PPC Exam 2 (91-100)

Drospirenone/Ethinyl Estradiol

Yaz

Etonogestrel/Ethinyl Estradiol Vaginal Ring

NuvaRing

Levonogestrel

Plan B One-Step

Medoxyprogesterone Injection

Depo-Provera

Norelgestromin/Ethinyl Estradiol Transdermal

Xulane

Norgestimate/Ethinyl Estradiol

Ortho Tr-Cyclen

Norethindrone

Micronor

Conjugated Estrogens

Premarin

Conjugated Estrogens/Medroxyprogesterone

Prempro

Premphase

Estradiol

Estrace

Estrogel

Climara

Progesterone

Prometrium

Testosterone

Androderm

AndroGel

Axiron

Drospirenone/Ethinyl Estradiol Class

Combined Hormonal Contraceptive (CHC): Estrogen + Progestin

Etonogestrel/Ethinyl Estradiol Vaginal Ring Class

Combined Hormonal Contraceptive (CHC): Estrogen + Progestin

54 mm flexible ring, 4 mm thick

Levonogestrel Class

Progestin Contraceptive

Medroxyprogesterone Injection

Progestin-only IM onjection

Norelgestromin/Ethinyl Estradiol Transdermal Class

Combined Hormonal Contraceptive (CHC): Estrogen + Progestin

Norgestimate/Ethinyl Estradiol Class

Combined Hormonal Contraceptive (CHC): Estrogen + Progestin

Norethindrone Class

Progestin-Only Pill (POP)

Contraceptive

Conjugated Estrogens Class

Estrogen derivative

Conjugated Estrogens/Medroxyprogesterone Class

Estrogen + Progestin Combination

Estradiol Class

Estrogen derivative

Progesterone Class

Progestin

IM Injection

Testosterone Class

Androgen

Drospirenone/Ethinyl Estradiol Indications

Contraception

Moderate acne vulgaris

Premenstrual dysphoric disorder (PMDD)

Etonogestrel/Ethinyl Estradiol Vaginal Ring Indications

Contraception

Levonogestrel Indications

Emergency contraceptive

Medroxyprogesterone Injection Indications

Contraception

Endometriosis

Norelgestromin/Ethinyl Estradiol Transdermal Indications

Contraception

Norgestimate/Ethinyl Estradiol Indications

Contraception

Moderate acne aulgaris

Norethindrone Indications

Contraception

Prevention of estrogen therapy-associated endometrial hyperplasia

Conjugated Estrogens Indications

Breast cancer (metastatic)

Prevention of osteoporosis (postmenopausal)

Advanced prostate cancer

Hypoestrogenism

Vasomotor symptoms associated with menopause

Vulvar and vaginal atrophy associated with menopause

Abnormal uterine bleeding (injection only)

Conjugated Estrogens/Medroxyprogesterone Indications

Osteoporosis prevention (female)

Vasomotor symptoms associated with menopause

Vulvar and vaginal atrophy associated with menopause

Estradiol Indications

Breast cancer (metastatic)

Prevention of osteoporosis (postmenopausal)

Advanced prostate cancer

Secondary amenorrhea (hypoestrogenism)

Vasomotor symptoms associated with menopause

Vulvar and vaginal atrophy associated with menopause

Progesterone Indications

Assisted reproductive technology

Estrogen therapy-associated endometrial hyperplasia (prevention)

Abnormal uterine bleeding

Testosterone Indications

Hypogonadism

Drospirenone/Ethinyl Estradiol Adverse Effects

First 3 cycles: Nausea, Bloating, Breakthrough bleeding

Irregular bleeding

Nausea

Skin breakouts/oily skin

Breast tenderness

Fatigue

Depression

Serious: ACHES

Abdominal pain

Chest pain

Headaches

Eye problems

Severe leg pain

Boxed warning:

- Cigarette smoking increases risk of serious CV events with CHC, risk increases with age

- Contradindications

Etonogestrel/Ethinyl Estradiol Vaginal Ring Adverse Effects

First 3 cycles: Nausea, Bloating, Breakthrough bleeding

Irregular bleeding

Nausea

Skin breakouts/oily skin

Breast tenderness

Fatigue

Depression

Serious: ACHES

Abdominal pain

Chest pain

Headaches

Eye problems

Severe leg pain

Boxed warning:

