Hormonal+Contraception+Slides

What are the two phases of the menstrual cycle as defined in the lecture?

Follicular phase and luteal phase.

CIs for combined hormonal contraception

• breastfeeding and < 21 days postpartum

• Smoker > 35 years old

• Multiple risk factors for CVD

• Current or hx of DVT or PE

• Major surgery with prolonged immobilization

• Migraine HA with aura

When can pts start progestin only oral contraceptive?

• start on FIRST day of menstrual period

• Tk at same time every day

• If first dose starts on a diff day, use backup contraceptive for 48 H

Time cutoff where it is okay to miss a dose of progesterone only oral; what to do if time has passed

3 hours; if more, backup contraceptive used for 48 hours

Pros and cons of injectable progestin only contraceptive

• Pros: efficacy independent of wt, avoids first pass metabolism

• Cons: return to fertility is delayed, can cause bone loss & (-) fx if prolonged use

When to start DMPA (progestin only injectable)

• give w/in 5 days of starting menstruation

• If > 7 days since start of cycle, use backup for 7 days

Missed dose for DMPA

• if 1 wk overdue, pregnancy test before next dose

• Concerning side fx = amenorrhea (irregular bleeding or cessation)

• Short term bone loss can occur

Why does the FDA only recommend use of DMPA for < 2 years unless other forms are inadequate

Potential irreversible bone loss

Important counseling points for IUD

• greatest risk of pelvic infection w/in first 20 days of initiation

  • Warning signs (PAINS)

    • Period is late

    • Abdominal pain or pain w/ intercourse

    • Infection, abnormal or odorous vaginal discharge

    • Not feeling well, fever, chills

    • String (missing, shorter or longer)

• Can be used for 3-5 years

When to start nexplanon

Between 1-5 days of onset of menses, no backup needed

• if placed after 5th day, backup for 7 days needed

Roles of estrogen and progestin in contraceptive

• Estrogen: prevents ovulation via suppression of FSH

• Progestin: helps thicken cervical mucus resulting in atrophy of endometrial lining (prevents passage of sperm)

Name the only hormonal contraceptive product that uses estetrol

Nextellis

Name the hormonal contraceptive that is less fx in females with a BMI > 30 kg/m²

Nextellis

What side fx would a first gen progestin contraceptive have?

Anti androgenic and anti mineralocorticoid

Ways to start COC

• Sunday start method

• First day/same day start method

• Quick start method

Sunday start method

Start active tablet on first Sunday AFTER menses begins

• use backup non hormonal contraception for first 7 days after starting

Quick start method

Start active tablet REGARDLESS of what day menses starts (ex: can start now)

• use backup contraception for first 7 days after starting

• Can also instruct pt to use backup contraception until NEXT menses occur

First day/same day start method

Take first active tablet the EXACT day that menses begins

Which COC start method does not require backup contraception?

First day/same day start method

What to do if pt misses one oral contraceptive pill or is late (~ < 24 H)

• tk as soon as you remember

• Continue taking the rest of the pills as scheduled —> no backup contraception needed

What if a pt misses TWO OR MORE consecutive oral contraceptive pills?

• tk ONE missed pill as soon as you remember

• Backup contraception needed for 7 days

Transdermal contraceptive patch directions for use

App to clean dry skin on upper arm, shoulder, buttock or abdomen. Change patch on same day q week (change site but same ish area - ex: other shoulder, other buttock). Remove patch (fold) during 4th week

Which contraceptive product is not a good option for women who have a hx or risk of VTE

Xulane (patch)

What is a common side effect of too much estrogen?

Nausea.

Important counseling points when starting patch

• wear patch for 7 days and change on day 8

• Use backup contraceptive for first 7 days after patch is applied

Missed dose instructions (patch)

• if < 24 H —> reapply ASAP, no backup needed

• If > 24H —> app NEW patch (starts new 4 wk cycle), use backup

In hormonal contraception, what does the term 'missed doses' refer to?

Not taking the pill or method as scheduled.

What products cannot be used if pt is on NuvaRing?

Anything that covers cervix (ex: sponge)

Instructions for pts starting NuvaRing

Insert ring vaginally on or before 5th day of menstrual cycle (same day of the weekend each time)

What is the effectiveness rate of the Copper IUD for preventing pregnancy?

Less than 1% pregnancy per 100 women in a year.

Annovera time cutoff for how long it can be left out w/o consequences

2 H

What initial steps should be taken when considering hormonal contraceptive options?

Consider medical conditions, age, risk factors, and patient preferences.

Major DDIs & how to manage

• antibiotics (rifampin/rifabutin) → recommend backup for 7-28 days after rifampin d/c

• BZDs → if long term, consider switching product or increase product w/ higher estrogen

• Corticosteroids, theophylline, aspirin, APAP → if long term, may need to reduce dose to prevent risks

• Anticonvulsants → if long term disorder, switch product

• SJW → d.c SJW or switch product

• Dropsirenone containing products → monitor K

What should be done if a patient misses one progestin-only pill?

Take the missed pill as soon as remembered; no backup contraception is needed.

What is the recommendation for switching to a new hormonal contraceptive method?

There should be no gap when switching methods.

For women who smoke and are over 35 years old, what is the risk category for combined hormonal contraception?

Category 4 (unacceptable health risk).

What are the two earliest types of hormonal contraception mentioned in the notes?

Combined oral contraceptive pill (COC) and transdermal contraceptive patch.

What hormone is primarily responsible for preventing ovulation in combined hormonal contraceptives?

Estrogen.

What does the term 'breakthrough bleeding' indicate in contraceptive use?

Unexpected bleeding during the cycle.

