NAPLEX: Male & Female Health - Contraception & Infertility

breakthrough bleeding

how long does it take to typically resolve

2-3 mo

phases of menstrual cycle

- follicular

- ovulatory

- luteal

menstrual cycle

follicular phase

FSH spurs follicle development + estrogen surges

Estrogen peaks by the end of this phase

This surge causes luteinizing hormone (LH) and FSH to increase

menstrual cycle

ovulatory phase

LH surge triggers ovulation 24-36 hrs after

Causes release of the egg (ova) from ovary

Oocyte (egg) lives for 24 hrs once released

menstrual cycle

luteal phase

Corpus luteum develops in ovaries + lasts 14 days

Progesterone dominant in this phase

what do ovulation kits test for

LH

ovulation kits

when should someone wishing to conceive have intercourse

when LH surge is detected + for the following 2 days (LH surge typically occurs 24-36 hrs prior to ovulation)

human chorionic gondatropin (hCG)

released when fertilized egg attaches to lining of uterus (implantation)

when should a home pregnancy test be taken

first thing in the morning

hCG level is highest then

what does it mean if hCG is present in blood or urine

pregnancy

recommended folic acid intake for women wishing to conceive

400 mcg of dietary equivalents (DFE) per day

recommended folic acid intake for pregnant women

600 mcg DFE/day

normal vs ovulation temperature

Typical temp prior to ovulation = 96-98 F

Ovulation = 97-99 F

FDA approved app to help w tracking + predicting ovulation

natural cycles

what types of lubricants should be avoided with condoms

oil based

only recommend water or silicone based lubricants

forms of progestin

norethindrone, levonorgestrel (LNG), drospirenone

forms of estrogen

ethinyl estradiol (EE)

progestins with low androgenic activity

norgestimate, desogestrel, dienogest

what other indications can be treated with COC

Dysmenorrhea (menstrual cramps)

PMS

Acne

Anemia (reducing blood loss)

Peri menopausal sx (hot flashes, night sweats)

Menstrual migraine ppx

polycystic ovary syndrome (PCOS)

infrequent, irregular, or prolonged menstrual periods are common

polycystic ovary syndrome (PCOS)

1st line treatment

COC

endometriosis

endometrial tissue grows outside of uterus

endometriosis

treatment

COC

Elagolix (Orilissa) = GnRH antagonist which suppresses LH and FSH FDA approved for moderate-severe pain associated with endometriosis

heavy menstrual bleeding (menorrhagia)

treatment

Natazia (COC), Mirena (levonorgestrel releasing IUD)

heavy menstrual bleeding with uterine fibroids

treatment

oriahnn

when can progestin only pills be started after delivery

3-6 wks postpartum

not safe to use estrogen so soon after delivery d/t increased risk of thrombosis

which contraceptive is safe to use in migraine with aura

progestin only pills

contraceptive patches have a _____ (higher/lower) systemic estrogen exposure than COC which leads to a _____ (higher/lower) risk of thromboembolism

higher systemic estrogen exposure than COC → higher risk of thromboembolism

contraceptive patches

populations to avoid use in

Anyone with high clotting risk (pt >35 who smoke, pt w CV disease, postpartum pt)

Women BMI >30 kg/m2 d/t increased risk of thromboembolism (Xulane, Zafemy) or decreased efficacy (Twirla)

- Xulane, Zafemy may also be less effective in women who weigh > 198 lbs (90 kg)

COC monophasic formulation examples

Junel Fe 1/20

Microgestin Fe 1/20

Sprintec 28

Loestrin 1/20

Yasmin 28

Yaz

Lo Loestrin Fe

COC biphasic, triphasic formulations

Tri-Sprintec

Phasic = differing hormone dose being delivered in phases

COC quadriphasic formulations

Natazia

Hormone dose change over 26 days (4 phases of estradiol valerate and dienogest) followed by 2 placebo pills to mimic menstrual cycle and minimize menstrual bleeding

