contraception/infertility

Normal menstrual cycle is ~__ days

28

What does the start of menses indicate?

The next cycle has begun and is counted as day 1 of the cycle

What is counted as day 1 of the cycle?

Start of menses because the remnants of the previous cycle are sloughing off

What are the 3 phases of the menstrual cycle? *

• Follicular: surge in estrogen causes LH & FSH to increase

• Ovulatory: LH surge triggers ovulation, ovulation occurs

• Luteal: start of ovulation begins, progesterone dominant

What surge triggers ovulation?

LH surge resulting in release of egg (oocyte)

The oocyte lives for ___ hours once released

24 hours

What do ovulation kits test for?

• LH in the urine, positive if present

• Predict the best time to have sex

When is the best time to have sex if u want a babyyyyy?

Once the LH surge is detected and for the following 2 days

When should hCG be tested for pregnancy?

First thing in the morning when hCG is highest

Preconception health for wanting to have a baby (5)

• Increase folic acid (folate) to prevent neural tube defects

• Stop smoking, drinking, doing drugs

• Up to date on vaccinations

• Avoid hazardous drugs

• Ask MD to evaluate if any meds u are taking are teratogenic

Why do preggos take folic acid?

Prevents neural tube defects

Folic acid dosing in adults vs. pregos

• Adults 400 mcg

• Pregnancy 600 mcg

What is the only REVERSIBLE contraceptive method that has a delay in return to fertility?

Medroxyprogesterone injection

What are the most effect contraceptive methods? (3)

• Nexplanon

• IUD

• Male or female sterilization (permanent)

What is the only 100% effective way to prevent pregnancy & STI?

ABSTINENCE woop

Tracking ____ body temperature is used to predict ovulation

Basal

What type of lubricants should we recommend with condoms?

Water or silicon based, don't recommend oil

Contraceptive foams, films, creams, etc contain what spermicide?

Nonoxynol-9

What is nonoxynol-9?

spermicide

Hormonal contraceptives MOA

Inhibit production of FSH and LH which prevent ovulation

Hormonal contraceptive options (2)

• Progestin only (pill, IM, implant, IUD)

• Estrogen/progestin combination (pill, patch, ring)

T/F: Hormonal contraceptives provide health benefit

True - like dec in menstrual pain, acne, etc

What is required per FDA to be dispensed with oral contraceptives?

PATIENT PACKAGE INSERT (PPI)

COC components

• Estrogen ethinyl estradiol (EE)

• Progestin (Norethindrone, levonorgesterol, drospirenone)

What is unique about drospirenone?

Used in some COC to reduce AE commonly seen with OC

• Mild K+ sparing diuretic which dec bloating, PMS, and weight gain

Indications for COC? (7)

• Contraception

• Dysmenorrhea (menstrual cramps)

• PMS

• Acne

• Anemia

• PCOS

• Endometriosis

Why would someone use progestin only pills?

If someone is breastfeeding, because estrogen decreases milk production

Progestin only pills require good adherence and must be taken daily within ___ hours of the scheduled time

3

T/F: Progestin only pills are safe in patients who have migraines with aura

True

Patches can cause a higher systemic _____ exposure

estrogen leading to higher risk of thromboembolism

Patch contraindications (3)

• Anyone with clotting risk (>35 yo who smoke, CVA, postpartum, etc)

• BMI ≥30

• Xulane patch is less effect in women >90kg

DMPA

Depot medroxyprogesterone acetate: injectable contraception

• IM or SC every 3 months

DMPA is administered IM or SC every ____ months

3

Extended cycle COC involve ___ days of active hormonal pills followed by 7 days of inactive

84

Bleeding occurs every 3 months

What OC is approved for suppressing menses altogether with continuous contraception?

Amethyst - all others are used off label

Monophasic meaning

COC that have same dose of estrogen and progestin throughout the pill pack

Mimics estrogen and progestin levels better

A. Monophasic

B. Biphasic, triphasic, quadraphasic

B. Biphasic, triphasic, quadraphasic

If you see "lo" it means there is ≤___ mcg of estrogen so they will have less SE

35

Monophasic COC formulations (7)

• Junel Fe 1/20

• Microgestin Fe 1/20

• Sprintec 28

• Loestrin 1/20

• Yasmin 28

• Yaz

• Lo Loestrin Fe

Biphasic, Triphasic COC formulations (1)

• Tri-sprintec

Extended cycle COC formulation (1)

• Seasonique

Drospirenone containing formulations (2)

• Yasmin 28

• Yaz

Contains that mild K+ diuretic to help with AE

Patches example (1)

• Xulane

OC vs patch vs ring estrogen concentration

• Patches have higher estrogen than pills

• Rings have lower estrogen than pills

Progestin only pills formulations (4)

• Errin

• Camila

• Nora-BE

• Slynd (O-pill)

When is Nuvaring removed?

1 week when you have your period, so worn for 3 weeks, removed for 1

ESTROGEN AE (8)

• Nausea

• Breast tenderness

• Bloating

• Weight gain

• HTN (due to fluid retention)

• Melasma (dark skin patches)

• Acne

• Hirsutism

The higher the estrogen dose or exposure, the higher the ____ risk

Clotting

Rare AE of estrogen *** (5)

• Abdominal pain

• Chest pain

• Headaches

• Eye problems

• Swelling or sudden leg pain

ACHES

How to manage breakthrough bleeding?

