Contraception

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32 Terms

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FSH

-Primary regulatory hormone in the follicular stage.

-Stimulates the conversion of androgens to estrogen in the ovaries → development of a dominant follicle that produces further estrogen.

-Peak of estrogen last in follicular stage stimulates a surge in luteinizing hormone (LH)

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LH

-Responsible for the maturation, release, and rupture of dominant follicle. Ovulation occurs 24-36 hours after beginning of LH surge.

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Preventing fertilization

Manipulation of hormones so ovulation never occurs

Interfering with implantation.

What are the three methods of preventing pregnacy?

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Periodic abstinence

Barrier devices

IUDs

  • Creates an inhospitable uterine environment.

What are the non-pharm methods of contraception.

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Saftey

Effectiveness

Convenience

Regular bleeding episodes

Rapid reversibility

What are the Goals of drug therapy for selecting contraception?

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Monophasic Contraception.

-Set amount of estrogen and progesterone x 21 days, placebo 22-28. → mensuration.

-Useful for pts. who experience breakthrough vaginal bleeding or sensitives to hormone fluctuations with biphasic or triphasic.

-Adjust to see what level works best for the patient.

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Bi/Tri phasic contraceptives

MOA: Suppression of FSH by continued high concentrations of circulating estrogen → prevents the development of dominant follicles.

  • suppression of LH by continued high concentrations of circulating progesterone → prevents LH surge responsible for ovulation; increases cervical mucus viscosity resulting in impaired sperm transport.

-Developed to better mimic hormonal fluctuations

-Major difference: the amount of progesterone delivered/cycle

  • Less progesterone

  • 20-35mcg of ethinyl estradiol/0.1-3 mg progesterone.

-Better for women experiencing progesterone-related side effects.

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-Blood/Circulatory disorders

-Markedly impaired liver function

-Breast cancer (known or suspected)

-Abnormal vaginal bleeding in absence of diagnosed cause

-Pregnancy

-Smokers older than 35

What are the absolute contraindications for combo oral contraceptive pills?

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Desogestrel and norgestimate

what are the least androgenic combined oral contraceptives?

  • work best for those who already struggle with the AE of progesterone.

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-Breast tenderness

-HA/Nausea

-Bloating

-Highly androgenic forms of progesterone affect:

  • Lipid

  • Carb metabolism

  • Acne

  • Weight gain

  • Hirsutism

What are the AE of Combined oral contraceptives?

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Signs of too much estrogen

-Heavy bleeding

-Cystic/enlarged/tender breasts

-Dysmenorrhea

-Bloating/GI symptoms

-Premenstrual edema/HA/Irritability

-Cervical exstrophy

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Signs of too little Estrogen.

-Bleeding (spotting early in cycle)

-Too light bleeding

-Bleeding throughout the cycle

-Amenorrhea

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Signs of too much Progestin

-Increased appetite

-Candidiasis

-Depression/fatigue

-Cervicitis

-Elevated blood pressure

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Signs of too little progestin

-Bleeding (spotting late in the cycle).

-Bleeding for fewer days, heavy bleeding, or delayed withdrawal of bleeding (abnormal bleeding)

-Dysmenorrhea

-Bloating/GI symptoms

-Premenstrual edema/HA/Irritability

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-Severe Abdominal pain

  • indicative of gallbladder disease

-Chest pain

  • Potentially related to PE or MI

-Headache

  • Relative to stroke, HTN, or migraine

-Eye problems

  • Relative to stroke or HTN

-Severe leg pain

  • Indicative of DVT

When to call primary care provider

-ACHES

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-Perfect use → <1% failure, typical failure is 3-8%

-Decreased risk of ovarian and endometrial cancers

-Decreased risk of basically all all diseases besides clotting.

-Improved PCOS symptoms of acne and hirsutism

What are the advantages of Combined Oral contraceptive?

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-Valproate → increased risk of seizures

-Oxcarbazepine and carbamazepine → contraceptive failure and breakthrough bleeding.

-Antibiotics → Decrease OCP effectiveness.

What are the drug interactions are for combined oral contraceptives?

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-Begin day 1 of menses or the Sunday after onset of menses

  • No menstruation on weekends

-Starting OCPs within first 5 days since bleeding → no back up contraceptive needed.

>5 days since menstrual bleeding started → Abstinence or back up x7 days.

What is the initiation process for OCPs?

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Unique administrations

-Patch: higher failure rate in women >198 lbs.

  • Wear/remove the patch every 7 days x3 weeks, then 1 patch-free week.

  • If off for >24hrs, use backup x7 days

-Ring: inserted vaginally and removed after 3 weeks; ring free x 1 week.

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Micronor, Camila, Errin, Nor-QD

  • 0.35 mg norethidrone

Ovrette:

  • 0.075mg norgestrel

  • Sometimes called the minipill

What are the progesterone-only hormonal contraceptives.