COC extended cycle formulations

Seasonieque

Seasonale

Ashlyna

Quasense

Period occurs every 3 mo

COC continuous formulation

Amethyst

No inactive pills (taken continuously) - no period occurs

Drospirenone Containing Formulations

Yasmin 28, Yaz, beyaz

Mild potassium sparing diuretic effect to reduce bloating and other effects

CI in renal or liver disease

Monitor K, kidney fxn during use

contraceptive patches

- examples

- dosing schedule

Xulane, Zafemy, Twirla

dosing schedule:

- weeks 1-3: apply once weekly

- week 4: off

Higher estrogen exposure than pills

vaginal ring

- examples

- dosing schedule

NuvaRing, EluRyng, Haloette, Annovera

Lower estrogen exposure than pills

Dosing schedule: insert monthly; leave in x3 wks, remove x1 wk

Annovera: reusable vaginal ring; wash and store when removed then reinsert

Used for 1 yr

progestin only pill examples

Errin

Camila

Nora-BE

- contain fixed dose of norethindrone

- take tablet every day (no placebo days)

Slynd (drospirenone only)

Opill (OTC)

depo provera

Contains depot medroxyprogesterone (DMPA)

Injected every 3 mo (150 mg IM or 104 mg SC)

estrogen SE

Common SE:

- Nausea

- Breast tenderness/fullness

- Bloating / weight gain

- Increased BP (partially d/t fluid retention)

- Melasma (dark skin patches most often on face)

Serious SE:

- Thrombosis

- Increased risk as pt ages, smokes, has DM, HTN, requires prolonged bed risk, or is overweight

- Higher estrogen dose / exposure = higher clotting risk

Reducing dose will decrease SE but a dose that is too low will cause breakthrough bleeding (spotting)

progestin SE

Breast tenderness

Headache

Fatigue

Depression

drospirenone SE

slightly higher risk of clotting, ↑ K levels

Do not use with kidney, liver, or adrenal gland disease or those with elevated K at baseline

injectable depot SE

loss in mineral bone density

Important for teens, young women still accumulating bone mass

Take calcium and vitamin D

breakthrough bleeding

which type of contraception typically has more breakthrough bleeding

continuous contraception

breakthrough bleeding

if spotting persists + currently taking <30 mcg estrogen daily

increase estrogen dose

breakthrough bleeding

if spotting persists + currently taking >30 mcg estrogen daily

try a different progestin

boxed warning for all CHC products

Do not use in women >35 who smokie d/t risk of serious CV events

boxed warning for estrogen + progestin transdermal patch

Do not use in women BMI >30 d/t increased risk of thromboembolism (Xulane, Zafemy) or decreased efficacy (Twirla)

boxed warning for depo-provera

Loss of mineral density with long term use

conditions to avoid estrogen in

DVT/PE, stroke, CAD, thrombosis of heart values, or acquired hypercoagulopathies

Breast, ovarian, liver, or endometrial cancer

Liver disease

Uncontrolled HTN (>160/100 mmHg)

Severe headaches or migraines with aura (especially if >35 y/o)

DM with vascular disease

Unexplained uterine bleeding

selecting a contraceptive

pt w acne or hirsutism

COC that has lower androgenic activity (norgestimate (Sprintec)) or no androgenic activity (drospirenone (Yaz, Yasmin)

selecting a contraceptive

breastfeeding

progestin only or non hormonal method

selecting a contraceptive

estrogen CI

progestin only or non hormonal method

selecting a contraceptive

migraine with aura

progestin only or non hormonal method

DO NOT USE ESTROGEN

selecting a contraceptive

migraine without aura

any method

selecting a contraceptive

fluid retention / bloating

product containing drospirenone

selecting a contraceptive

heavy menstrual bleeding (menorrhagia)

Natazia (COC), Mirena (levonorgestrel releasing IUD) are indicated for this condition

