Contraceptives

Ovulation test detect…

Pregnancy test detect…

Ovulation test detect rise in LH (will also notice increase in temp)

Pregnancy test detect rise of beta-HCG

MOA of COC

• Estrogen →

• Progestin →

• Both →

Indications of COC

• (3)

NOT for…

MOA of COC

• Estrogen → Inhibition of LH surge and FSH secretion (ovulation)

• Progestin → Alteration in cervical mucus (sperm can’t get to egg)

• Both → Cycle control

Indications of COC

• Menstrual cycle irregularity

• Acne, hirsutism

• Prevention of menstrual migraine

NOT for STI prevention

DDI for COC

• (3)

Day 1 start vs Sunday start (how to, benefits)

DDI

• Griseofulvin → CYP3A4 inducer

• CYP3A4 substrate → avoid CYP3A4 inducers and inhibitors

• COC decrease conc of lamotrigine by 45-60%

Day 1 start vs Sunday start

• Begin on the first day of your period → eliminated need for contraception

• Begin first Sunday after period begins → prevent period on weekends

Contraindications of combined oral contraceptives

…cancer

Hx of…

Severe…disease

…with…

Uncontrolled…

Age…who…

Breast and endometrial cancer

Hx of stroke and VTE

Severe hepatic disease

Migraine with aura

Uncontrolled HTN (>160/100)

**Age over 35 yo who smoke heavily (15 cig)**

Emergency Contraception for unprotected sex

OTC → (1) → use within…

Rx → (2) → use within…

Weight → If BMI…or weight… → use …

-

Ella

OTC → Levonorgestrel 1.5 mg tab (Plan B, My Way) → use within 3 days (no age restriction)

Rx →

• Ulipristal 30 mg tab (Ella) → selective progesterone receptor modulator

• Copper IUD → avoid in Wilson’s disease and pelvic inflammatory disease

• Both use within 5 days

Weight → BMI >25 or weight >75 kg → use Copper IUD (levonorgestrel and Ulipristal less effective)

Norethindrone

Class

Give when…

• (2)

Initate on…, what kind of pills

Considered missed dose if…

Missed dose instructions →

Class → “Mini-pill” (progestin only pills)

Give in patients who don’t want to use estrogen…

• Worried about clots (estrogen)

• Patient is early postpartum and breastfeeding → estrogen reduction in milk production

-

Initiate on the 1st day of menses. No placebo

Considered missed dose if >3 hrs late

Missed dose instructions → take 1 pill now, continue 1 pill at usual time tmr, backup for 48 hrs, emergency contraception with recent unprotected sex (within 5 days)

Generic

Depo-Provera → dosing, formulation

Depo-Provera 104 → dosing, formulation

Both frequency

ADE →

Medroxyprogesterone (progestin only)

Depo-Provera → 150 mg IM

Depo-Provera 104 → 104 mg SubQ

Both given by PCP every 3 months

ADE → weight gain

Remember Prempro (Medroxyprogesterone + Estrogen)

Missed doses

1 dose →

2 doses →

2 doses in week 3 or 3 doses anytime →

1 dose → take 2 doses ASAP. No backup needed

2 doses → Take 2 doses ASAP. Backup for 7 days

2 doses in week 3 or 3 doses anytime → Finish active tab then start new pack. Backup for 7 days.

Chewable COC (2)

Minastrin Fe, Femcon Fe

Fe = has iron → drink w water to avoid constipation

NuvaRing

Generic

Used for…

Discard →

Etonorgestrel + EE

Used for 3 weeks

Stored in the fridge, can be out of the fridge for 4 months

Discard → throw in trash, dont flush (limit environmental release)

Yaz / Yasmin (→ generic)

Yaz →

Drospirenone + EE

Has Drospirenone → good for acne

Yaz → shorter periods with fewer placebo days

Slynd

Class, unique

Generic

Good for…

ADE →

Equivalent to…

Drospirenone

Only progestin only pill that...

• Has placebo

• Does not need backup if missed 1 pill

Good for acne

ADE → hyperkalemia (anti-mineralocorticoid activity)

3 mg Drospirenone = 25 mg spironolactone

Remember Yaz / Yasmin -> Drospirenone + EE

Lybrel

Generic

Unique

ADE

Levonorgestrel + EE

No placebo days

ADE→ Early breakthrough bleeding that decreases with time

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Natazia

Generic

…phase

Need…

Dienogest + estradiol valerate (not the usual ethinyl estradiol)

4-phase OC

Need backup for 9 days when starting (not the usual 7)

Remember Ortho Tri-Cyclen → norgestimate + EE

Seasonique, Quartette

Generic

…cycle

Unique tabs

Levonorgestrel + ethinyl estradiol

Extended cycle preparation (91 days)

Unique tabs → 84 active, 7 days low EE (not placebo)

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Xulane

Formulation changed…for…with.,..