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Progestin-Only Hormonal Contraceptives

-hormonal contraceptive of choice in women who cannot take/tolerate estrogen-containing formulations.

  • Better in some comorbidities: HTN, DM, Smokers over 35, migraines or clotting history.

  • Recommended for lactating (Breastfeeding) women

MOA: Does not consistently suppress ovulation; primary effects are exerted through changing the endometrial and cervical mucus environments.

-Take at exact same time every day, no placebo week.

  • If does is more than 3 hours late, use a backup form of contraception.

-Start on the first day of menses with backup for 7 days.

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Depot-medroxyprogesterone acetate (DMPA) - Depo-Provera

MOA: Suppresses ovulation in addition to affecting cervical mucus

  • Dose IM or SC every 3 months (13 weeks latest)

  • Be given within the first 5 days after the onset of menses.

-Good for women with poor compliance with daily medication.

-All-around safe drug.

AE: Weight gain, amenorrhea, and irregular bleeding with unpredictable bleeding lasting more than 7 days.

  • Prolonged use → significant loss of bone mineral density (increase calcium/Vit. D intake, exercise regularly)

  • Reversible on d/c

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IUDs

-Flexible plastic devices that cause a sterile inflammatory reaction in the uterus, which interferes with sperm transport into and within the uterine cavity.

  • Effective for up to 10 years.

-Most effective, reversible contraception with a failure rate of < 1%

-Paragarud → hormone-free option (copper)

-Mirena → Hormone option

  • progesterone, NO estrogen.

  • Can be effective for dysmenorrhea, menorrhagia, and anemia.

-Inserted within 5 days of unprotected sex as emergency contraception

-Not associated with a decline in fertility

Contraindication:

  • Significant distortion of the uterus, PID, Unexplained vaginal bleeding.

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Progestin-only implants

-Nexplanon (Etonogestrel)

-Subdermal rod implanted in the upper arm in the office.

MOA: Blocks the LH surge, preventing ovulation, thickening cervical mucus, things endometrial lining.

  • Remains active for 3 years, effective as sterilization or IUD

-Unique: Caues estradiol to gradually rise to normal endogenous levels after initial decrease

AE: Irregular bleeding, acne, HA, weight gain.

Contraindicated:

  • Acute liver disease

  • Hx fo thrombosis (unlike other progestin-only methods)

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True

T/F: There are no absolute medical contraindications to the use of emergency contraception except for pregnancy.

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Cu-IUD

Levonorgestrel

Ulipristal acetate

Yuzpe regimen

  • Combined estrogen and progestin

What are the current forms of Emergency contraception (ECPs) available in the US?

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Emergency Contraception

-Take ASAP, within 120 hrs (5 days) of unprotected intercourse.

-Menstruation should occur within 21 days of administration.

  • Preg. test recommended if not.

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Ulipristal acetate (UPA) Ella

-Progesterone receptor antagonist

  • Inhibits follicle rupture

  • Effective near ovulation

-Single 30 mg dose

-More effective than levonorgestrel 3-5 days after unprotected intercourse; similar efficacy if taken within 3 days.

-Wait at least 5 days after taking, before starting or continuing hormonal contraception.

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Levonorgestrel

-Available OTC (Plan B)
-Similar effect to UPA if taken within 3 days of unprotected sex.

  • May be less effective in obese women.

  • Effectiveness decreases between 72-120 hrs

    • (3-5 days)

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EE/Levonorgestrel Combo (Yuzpe)

Utilizes OCPs as emergency contraception

-Less effective than UPA or levonorgestrel

-More side effects → N/V

Drug Interactions:

  • Drugs that increase GI motility (decrease absorption)

  • Ascorbic acid → more Estrogen AE

  • CYP3A4 Inducers (neuro drugs)

    • Use higher doses of EE or progestin -only.

  • Warfarin

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Selecting the most appropriate agent

-Oral, Transdermal, and vaginal hormonal contraception are first choice because the return of fertility after discontinuing use is expected.

-Endometriosis

  • Monophasic continuous therapy

-Postpartum, lactating

  • Progesterone-only minipill

-Noncompliance

  • Depot medroxyprogesterone acetate

  • Levonorgestrel subdermal implants

-Breakthrough bleeding (First half of cycle)

  • Change to a combination pill with a higher estrogen content

-Breakthrough bleeding (second half of cycle)

  • Change to a combination pill with higher progestin content

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Guidelines for missed pillls.

-One pill

  • Take missed pill ASAP and resume schedule

  • Backup method of contraception not needed.

-Two 30-35 mg pills:

  • Take missed pill ASAP and resume schedule

  • Backup method not needed.

-Two 20mg pills:

  • Follow directions for more than 2 pills.

-More than 2 pills:

  • Take pill and continue taking pill dailly

  • Use condom or abstinence for 7 days.

  • If missed in week 3, finish active pills in current pack and start a new pack the next day. (skip current inactive pills)

  • If missed pills in first week and had sex, use EC and then resume taking pills the next day after EC.