COC with only 4 placebo pills (rather than 7) or continuous/extended regimens will minimize bleed time

selecting a contraceptive

HTN

If BP is uncontrolled some estrogen formulations are CI

Choose progestin only or non hormonal method

selecting a contraceptive

mood changes / disorder

Use monophasic COC - extended cycle or continuous with drospirenone is preferred

selecting a contraceptive

nausea

Take at night with food

Consider decreasing estrogen dose or switching to progestin only method, vaginal ring, or non hormonal method (ideally after 3 mo trial)

selecting a contraceptive

overweight

Counsel pt on the possibility of reduced effectiveness with contraceptive patch

- Do not use patch in obesity (BMI > 30)

Do not use DMPA if trying to avoid weight gain

selecting a contraceptive

postpartum

do not use CHC for 3 wks or 6 wks if pt has additional risk factors for VTE

can use progestin only or non hormonal method during this time

selecting a contraceptive

premenstrual dysphoric disorder

Choose a product drospirenone (Yaz)

SSRI antidepressant may be needed

selecting a contraceptive

spotting / breakthrough bleeding - early or mid cycle

Usually resolves within 3-6 mo

Wait 3 cycles before switching

If early or mid cycle spotting occurs - estrogen dose may need to be increased

selecting a contraceptive

spotting / breakthrough bleeding - late in cycle

Usually resolves within 3-6 mo

Wait 3 cycles before switching

If late in the cycle - progestin dose may need to be increased

selecting a contraceptive

wishes to avoid monthly cycle / menses

Use extended (91 day) or continuous formulations

Alt = monophasic 28 day formulations + skip placebo pills

_____ contraceptive method bypasses first pass metabolism + achieves higher serum concentration which decreases DDIs

injectable contraceptive

DDIs that decrease hormonal contraceptive efficacy

Antibiotics (rifampin, rifabutin, rifapentine - strong CYP450 inducers)

- Rifampin: induction can be prolonged

- Backup method needed x6 wks after rifampin is discontinued

Antifungals (griseofulvin)

Anticonvulsants (carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, barbituates, permapenal)

St John's Wort

Smoking tobacco

Ritonavir boosted protease inhibitors, bosentan (Tracleer), mycophenolate (CellCept, Myfortic)

Colesevelam

- Separate by at least 4 hrs

Mounjaro (for COC): use backup contraception for 4 wks after initiation and dose increases

DDIs with hormonal contraception

mavyret

not recommended with any formulation containing >20 mcg EE d/t risk of liver toxicity

DDIs with hormonal contraception

drospirenone

risk of ↑ potassium

quick start method

start today - best practice recommendation

sunday start method

start Sunday after onset of menstruation

Commonly used if pt prefers menstruation to occur during the week + is complete before following weekend

Can lead to missed doses if pt runs out over the weekend

first day start method

start on first day of menses

B/c COC is started within 5 days after start of period, no backup method is needed

starting COC hormonal pills

how long does it take to achieve contraceptive efficacy

7 days

starting COC hormonal pills

how long should a backup method be used

x7 days unless COC is started within 5 days after start of period

starting progestin only pills

how long does it take to achieve contraceptive efficacy

2 days

starting progestin only pills

how long should a backup method be used

x48 hrs (unless within 5 days of start of menses)

COC missed pills

1 late or missed pill (<48 hrs since last dose)

- when to take missed pill

- backup contraception

- emergency contraception

Take missed pill ASAP and take next dose on schedule (even if that makes 2 pills in 1 day)

Backup contraception needed? NO

Emergency contraception: not usually needed. Consider if missed doses earlier in the same cycle or in week 3 of the previous cycle

COC missed pills

week 1

2 missed pills (>48 hrs since last dose)

- when to take missed pill

- backup contraception

- emergency contraception

Take most recent missed pill ASAP (discard any other missed pills) + take next dose on schedule (even if that makes 2 pills in 1 day)

