Hormonal Contraception Therapeutics

What are the combination options of contraceptives?

monophasic, biphasic, triphasic, 4-phasic

What are estrogens dosed between 10 and 20 mcg associated with?

breakthrough bleeding, less CV risk

What are estrogens dosed at 50 mcg normally used for?

anticonvulsants, intractable breakthrough bleeding, persistent functional ovarian cysts

What is the risk of higher doses of estrogen?

higher CV risk

What is the difference between first gen and later gens of progestin?

early gens = more androgenic effects

What are the 2 ways that we can start the first pill packet?

start within 24 hours of menses = effective immediately, start 1st sunday after menses start = backup protection for first week

What are advantages of estrogen component in oral contaceptives?

less iron deficiency anemia/menstrual flow/cramping/ectopic pregnancy risk/PID/ovarian cysts/ovarian cancer/endometrial cancer

What are disadvantages of estrogen?

compliance, VTE/stroke risk, increase TG/BP, STI, benign hepatocellular adenomas, breast/cervical cancer risk

What are CI of estrogen?

thromboembolic disorders, history of VTE/stroke, CAD, known breast cancer, migraine with aura

What is the boxed warning on all contraceptives?

increase CV risk with age > 35 and smoking > 15 cigs/day

What are side effects of excess estrogen?

nausea, bloating/edema, cervical mucorrhea, polyposis, melasma, HTN, migraines, breast tenderness/fullness

What are side effects of estrogen deficiency?

early/midcycle breakthrough bleeding, increase spotting, hypomenorrhea

What are side effects of excess progestin?

increase appetite, weight gain, tired/fatigue, hypomenorrhea, acne, oily scalp, hair loss/hirsutism, depression, monilial vaginitis, breast regression

What are side effects of progestin deficiency?

late breakthrough bleeding, amenorrhea, hypermenorrhea

What are drug interactions with estrogen?

anticonvulsants, rifampin, antivirals = NNRTI/protease inhibitors/HIV

What medications are decreased by estrogen?

warfarin, lamotrigine

What is the proposed mechanism between antibiotics and contraceptives interaction?

liver enzyme induction with rifampin/griseofulvin = accelerate metabolism of estrogen/progestin

What is the point of the interaction between antibiotics and contraceptives according to US medical eligibility criteria?

no restriction with use of them together

What is the recommendation for one missed dose?

take as soon as remembered then take next pill at regular time that day, alternative contraception not needed

What is the recommendation for 2 or more missed doses?

take most recent pill as soon as possible, discard other pills or take 2 on day patient remembers, alternative protection for 7 days

What are agents available as combo products?

oral, patch, ring

What is the MOA of progestin only contraceptives?

inhibits LH surge, creates atrophied endometrium so implantation will not occur, thickens mucus to interfere with sperm transport, alters fallopian tube secretions

What are advantages to progestin only products?

lactation, no CV risk, no estrogen SE, decrease PID

What are disadvantages of progestin only products?

amenorrhea/spotting

What is the recommendation for missing a dose for progestin only products?

even if three hours late, use another contraception for next 48 hours = except drospirenone/norgestrel

What are advantages of depo-provera?

IJ every 12 weeks, grace period of 2 weeks, effective immediately if given first 5 days of menses, low failure rate, decrease/no menstrual flow/cramps, no lactation suppression, passive, avoid estrogen SE, sickle cell crisis, few DI

What are disadvantages of depo-provera?

return of fertility may be delayed, possible breakthrough bleeding, weight gain = 2-5 kg every year, high VTE risk, decrease HDL/increase T, high osteoporosis risk = bone mineral density decreased

What is the BBW for depo-provera?

decreased bone mineral density = limit to < 2 years use if possible

What is given with depo-provera to reduce bone mineral density loss risk?

calcium 1000-1500 mg/day + vit D 800-1000 IU QD

What are CI of nexplanon?

past/present VTE, positive risk of PE/stroke

What is a caution with nexplanon?

> 130% of IBW

What are SE of nexplanon?

amenorrhea, infrequent bleeding

What are advantages to progestin IUDs?

long term, passive, low failure rate, less bleeding/cramping/dysmenorrhea, fertility

What are disadvantages of progestin IUDs?

spotting, ectopic pregnancy, office visit, uterine perforation

What are SE of IUDs?

uterine bleeding

What does ACHES stand for?

abdominal pain, chest pain, HA, eye problems, severe leg pain