Which method of hormonal contraception is described as providing a local effect within the uterus?

Intrauterine device (IUD).

Which generation of progestin is suggested to have lower androgenic side effects?

4th generation progestins.

What is considered the most effective method of contraception according to the lecture?

Vasectomy.

What is the expected action of the emergency contraceptive pill?

To prevent pregnancy after unprotected intercourse.

What does the acronym DMPA stand for?

Depot medroxyprogesterone acetate.

What should be avoided in postpartum women when considering hormonal contraception?

Using progestin-only pill before 6 weeks exclusively breastfeeding.

What is one recommended counseling point for patients starting the contraceptive patch?

Rotate application sites each week.

What indicates a Category 4 health risk according to the CDC USMEC chart?

Current breast cancer.

When is the optimal time to start a combined oral contraceptive pill?

On the first day of the menstrual cycle.

What is the primary chemical composition of a combined oral contraceptive pill?

Estrogen and progestin.

What is an example of a major inducer that can decrease the effectiveness of hormonal contraceptives?

Rifampin.

What are drospirenone and levonorgestrel examples of?

Progestins.

What is the mechanism of action for the contraceptive vaginal ring?

Delivers hormones through the vaginal mucosa.

What should be advised if a contraceptive vaginal ring is accidentally removed for more than 3 hours?

Reinsert and use backup contraception for 7 days.

How long is a progestin IUD effective?

3 to 5 years.

What hormone does the injectable contraceptive DMPA primarily release?

Medroxyprogesterone.

What should patients be advised regarding missed doses of injectable contraception?

Pregnancy test if more than a week overdue.

How should contraceptive emergencies be addressed?

Consider emergency contraception if hormonal pills were missed.

What side effect can occur from hormonal contraceptive methods that require monitoring?

Deep vein thrombosis (DVT).

What is the recommended action if two progestin-only pills are missed?

Take one missed pill as soon as possible and use backup contraception.

Name one benefit of using transdermal contraceptive patches.

Easier adherence for women who dislike pills.

How is the efficacy of emergency contraception affected by body mass index (BMI)?

May be less effective with BMI over 26.

What factor can increase a woman's chance of experiencing headaches while on hormonal contraceptives?

Sharp decrease in estrogen during the placebo week.

What is deemed contraindicated for women with a history of migraines with aura?

Combined hormonal contraception.

For how long after insertion should a Copper IUD be checked for effectiveness?

It’s considered effective immediately.

What advice should be given to women about the contraceptive ring during intercourse?

It can be left in place during sex.

What concerns should be addressed for those receiving long-term DMPA?

Possible bone density loss.

What is one important follow-up after missing hormonal contraception doses?

Evaluate need for backup contraception.

How is the side effect of acne attributed in hormonal contraception?

High androgenic properties in certain progestins.

What kind of contraceptive options do adolescents generally need to avoid?

Options with high estrogen or progestin content.

What is the typical course of action after a missed dose of emergency contraception?

Take it as soon as possible.

What are potential side effects of the contraceptive vaginal ring?

Vaginal discomfort and foreign body sensation.

What would be an appropriate contraceptive choice for a postpartum breastfeeding woman?

Progestin-only pill (POP).

How often should the DMPA injection be administered?

Every three months.

When starting the patch, how long should backup contraception be used?

For the first 7 days.

What is one reason to consult the CDC USMEC chart?

To help choose the appropriate contraceptive formulation.

What should a patient be aware of when using a progestin IUD?

Risk of spotting and potential for anemia.

What is the significance of the 'Sunday start' method for oral contraceptives?

Start on the first Sunday after the menstrual period begins.

What hormonal form does Nexplanon offer?

A single-rod progestin implant.

What does the recommendation state for weight management in hormonal contraception?

Women over 70kg may have increased pregnancy risk.

What is an appropriate course of action for patients on antibiotics while using hormonal birth control?

Use backup contraception.

Commitment to compliance in using hormonal contraception leads to better effectiveness.

True.

What are the common side effects of DMPA?

Irregular bleeding and weight gain.

What is the action required if any hormonal contraceptive is missed?

Follow specific rules depending on timing since missed.

What is the best time frame to take emergency contraceptive pills?

As soon as possible, ideally within 72 to 120 hours.

What is an indication that a woman might need additional support for her hormonal method?

Experiencing severe side effects or adverse reactions.

What is one counseling point for clients about using condoms during hormonal contraceptive use?

Always recommended to reduce risk of STDs.

When should a woman consider switching her contraceptive method?

After experiencing adverse effects or lack of efficacy.

What should patients be advised regarding the copper IUD?

It is a non-hormonal effective option.

What is the significance of estrogen in contraceptive pills for the menstrual cycle?

It regulates the menstrual cycle and prevents ovulation.

What are the dangers of misusing emergency contraception?

Over-reliance may lead to unintended pregnancies.

For which population is the progestin-only pill specially indicated?

Postpartum women, especially breastfeeding.

What key consideration should guide contraceptive choice?

Individual medical history and risk factors.

What is one action to take after missing a hormonal contraceptive dose within 24 hours?

Take the missed dose immediately.

What are common side effects of too much progestin?

Weight gain and mood changes.

What is an important factor to monitor when using hormonal contraception?

Blood pressure.

How do hormonal contraceptives affect the menstrual cycle?

They regulate and often diminish menstrual flow.

What should be the primary goal when counseling a patient about hormonal contraceptives?

Ensure understanding of proper use and side effects.

What is a notable concern for patients with a history of estrogen-related cancers?

Avoidance of estrogen-containing contraceptives.

When starting a new contraceptive, what should patients be aware of in terms of waiting periods?

Different methods may require varying lengths of backup contraception.