UWORLD Chapter 47: Contraception & Infertility

What is the range of a woman's menstrual cycle?

23-35 days, average is 28 days

What does the start of bleeding indicate?

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

What happens in the follicular phase?

-begins with cessation of previous cycle

-FSH secreted by the anterior pituitary promotes the development of the follicle, which grows and begins secreting estrogen

- Surge in estrogen causes luteinizing hormone and FSH to increase

What happens in ovulation?

LH surge causes expulsion of oocyte from ovary (ovulation)

What happens in the luteal phase?

the follicle develops into a corpus luteum which secretes progesterone, lasts about 14 days

How long can the oocyte live once released from the ovary?

24 hours

How do ovulation predictor kits work?

- Best time to start testing ovulation is a few days before you are scheduled to ovulate

- Test urine for a sharp increase in LH (24-36 hours before ovulation)

- Dip the stick in urine (preferably in the morning)

- The control line signals the test is working properly

- The test line will be lighter or darker than the control line depending on whether you're ovulating e.g. lighter when LH levels are low and darker with LH levels are high.

- A person trying to conceive should have intercourse when the test is positive and the following 2 days

What does a pregnancy test detect and when is this value highest?

hCG; first urine in the morning has the highest hCG levels

What should a woman do to help preconception health if trying to have a baby?

- increase folic acid to prevent neural tube defects in the baby; nonpregnant women is 400 mcg/day, pregnant women increases to 600 mcg/day

- stop smoking, using illicit drugs, and alcohol

- keep vaccinations current

- avoid toxic chemicals on the NIOSH Hazardous Drugs List

- Check with healthcare provider of teratogenic potential of all current medications

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

medroxyprogesterone injection

What is the most effective reversible birth control?

implant or IUD

What is the most effective permanent birth control?

male and female sterilization

Which forms of birth control result in 6-12 pregnancies out of 100 women in a year?

injection, pills, patch, ring, diaphragm

Which forms of birth control result in 18 or more pregnancies out of 100 women in a year?

male condom, female condom, withdrawal, sponge, fertility awareness, spermicide

What is the only method thats 100% in no pregnancies?

Abstinence

What is involved in the temperature and cervical mucus methods of contraception?

basal body temperature is tracked to predict ovulation, because a small (~1 degree) could be missed, this should be done in conjunction with cervical mucus changes

What can condoms do that other methods of contraception can't?

protect from STIs if they are latex or polyurethane (plastic)

What are recommended lubricants that make condoms less likely to break?

water or silicone based lubricants

What do spermicides contain?

nonoxynol-9

How do hormonal contraceptives work?

inhibit the production of FSH and LH, which prevents ovulation

What are the names of the different types of hormonal contraceptives?

progestin only, estrogen/progestin (combined hormonal contraceptives)

What can hormonal contraceptives also provide to women?

health benefits

What are the most common components (estrogen/progestin) of COCs?

- estrogen: ethinyl estradiol

- progestin: norethindrone, levonorgestrel, and drosperinone

What are the phasic types COCs come in?

- Monophasic: same dose of estrogen and progestin throughout the pill pack

- Biphasic, triphasic, and quadriphasic mimic the estrogen/progesterone in a menstrual cycle

What is unique about drosperinone?

its a potassium sparing diuretic that decreases bloating, premenstrual syndrome (PMS)

What are progestins with low androgenic activity?

drosperinone, norgestimate, desogestrel, dienogest

What other indications do COCs have?

dysmenorrhea (menstrual cramps), PMS, acne, anemia, PCOS, endometriosis, heavy menstrual bleeding (menorrhagia)

What are the uses and pearls of progestin only pills?

- suppress ovulation, primarily used in breastfeeding women because estrogen decreases milk production, safe in women who have migraines with aura

- Must be taken within three hours of the scheduled time to work

When should estrogen patches be avoided?

have higher systemic estrogen exposure and an even higher risk of thromboembolism, avoid if over 35 and/or smoking and/or BMI 30 or more

At what weight is Xulane and Zafemy less effective?

women >198 lbs (90 kg)

What routes and frequencies is depot medroxyprogesterone acetate (DMPA) given?

IM (150) or SC (104) every 3 months

What is the length of most COC pill packs?

28 days or 4 weeks, with 21-24 pills containing active hormones. During week 4 (inactive pills) menses occurs for 3-7 days

How do extended cycle COCs work?

84 days of active hormonal pills followed by 7 days of very low dose estrogen. bleeding occurs every 3 months, if skipping the placebo through continuous contraception, it is possible to suppress menses altogether

What occurs commonly with continuous contraception? When does it resolve?

breakthrough bleeding (spotting), resolves after 3-6 months

What is the significance of Lo in birth controls?

indicates 35 mcg or less of estrogen (less side effects)

What is the significance of Fe in birth controls?

iron supplementation is included in

What is the significance of 24 in birth controls?

shorter placebo time with 24 active pills and 4 placebo pills

What is the significance of Pro in birth controls?

progestin in product

What are the names of the monophasic COCs?

Junel Fe 1/20, Microgestin Fe 1/20, Sprintec 28, Loestrin 1/20, Yasmin 28, Yaz, Lo Loestrin Fe

What is an example of a Triphasic formulation?

Tri-Sprintec

What is an example of the quadriphasic formulation?

Natazia

What are names of extended cycle formulations?

Jolessa, Seasonique

What are names of continuous formulations?

Amethyst, Dolishale

What are the names of drosperinone containing COCs?

Yasmin 28, Yaz

What are the names of the transdermal patches?

