt do

reapply to same place or replace with new patch

if CHC patch detaches and its been 48 hours or more what should pt do?

start new cycle with new patch and use backup x7 days

eluryng, nuvaring API

ethinyl estradiol 15 mcg and etonogestrel 120 mg/d

nuvaring insertion timeline

inserted every 3 wks and removed on week 4 for menses

NEW RING INSERTED EVERY MONTH

how long can the nuvaring be removed for?

up to 3 hours

if nuvaring is out for >3 hours or unknown period of time what should patient do

reinsert and use backup for 7 days

can you stack the annovera to skip menses

NO

can you stack the nuvaring to skip menses

YES

annovera is good for how many cycles

13

how long can the annovera be out of the vagina to NOT change contraceptive efficacy

<2 hours TOTAL for 21 days

avoid annovera in what weight

BMI >29

Depo-Provera API and schedule

150 mg medroxyprogestrone IM every 12 weeks

if >13 weeks between depo injections what is required

negative pregnancy test

what is ADE of depos?

weight gain and bone loss with >2 years of use

nexplanon api & frequency

etonogestrel 68 mg q3 yrs

Nexplanon ADR

-variable bleeding pattern
-weight gain

IUD MOA

prevents implantation and impairs sperm motility

kyleena is replaced every _______ years

5

liletta is replaced every _____ years

8

mirena is replaced every _____ years

8

skyla is replaced every ____ years

3

IUD ADRs

cramping, expulsion risk, PID risk

non copper IUD API

levonorgestrel

hormonal IUD contraindication

breast cancer

estrogen sensitive patients

<110 and >35

higher estrogen requirements if patient is

>160 lbs

you must be _____________ prior to selecting a contraceptive method for patient

REASONAVLY SURE PT IS NOT PREGNANT

what contraceptive has the smallest % of accidental pregnancy within 1st year of use

Levonorgestrel IUD

contraceptive DDI considerations

caution with CYP3A4

contraception with exogenous testosterone

Exogenous testosterone supplementation alone is not sufficient to guarantee CONSISTENT ovulation
suppression.

selective progesterone receptor modulator EC

Ulipristal

ulipristal can be used up to

5 days after intercourse

progestin only EC can be used up to

3 days after intercourse

EC will/will not disrupt an already implanted pregnancy

will NOT -- EC is not an abortifaciant

if pt uses EC progestin only how should they proceed with oral BC

start a new pack day after EC and use backup for one week