Associated with… → increased risk of…

If patch fails off for…

• (2)

Transdermal patch changed once weekly for 3 weeks with 1 patch free week

Associated with increased estrogen exposure than COC → may increase risk of VTE

If patch fails off for…

• <24 hrs → just put back on

• >24 hrs → new patch + backup 7 days

Contraceptive diaphragm

What is it, how does it work

Always use with…

Avoid with…

Reusable female contraceptive device blocks sperm entry to cervix

Always use with spermicide (nonoxynol 9)

Avoid with oil based lubricants (deterioration)

Duavee

Generic

Indication

ADE

Bazedoxifene (SERM) + Estrogen

Hormone replacement therapy for intact uterus but with SERM instead of progestin

• SERM still protects against estrogen-induce endometrial effects (alt to progestin)

• Estrogen still helps with…

  • Vasomotor symptoms in menopause

  • Prevention of postmenopausal osteoporosis

ADE -> clots (SERM)

Osphena

Generic, class

Indication

ADE → (2)

Ospemifene (SERM)

Non-estrogen option for dysparenuia (pain during intercourse) caused by menopausal atrophic vaginitis (vag dryness)

ADE→ hot flashes, clots (like all SERMs)

Remember Vagifem = estrogen vag tab for same indication

Remember Clomiphene (Clomid) = SERM for infertility

Vagifem

Formulation for what indication

Do NOT….NOT

Estradiol vaginal tab indicated for dysparenuia (pain during intercourse) caused by menopausal atrophic vaginitis (vag dryness)

Do NOT take during pregnancy. NOT birth control

Does not have systemic absorption → wont cause clots

Remember Osphemifene (Osphena) = SERM for same indication

Prometrium

Class

Avoid in…

Progesterone

Avoid in peanut allergy

Presentation

Yeast infection →

Bacterial Vaginosis →

Yeast infection → itching, no smell, check for DM

Bacterial Vaginosis → fishy odor, used metronidazole or secnidazole

Gyne-Lotrimin → generic

Monistat → generic

Vagistat → generic

Indication

Insert…

Gyne-Lotrimin → Clotrimazole

Monistat → Miconazole

Vagistat → Tioconazole

All OTC for yeast infection

Insert at night

Clomid

Generic, class

Indicated for…by…

Clomiphene (SERM)

Indicated for infertility by inducing ovulation (may cause clots)

Remember Osphemifene (Osphena) = SERM for menopausal atrophic vaginitis

Annovera Vaginal Ring

Generic

vs Nuvaring

Segestrol (progestin) + EE

Similar to Nuvaring (Etonorgestrel + EE) but use the same ring for the whole year

Prempro → generic

Premarin → generic

Indication, when to use what

Hormone replacement therapy

Prempro (Medroxyprogesterone + Estrogen)

Premarin (Estrogen only)

After hysterectomy → switch to Premarin and eliminate progestin’s protection of the uterus to prevent estrogen-induced endometrial cancer → keep estrogen just for postmenopausal vasomotor symptoms treatment and osteoporosis prevention

Remember Depo-Provera → Medroxyprogesterone

ClimaraPro → contains…

Menostar, Climara, Fempatch → contains…

Formulation, frequency

Hormone replacement therapy

ClimaraPro → contains progestin + estrogen

Menostar, Climara, Fempatch → estrogen only (used w/ hx of hysterectomy)

Transdermal patch applied ONCE WEEKLY (vs Combipatch, Vivelle, Minivelle TWICE WEEKLY)

Combipatch → contains…

Vivelle, Vivelle Dot, Minivelle → contains…

Formulation, frequency

Hormone replacement therapy

Combipatch → contains progestin + estrogen

Vivelle, Vivelle Dot, Minivelle → estrogen only (used w/ hx of hysterectomy)

Transdermal patch applied TWICE WEEKLY (vs ClimaraPro, Climara, Menostar, Fempatch ONCE WEEKLY)

Ortho Tri-Cyclen → generic

Triphasil 28 → generic

Both …

Ortho Tri-Cyclen → norgestimate + EE

Triphasil 28 → levonorgestrel + EE

Both triphasic COC

Note that any COC containing “…7/7/7” or “Tri” are all triphasic

Remember Triphasil 28, Lybrel, Seasonique, Quartette → Levonorgestrel + EE

Danazol

Class, indication

Preg

Synthetic androgen for endometrosis

Pregnancy Category X

Lysteda

Generic

Class → MOA (avoid in..)

Tranexamic acid

Antifibrinolytic med → prevents break down of clots (avoid in any hx of thrombosis)