Xulane, Zafemy, Twirla

What are names of the vaginal rings?

Nuvaring, Annovera (reusable vaginal ring for 1 year)

What are the names of POPs and what specific progestin do they contain?

- Errin, Camila, Nora-BE: Norethindrone

- Slynd: drosperinone

- Opill

What is the only POP available OTC?

Opill

What is the name of the contraceptive injection?

Depo-Provera

What are side effects of estrogen?

nausea, breast tenderness, bloating, weight gain, increased blood pressure

What does an estrogen dose that is too low cause?

breakthrough bleeding (spotting)

What is the acronym and meaning of rare but serious adverse effects that can occur with estrogen?

- A: Abdominal pain that's severe

- C: Chest pain

- H: Headaches

- E: Eye problems

- S: Swelling or sudden leg pain

What are the risks of drosperinone?

higher risk of clotting, increased potassium (don't use with kidney, liver, or adrenal gland disease)

What is the risk of injectable DMPA?

loss in bone mineral density, need to take adequate calcium and vitamin D

How do you manage persistent spotting on COCs?

if currently taking <30 mcg: increase estrogen dose

if currently taking 30 or more mcg: try a different progestin

What are boxed warnings for all CHC products?

Don't use in women > 35 years old who smoke

What are boxed warnings for all estrogen + progestin transdermal patches?

don't use with BMI 30 or more due to increased clotting risk

What are boxed warnings for all depo provera products?

loss of bone mineral density

What conditions should you not use estrogen contraceptives in?

history of DVT, PE, stroke, or CAD

history of breast, ovarian, liver, or endometrial cancer

migraines with aura

What birth control is recommended with acne or hirsuitism?

a COC with a progestin that has low androgenic activity (sprintec) or no androgenic activity (Yaz)

What birth control is recommended with breastfeeding or estrogen contraindication?

POP or non hormonal method

What birth control is recommended with fluid retention/bloating?

drosperinone containing product

What birth control is recommended with heavy menstrual bleeding (menorrhagia)?

Natazia (a COC) and Mirena (levonorgestrel releasing IUD)

What birth control is recommended with HTN?

POPs or non hormonal

What birth control is recommended with mood changes/disorder?

monophasic COC - extended cycle or continuous with drosperinone is preferred

What birth control is recommended with nausea?

decreasing estrogen

What birth control is recommended with overweight?

anything but patch in obesity and DMPA

What birth control is recommended with postpartum?

POP or no hormonal

What birth control is recommended with premenstrual dysphoric disorder?

Yaz or an SSRI antidepressant

What birth control is recommended with patients that wish to avoid monthly cycle?

extended or continuous formulations

Which type of contraceptive has the least drug interactions?

injectable contraceptives

What are drugs that decrease effectiveness of oral contraceptives?

- Rifampin, rifabutin: back up method needed for 6 weeks post DC of rifampin

- carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, barbiturates

- St. John's wort

- Tobacco

- ritonavir, cobicistat

- Tirzepatide

What is a risk of Mavyret in combination with >20 mcg of estrogen?

liver toxicity

How long does it take for COCs to become fully effective?

7 days (use back up method during then) unless COC is started within 5 days after the start of a period

What are the three ways to start COC birth control?

start today, sunday start, first day of period start

When should POPs be started

any time

What are missed dosing schedules for 28-day cycle Ocs?

• 28-day-cycle schedules

• One or more pills missed 1st week: Take one pill as soon as possible (ASAP) and continue with the pack; use an additional form of contraception for 7 days

• One or two pills missed 2nd or 3rd week: Take one pill ASAP and continue with active pills in the pack; skip placebo pills and go straight to a new pack once all the active pills have been taken

• Three or more pills missed 2nd or 3rd week: Follow instructions given for missing one or two pills; also, use an additional form of contraception for 7 days

Which copper IUD can be used for emergency contraception as well as regular birth control?

Paragard

What progestin and how long is Nexplanon implanted for?

etonogestrel for 3 years

When should ulipristal acetate be taken for emergency contraception?

ASAP within 5 days

When should levonogestrel be taken for emergency contraception?

1.5 mg tablet, ASAP within 3 days, more effective the sooner it's taken

What is the MOA of plan B?

Preventing or delaying ovulation and thickens cervical mucus

What is the primary side effect of plan B?

nausea, if patient vomits within 2 hours of the med, take another dose

How does one acquire ulipristal? What's its MOA and dose?

prescription only, prevents or delays ovulation, 30 mg as a single dose

Where is Xulane patch applied?

upper back, abdomen, buttock

How do you dispose of the Xulane patch?

folding sticky sides together and throw in the trash, not the toilet

How does the NuvaRing work?

wears for 3 weeks, takes out for a week (period), and inserts new ring

Can be kept in place all four weeks to avoid a period

How do you dispose of a NuvaRing?

place ring back in reclosable satchet it came in, then throw away in the trash. Don't flush down the toilet

How do misoprostol and mifepristone work in miscarriage?

misoprostol causes uterine contractions, mifepristone aids that process, to cause termination in pregnancy

What is the definition of infertility?

Failure to conceive after 1 year of unprotected intercourse

What is the MOA of clomiphene?

Selective estrogen receptor modulator (SERM), act as estrogen agonists in some tissues and antagonists in other tissues

What are the most common side effects of clomiphene?

hot flashes and increased clotting risk

What do gonadotropins do in infertility?

act similarly to endogenous gonadotropins FSH of LH

What is a risk of gonadotropins and clomiphene?

multiple births at a time