Ch. 47 Contraception & Infertility

A normal menstrual cycle ranges from ______ to_____ days.

23 - 35 days (average 28 days)

Menses marks the first day of the cycle (True/False)

True

Phases of the Menstrual cycle

- Follicular phase (Follicles mature and prepare to release eggs)

- Ovulation (egg release)

- Luteal phase (prepares uterus for pregnancy by thickening the uterine lining)

Which phase of the Menstrual Cycle are the following hormones predominant?

- Estrogen

- LH

- FSH

- Progesterone

- Estrogen: Follicular phase

- LH: Ovulation

- FSH: Ovulation

- Progesterone: Luteal phase

The oocyte lives for ~ ________ hours after release and sperm survives for ~ ______ days after release?

Oocyte: 24 Hours

Sperm: 3 days

When is hCG released?

When a fertilized egg attaches to the uterine lining.

Any woman planning to conceive should increase folate intake to ________ mcg/day and this requirement should be increased to _________ mcg/day once pregnant.

Conception: 400 mcg/day

Pregnancy: 600 mcg/day

What contraceptive method may delay the return of fertility?

medroxyprogesterone injection (Depo-provera injection)

Natural condoms (Sheepskin) does not prevent STD transmission. (True/False)

True

Drosperinone is a progestin that reduces adverse effects by acting as a mild _________________________ that decreases bloating, PMS symptoms, acne, and weight gain.

Potassium-sparing diuretic

What are other indications for Combined Oral Contraceptives?

- Dysmenorrhea (menstrual cramps)

- Premenstrual Syndrome (PMS)

- Acne

- Anemia

- Perimenopausal symptoms

- PCOS (1st line)

- Endometriosis (1st line)

- Heavy menstrual bleed

Progestin-only pills (POPs) require great adherence and must be taken within ______ hours of scheduled dose.

Within 3 Hours

What cannot be used as birth control in women with migraines with aura?

Estrogen-containing (risk of stroke)

Contraceptive Patches

• Higher systemic estrogen exposure

  • Leads to even higher risk of thromboembolism

    • Avoid use in anyone with a high clotting risk

  • Avoid in BMI ≥ 30

• Xulane and Zafemy may also be less effective in women who weigh > 198 pounds (90 kg)

Extended-cycle COCs vs. Continuous contraception

Extended: 84 days of active hormone followed by a 7 day off period to allow for menses

Continuous: Continuously taking active hormone to prevent menses all together.

Contraceptive Names

"Lo" indicates what?

ex: Loestrin

≤ 35 mcg of estrogen

Contraceptive Names

"Fe" indicates what?

ex: Loestrin Fe

iron supplement is included

Contraceptive Names

"24" indicates what?

ex: Minastrin 24 Fe

24 days of active hormone

Contraceptive Names

"Tri" indicates what?

ex: Tri-Sprintec

Triphasic (3 different strengths of hormones)

Quadriphasic COC

Natazia

Continuous COC

Amethyst

Drosperinone-containing COC

Yaz, Yasmin 28

Transdermal patches

Xulane, Zafemy, Twirla

Vaginal Rings

NuvaRing, Annovera

POPs

Errin, Camila, Nora-BE

Drosperinone-only

Slynd

Contraceptive Injection

Depo-Provera

Estrogen

Adverse effects:

- Nausea

- Breast tenderness

- Bloating/Weight gain

- Increased BP

- Thrombosis

Severe Adverse effects of estrogen

"ACHES"

- Abdominal pain

- Chest pain

- Headaches

- Eye problems (blurred vision , etc.)

- Swelling/Sudden leg pain (DVT)

Progestin

Adverse effects:

- Breast tenderness

- HA

- Fatigue

- Depression

Compared with other progestins, Drosperinone has a slightly higher risk of clotting. (True/False)

True

Depo-Provera injection can cause loss in bone mineral density. (True/False)

True

• Supplement with calcium and vitamin D

Estrogen-containing birth control

Boxed Warnings:

- Do not use in women ≥ 35 who smoke (CV events)

Estrogen + Progestin patch

Boxed Warnings:

- Increased risk of VTE

Depo-Provera

Boxed Warnings:

Loss of bone mineral density with long term use

Estrogen should not be used with these conditions:

- History of VTE, Stroke, CAD, valve thrombosis, etc.

- Breast, ovarian, liver cancer

- Migraines with aura

Considerations for Birth control selection

Acne:

- Drosperinone-containing > Norgestimate

Considerations for Birth control selection

Breastfeeding:

- POPs

- Non-hormonal method

Considerations for Birth control selection

Estrogen CI:

- POPs

- Non-hormonal method

Considerations for Birth control selection

Migraine with aura:

- POPs

- Non-hormonal method

Considerations for Birth control selection

Bloating/fluid retention:

- Drosperinone-containing

Considerations for Birth control selection

Heavy menstrual bleeding:

- Natazia

- Mirena (IUD)

Considerations for Birth control selection

Uncontrolled HTN:

- POPs

- Non-hormonal methods

Considerations for Birth control selection

Mood changes or disorder:

- Monophasic

- Extended cycle or Continuous cycle with drosperinone is preferred

Considerations for Birth control selection

Nausea:

- Take at night

- Decrease estrogen dose

- POPs

Considerations for Birth control selection

Overweight:

- do not use Depo-Provera if trying to avoid weight gain

Considerations for Birth control selection

Postpartum:"

- Avoid CHCs for 3 weeks, 6 weeks if additional risk factors

- POPs

- Non-hormonal methods

Considerations for Birth control selection

Premenstrual dysphoric disorder (PMDD):

- Yaz

- Antidepressant (SSRI, etc.)

Drug interactions that decrease hormonal contraceptive efficacy

- Abx (rifampin, rifabutin)

- Anticonvulsants (carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, lamotrigine, etc.)

- St. John's Wort

- Smoking tobacco

- Ritonavir-boosted protease inhibitors

- Colesevelam (separate by 4H)

- Byetta (take BC 1H before injection)

- Mavyret & Viekira Pak (Liver toxicity)

Back up contraception method is needed for 6 weeks following rifampin use. (True/False)

True

Long-Acting Reversible Contraceptives

• Intrauterine devices (Mirena)

• Copper-T IUD (Paragard)

  • Can be used for emergency contraception (EC) and/or regular birth control

• Implant (Nexplanon)

  • Releases the progestin etonogestrel for three years

Emergency Contraception (EC)

• IUD (copper IUD)

• Oral options (levonorgestrel and ulipristal acetate)

Sooner EC is used, the higher the efficacy

Copper IUD (Paragard)

Most effective

• within 5 days

Ulipristal Acetate (Ella)

More effective than levonorgestrel

• ASAP, within 5 days

Levonorgestrel (Plan B One-Step)

• ASAP, within 3 days

  • Remains moderately effective within 5 days

Drugs used in infertility

• Clomiphene

  • Selective estrogen receptor modulator (SERM)

    • Act as estrogen to increase LH/FSH

• Gonadotropins

  • act as LH, FSH or hCG to trigger ovulation