• Usually resolves within 3-6 months

• <30 mcg estrogen: increase dose

• ≥30 mcg estrogen: try a different progestin

• If early or midcycle spotting occurs, the estrogen dose may need to be increased

• If later in the cycle the progestin dose may need to be increased

BW for pills, ring, patch (1)

Do not use in women >35 yo who smoke due to risk of serious CV events

Estrogen & progestin patch BW (1)

Do not use in women with BMI ≥30 due to increased risk of thromboembolism

DMPA injection BW (1)

Loss of BMD with long term use (so ensure adequate vitamin D & calcium administration)

DO NOT USE ESTROGEN WITH WHAT CONDITIONS (6)

• History of DVT/PE

• CAD

• Stroke

• History of breast, ovarian, liver or endometrial cancer

• Uncontrolled HTN (>160/110)

• Severe headaches or migraine with aura

• DM with vascular disease

DOC for patients with acne or hirsutism (2)

• Progestin with lower androgenic activity (norgestimate (sprintec 28)

• No androgenic activity (drospirenone (Yaz, Yasmin))

DOC for patients breast feeding (2)

• Progestin only

• Non-hormonal contraception

DOC for patients with migraine (1)

• Aura: do not use estrogen, choose progestin only or non-hormonal

• No Aura: choose any method

DOC for patients with heavy menstrual bleeding (menorrhagia) (2)

• Natazia (COC)

• Mirena (IUD)

DOC for patients with HTN (2)

• Progestin only

• Nonhormonal contraception

DOC for patients with mood changes/disorders (2)

• Monophasic COC with extended cycle

• Continuous drospirenone

Management for patients with nausea from OC? (2)

• Take at night with food

• Consider decreasing estrogen

What option should you not use if you are trying to avoid weight gain?

DMPA

DOC for postpartum (1)

• Nonhormonal

DOC for patients with PMDD (2)

• Drospirenone (Yaz)

• SSRI antidepressant

DDI with hormonal contraceptives (6)

• Rifampin, rabutin (need back up contraception 6 weeks after d/c rifampin)

• Carbamazepine, oxcarbaz, phenytoin, primidine, topirmate (COPPT)

• St Johns Wort

• Tobacco

• PI (ritonavit, cobicistat)

• Tirzepatide

Mavyret should be avoid with any formulation containing >20 mcg of ethinyl estradiol due to what risk?

Hepatotoxicity

It takes ___ days of COC to achieve efficacy. So how many days do you need back up?

• 7 days & 7 days unless doing the first day start

COC start dates and how long do you need backup (3)

• Start today - best practice; need 7 days backup

• Sunday start - starts sunday after onset of period; need 7 days of backup

• First day start - starts on first day of period so because its started within 5 days of the start of period, no back up method is needed since protection is immediate

When should progestin only pills be started?

At any time

Late or missed pills counseling ***** add chart

• Start as soon as remember

• If ≥1 pill is missed: back up is needed for 7 days

• If missed during 3rd week, dont take the placebo week and start need package: back up is needed for 7 days; consider plan B if missed during first week and unprotected sex in the past 5 days, if in weeks 2-3 can still consider.

• Progestin only: if missed >3 hours past, take ASAP and back up for 48 hours, consider plan B if unprotected sex in past 5 days.

IUD name

Mirena: contains progestin levonorgesterol

What does nexplanon release?

Progestin etonogesteol for 3 years

Emergency contraception options (3)

• Copper IUD: Paragard, most effective, last 10 years

• Ulipristal acetate (Ella) RX: ASAP, within 5 days

• Levonorgestrel (Plan B One Step): ASAP, within 3 days

Levonorgesterol dose

• Plan B: 1.5 mg tablet of levonorgestrel within 3 days

• The sooner taken, the higher the efficacy

Primary AE with plan-B & how to manage it

• Nausea

• If emesis occurs within 2 hours of taking Plan B, consider redosing

Diaphragm contraceptive counseling

• Place one tbsp of spermicide into it and place into vag

• Leave in for 6 hours (don't leave for >24 hrs)

• Reapply spermicide if intercourse is repeated or if its in there for >2 hours

• Can be used for 2-5 years

Foams, creams, jellies, supp counseling

• Place deep into vag 10-15 mins before sex

• Reinsert if >1 passes before intercourse

Sponge counseling

• Wet sponge and squeeze to activate spermicide

• Place deep in vag before sex

• Leave in for at least 6 hours before sex and can be used for 24 hours

• Discard after

Patch counseling

• Apply to buttocks, abdomen, or upper back once a week for 21 days

• Start on day 1 (no backup) or on sunday (7 day backup)

• Fold and throw in trash (do not flush)

Ring counseling

• Insert into vag for 3 weeks and taken out for 1 week before replacing with new ring

• If ring kept in for 4 weeks, remove & confirm no pregnancy before inserting new one + 7 days of backup

• Insert on first day of menses

• Discard in reclosable satchet it came in and throw away (do not flush)

• Store for up to 4 months at room temp (refrigerate prior to dispensing)

Miscarrige is nonviable pregnancy up to ___ weeks of gestation

20

What is used to treat miscarrige?

Misoprostol (prostaglandin analog) +/- mifepristone (antiprogestin)

Infertility is defined as not being able to get pregnant after ≥____ year of unprotected sex

≥1

Infertility treatment ***

• Clomiphene (SERM): induces ovulation, estrogen agonist in some tissue, and estrogen antagonist in other tissues

- Causes LH surge and therefore hot flashes

- Clotting risk

• Letrozole (aromatase inhibitor): impacts ovulation through negative feedback causing an FSH surge

• Gonadotropins: acts similar to FSH and LH

- Used if poor response to clomiphene or letrozole, or to spur egg release for procedures

Cause multiple eggs to be released therefore increasing risk of multiple births

• Administered SC or IM

COMBINED (estrogen & progestin) OPTIONS vs. PROGESTIN ONLY OPTIONS *****

COMBINED:

• Oral contraceptives

• Patch

• Ring

PROGESTIN:

• Progestin only pills

• IUD

• Nexplanon

• DMPA shot