- Cigarette smoking increases risk of serious CV events with CHC, risk increases with age

- Contraindications

Levonogesrel Adverse Effects

Irregular menses

Abdominal pain

Nausea

Breast tenderness

Dizziness

Fatigue

Headache

Medroxyprogesterone Injection Adverse Effects

Boxed warning:

- May lose significant bone mineral density

- Unknown if it increases risk for osteoporotic fracture (later in life)

Menstrual bleeding irregularities

Weight gain

Norelgestromin/Ethinyl Estradiol Trasndermal Adverse Effects

First 3 cycles: Nausea, Bloating, Breakthrough bleeding

Irregular bleeding

Nausea

Skin breakouts/oily skin

Breast tenderness

Fatigue

Depression

Serious: ACHES

Abdominal pain

Chest pain

Headaches

Eye problems

Severe leg pain

Boxed warning:

- Do NOT use if BMI is 30 kg/m2 or more (may have

higher risk of developing blood clots)

Norgestimate/Ethinyl Estradiol Adverse Effects

First 3 cycles: Nausea, Bloating, Breakthrough bleeding

Irregular bleeding

Nausea

Skin breakouts/oily skin

Breast tenderness

Fatigue

Depression

Serious: ACHES

Abdominal pain

Chest pain

Headaches

Eye problems

Severe leg pain

Boxed warning:

- Cigarette smoking increases risk of serious CV events with CHC, risk increases with age

- Contraindications

Norethindrone Adverse Effects

Irregular/unpredictable menstrual bleeding

Conjugated Estrogens Adverse Effects

Estrogen monotherapy contraindicated in women with a uterus (have not had a hysterectomy) due to risk of endometrial cancer

Absolute and relative contraindications

Nausea

Headache

Cramping

Breast tenderness

Boxed warnings:

- Increased risk of breast cancer

- NOT for dementia prevention

Conjugated Estrogens/Medroxyprogesterone Adverse Effects

Nausea

Headache

Cramping

Breast tenderness

Boxed warnings:

- Increased risk of breast cancer

- NOT for dementia prevention

Absolute and relative contraindications

Estradiol Adverse Effects

Estrogen monotherapy contraindicated in women with a uterus (have not had a hysterectomy) due to risk of endometrial cancer

Absolute and relative contraindications

Nausea

Headache

Cramping

Breast tenderness

Boxed warnings:

- Increased risk of breast cancer

- NOT for dementia prevention

Progesterone Adverse Effects

Nausea

Headache

Cramping

Breast tenderness

Boxed warnings:

- Increased risk of breast cancer

- NOT for dementia prevention

Testosterone Adverse Effects

Acne

Gynecomastia

Headache

Enlarged prostate/worsening of BPH

Serious:

Blood clots

Increased risk of heart attack or stroke

Increased risk of prostate cancer

Drospirenone/Ethinyl Estradiol Counseling

-Monophasic dosing (24 active tablets, 4 inert)

-Monitor hyperkalemia (check labs before start, make sure K not too high cuz dros is potassium sparing, sim to spiro, check if on ace, arb, etc)

-Take at same time every day

-Have an action plan for missed doses and initiating

-Doses do NOT protect against STIs

-Be aware of serious warning signs (ACHES) & contact provider immediately

-Drug interactions: Rifampin/other antibiotics, anticonvulsants, protease inhibitors, St. John's wort

Etonogestrel/Ethinyl Estradiol Vaginal Ring Counseling

-Releases hormones over 3-week period; change every 3 wks

-Have action plan for hours removed

-Does NOT protect against STIs

-Be aware of serious warning signs (ACHES) & contact provider immediately

-In fridge at pharm, good for 4 mo unfreg

Levonogestrel Counseling

One dose given within 72 hours of unprotected intercourse

Available OTC with no age restriction

Inhibits/delays ovulation

Evaluate for pregnancy, menstruation delayed for 1+ week, or lower abdominal pain/persistent irregular bleeding occurs