Backup contraception needed? YES x7 days

Emergency contraception: consider if unprotected sex in last 5 days

COC missed pills

week 2

2 missed pills (>48 hrs since last dose)

- when to take missed pill

- backup contraception

- emergency contraception

Take most recent missed pill ASAP (discard any other missed pills) + take next dose on schedule (even if that makes 2 pills in 1 day)

Backup contraception needed? YES x7 days

Emergency contraception: can be considered

COC missed pills

week 3

2 missed pills (>48 hrs since last dose)

- when to take missed pill

- backup contraception

- emergency contraception

Take most recent missed pill ASAP (discard any other missed pills) + take next dose on schedule (even if that makes 2 pills in 1 day)

Omit hormone free week; start next pack of pills right after finishing current pack

Backup contraception needed? YES x7 days

Emergency contraception: can be considered

POP

If >3 hrs past scheduled time

- when to take missed pill

- backup contraception

- emergency contraception

Take pill ASAP and take next dose on schedule

Backup contraception required? YES x48 hrs

Emergency contraception: consider if unprotected sex in last 5 days

IUDs that contain progestin levonorgestrel

Mirena, Skyla, Kyleena, Liletta

which IUDs are FDA approved for heavy menstrual bleeding

Mirena

Liletta

how long can hormonal IUDs be left in place before they need to be replaced

3-8 yrs

hormonal IUDs

SE

Cause lighter menstrual bleeding + minor to no cramping

Half of women will become amenorrheic after 2 yrs of use

copper IUD

SE

Causes heavier menstrual bleeding + cramping

does copper IUD have hormones

no

how long can a copper IUD be left in place

10 yrs

how long can the implant (nexplanon) be left in place

3 yrs

does the implant (nexplanon) have hormones

progestin etonogestrel

emergency contraception

if SA occurs what other empiric treatment should be started

STI treatment (chlamydia, gonorrhea, trichomoniasis)

HIV PrEP

HBV, HPV vaccinations

emergency contraception

copper IUD (paragard)

- effectiveness

- timing

- considerations

Most effective (99.9%)

Timing: Within 5 days

Within 5 days

emergency contraception

ulipristal acetate (ella)

- effectiveness

- timing

- considerations

More effective than levonorgestrel

Less effective if 195 lbs or BMI >30 kg/m2 (consider IUD)

Timing: ASAP within 5 days

Prescription required

Must be taken after every episode of unprotected sex

emergency contraception

levonorgestrel (plan b one step)

- effectiveness

- timing

- considerations

Less effective if >165 lbs or BMI >25 kg/m2 (consider Ella or IUD)

Timing: ASAP within 3 days

Available OTC

Must be taken after every episode of unprotected sex

levonorgestrel (plan b) SE

nausea

OTC antiemetic can be recommended to avoid losing the dose

If pt vomits within 2 hrs of taking medication consider repeating the dose

ulipristal acetate (ella) SE

headache, nausea, abdominal pain

Can only use once per cycle

Use barrier method for rest of cycle as ovulation may occur later than normal

Menstrual period typically restarts within 1 wk of expected date

ulipristal acetate (ella) + contraception

Progestin containing contraceptives should NOT be used in combo or within 5 days of ulipristal administration d/t concern for decreased efficacy of ulipristal

when is ulipristal acetate (ella) preferred over levonorgestrel (plan b)

72-120 hrs since unprotected intercourse or if women is overweight

diaphragm counseling

Wash hands thoroughly

Place 1 tablespoon of spermicide in diaphragm and disperse inside and around the rim

Pinch ends of cup and insert pinched end into vagina

Leave in for 6 hrs after intercourse

Do not leave in place for greater than 24 hrs

Reapply spermicide if intercourse is repeated or diaphragm is in place for more than 2 hrs before sex by inserting jelly with applicator

Wash with mild soap and warm water after removal, air dry

Can be used for 2-5 years depending on material - check frequently for holes between uses