Contraception

FSH

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)

LH

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

Preventing fertilization

Manipulation of hormones so ovulation never occurs

Interfering with implantation.

What are the three methods of preventing pregnacy?

Periodic abstinence

Barrier devices

IUDs

• Creates an inhospitable uterine environment.

What are the non-pharm methods of contraception.

Saftey

Effectiveness

Convenience

Regular bleeding episodes

Rapid reversibility

What are the Goals of drug therapy for selecting contraception?

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.

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.

-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?

Desogestrel and norgestimate

what are the least androgenic combined oral contraceptives?

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

-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?

Signs of too much estrogen

-Heavy bleeding

-Cystic/enlarged/tender breasts

-Dysmenorrhea

-Bloating/GI symptoms

-Premenstrual edema/HA/Irritability

-Cervical exstrophy

Signs of too little Estrogen.

-Bleeding (spotting early in cycle)

-Too light bleeding

-Bleeding throughout the cycle

-Amenorrhea

Signs of too much Progestin

-Increased appetite

-Candidiasis

-Depression/fatigue

-Cervicitis

-Elevated blood pressure

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

-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

-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?

-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?

-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?

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.

Micronor, Camila, Errin, Nor-QD

• 0.35 mg norethidrone

Ovrette:

• 0.075mg norgestrel

• Sometimes called the minipill

What are the progesterone-only hormonal contraceptives.

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.

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

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.

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)

True

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

Cu-IUD

Levonorgestrel

Ulipristal acetate

Yuzpe regimen

• Combined estrogen and progestin

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

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.

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.

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)

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

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

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.