Medroxyprogesterone Injection Counseling

Administered in providers office every 12 weeks

Lower failure rate than CHCs

Monitor blood glucose and depression in those with history

Norelgestromin/Ethinyl Estradiol Transdermal Counseling

Transdermal patch: Provides hormones over 7 days

Apply patch to abdomen, buttocks, upper torso, upper arm at beginning of menstrual cycle

NOT recommended for women >90kg

Have an action plan for patch removal/detaches: If >24 hours, apply a new patch and start a 4-week cycle, use backup 7 days

Does NOT protect against STIs

Boxed Warning: Do not use if BMI is 30 kg/m2 or more, may have higher risk of developing blood clots

Norgetsimate/Ethinyl Estradiol Cousneling

-Take at same time every day

-Have an action plan for missed doses and initiating

-Doses do NOT protect against STIs

-Be aware of serious warning signs (ACHES) & contact provider immediately

-Drug interactions: Rifampin/other antibiotics, anticonvulsants, protease inhibitors, St. John's wort

-Triphasic dosing: Norgestimate dose increases every 7 days, last 7 days inert tablets

Norethindrone Counseling

All pills active

Must take at the same time every day

If pill is taken >3 hours late, must use backup for 48 hours

Conjugated Estrogens Counseling

Available as oral tablet and vaginal cream

Should be evaluated routinely to confirm appropriateness

Monitor BP and baseline risk for breast cancer and CVD

Monitor for menopausal symptoms at least annually

Conjugated estrogens/Medroxyprogesterone Counseling

Available as oral tablet

Prempro: Take same dose every day

Premphase: 2 different doses (days 1-14, 15-28)

Estradiol Counseling

Estrace: Oral tablet

Estrogel: Vaginal gel

Climara: Transdermal patch

Progesterone Counseling

Available as oral tablet, vaginal gel, and IM injection

Testosterone Counseling

Androderm: Transdermal patch

Angrogel: Topical jelly

Axiron: Topical solution

*Application counseling

Women and children at increased risk of virilization if exposed to testosterone

Avoid smoking, fire, or open flame (gel is flammable)

CHC Contraindications

-Estrogen or progestin-dependent cancer

-Hepatic disease/tumors

-Cerebrovascular disease

-Coronary artery disease

-Diabetes with vascular disease

-Uncontrolled hypertension

-Migraine w/ aura or migraine and age > 35

-Smoking and age > 35

CHC serious side effects

ACHES:

Abdominal pain

Chest pain

Headaches

Eye problems

Severe leg pain

Risk of Blood clot

Is higher in pregnancy and even higher in post-partum

Use progestin only after birth

Drug interactions with CHC

-Rifampin; other antibiotics(?)

-Anticonvulsants

-Phenobarbital, carbamazepine, phenytoin- reduce OC efficacy

-Lamotrigine- increase seizures

-Protease inhibitors

-St. John’s wort

Methods to start CHC

Day 1:

•Take first active tablet on the first day of menstruation

•NO backup method required

Sunday:

-Take first active tablet on the Sunday after the start of menstruation

-Use backup method for 7 days

Quick Start:

-Take first active tablet without regards to menstruation

-Use backup method for 7 days

CHC Missed Dose Counseling

Miss 1 tab in week 1-3:

-Take the tablet at soon as you remember

-Continue taking active pack until finished

-No backup method needed

Miss 2 tabs in Weeks 1-2:

-Take the two missed tablets as soon as you remember

-Continue active pack until finished

-Use backup method for 7 days after missing tablets

Miss 2 tabs in Week 3: *Depends when you started!

Day 1: throw away pack; start new pack same day;

Sunday: continue taking 1 tablet daily until Sunday, then throw out the rest of the pack and start a new pack that same day. Use backup for 7 days after missing tabs

CHC General Counseling

-Take at the same time every day

-Action plan for missed doses

-Does not protect against STIs!

-Common vs. severe side effects (ACHES)

Plan if NuvaRing falls out

< 3 hrs in Weeks 1-3:

-Rinse w/ warm water and reinsert;

-NO backup needed

> 3 hrs Weeks 1-2:

-Reinsert as soon as possible

-Use backup until ring has been in for 7 days

< 3hrs Week 3:

-Discard old ring

-Start new ring/3 week interval

OR

-Remove for 7 days and start new 3 week interval

-