RX Contraception- TBL

CHC vs POP

combined hormonal contraceptive (oral BC pills, transdermal patch, vaginal ring)

POP= progestin only pill

what are the current rules regarding pharmacist prescription of contraceptives

- bill passed Jan 2025, allowing us to prescribe and be covered by ins

- LARA and Board are making rules by fall 2026

before starting contraception, how does a provider know a woman is not pregnant

1. no sx of pregnancy and ONE OTHER SIGN:

- had period or abortion <7 days ago

- has not had sex since last period

- has been using contraception correctly

- within 4 weeks postpartum

- breastfeeding >85% of times, no period, and <6 months postpartum

which progestin requires potassium monitoring

drosperinone (spironolactone analog-> lowers Na, increases K)

estrogens MOA

1. suppress FSH rise= no follicles develop (via neg feedback)

2. enhance progestin action= LH surge suppressed

3. stabilize endometrial lining= minimal+controlled bleeding during hormone free week

"PFE= progestin enhancement, fsh suppression, endo lining stabilization"

progestin MOA

1. cervical mucous thickening (sperm barrier)

2. prevents LH surge (can block ovulation, but sometimes still occurs)

3. reduce ovum motility in fallopian tube

4. cause thin/atrophy of endometrium (less likely to implant)

NOTE FSH is not greatly suppressed so follicles can still grow

MOLE= mucus, ovum motility, LH surge, endometrium

compare estrogen vs progestin moa

estrogen= suppress FSH, potentiate progestin which suppresses LH, stabilize endometrium lining

progestin= cervical mucus thickens, prevent LH surge, lower ovum motility, thin endometrium (less implantation)

-> note FSH not suppressed so follicles can grow

compare estrogen vs progesterone in regards to ovulation suppression

Estrogen always suppresses ovulation (via FSH suppression)

Progestin sometimes suppresses ovulation (via LH suppression), but not always (backup: reduces ovum motility, thin endometrium)

t/f: POPs prevent ovulation

false. ovulation often times still occurs

t/f: all CHCs disrupt ovulation and eliminate monthly menses

true (dont have actual period since theres no ovulation/corpus luteum but have withdrawal bleeding)

what is a CHC pill designed like and why

28 day design= 21 active pills and 7 placebo pills (withdrawal bleeding)

-> POPs have 28 days but no placebo

t/f: during the 7 days of placebo pills, women will experience menses

false, this is not menses since there is no thickening of wall or ovulation. bleeding is coming from hormonal withdrawal

CHC monophasic vs biphasic vs triphasic vs four phasic

monophasic= same dose of estrogen and progestin in every pill

biphasic= lower monthly dose of hormone; 2 diff doses

tri= lower monthly dose; 3 diff doses

four= for pts with symptoms on monophasic or need lower androgen

progestin only pills (POPs)

compare efficacy to CHCs. which preferred?

associated with which symptoms?

- POPs less effective than CHCs

- CHCs preferred (would only use POP if cant use CHC, ex: estrogen CI)

- associated with irregular bleeding or spotting (bc no placebo/withdrawal week)

how many pills do POPs have? what kind of periods do pts have?

28 active pills (no placebo)

- pts have light or absent periods

- may have irregular bleeding or spotting

(bc no placebo/withdrawal week)

when would a pt use POPs instead of CHCs

if they have a contraindication to CHC- ex: estrogen

who are four phasic pills reserved for

pts with symptoms on monophasic or those needing lower androgen

what is the preferred option for starting birth control w no coexisting conditions

monophasic CHC pill with

30-35mcg ethinyl estradiol AND

<0.5mg norethindrone

if

monophasic CHC pill with

30-35mcg ethinyl estradiol + <0.5mg norethindrone is preferred to start...

what does a lower ethinyl estradiol (<30mcg) offer?

higher (>35mcg)?

lower (<30): higher rates of breakthrough bleeding BUT lower estrogen side effects like nausea

higher (>35): more cardiovasc risks; only for special situations

progestins with lower androgen content (ex: drospirenone) may be advantageous to ppl with __________

acne

examples of birth control with lower androgen content that may be prescribed to pts with acne

- drospirenone (Yaz, Yasmin)

-ortho-tricylcen (norgestimate)

- Estrostep Fe (norethindrone)

(FDA indicated)

pt starting CHC asks when they should expect breakthrough bleeding

when should therapy be re-evaluated?

will experience breakthrough bleeding in 1st month/ often resolves in 2nd or 3rd cycle

reevaluate therapy after 3-6 months of initiation before changing dose

what are the advantages of hormonal/oral contraceptives

- lower menstrual symptoms

- less dysmenorrhea (painful) and menorrhagia (heavy)

- lower risk of ovarian cancer, endometrial cancer, cysts

- lower risk of ectopic pregnancy

- less pelvic inflammatory disease

- less benign breast disease

- less anemia

- less bone resorption

- sex

4 types of estrogens in hormonal contraception

-ethinyl estradiol (EE)

-mestranol

- estradiol valerate (EV)

- estetrol (E4)

what other hormonal activity do progestins possess

estrogenic

androgenic

anti-androgenic

what activity do the following progestins possess:

drospirenone=

dienogest=

drospirenone= antimineralocorticoid with ANTIandrogenic activity

-spironolactone derivative

-recommended w acne

- check K

dienogest= lower androgenic activity

t/f: if 2 contraceptives are both progestins, they are equivalent in dose

false.

each progestin has different potency. a higher potency progestin in a small dose could be the same as low potency&high dose

which generation of synthetic progestins have no estrogenic activity, and only progestinal and androgenic

second gen

- levonorgestrel

-norgestrel

serious adverse effects related to hormonal contraceptives (discontinue if occur)

ACHES

Abdominal pain (thrombosis of abdominal artery)

Chest pain (pulmonary embolism, MI)

Headaches (stroke, vascular spasm)

Eye problems (stroke, HTN)

Swelling/ aching in leggs (DVT)

usual estrogenic side effects

nausea, bloat

breast tenderness, mood changes

increased bp, headache, cyclic weight gain

higher HDL and TG, lower LDL (good for u)

usual progestogenic side effects

headache, fatigue, depression

LOW HDL and HIGH LDL (opposite of estrogen)

usual androgenic side effects

increased appetitie, sex drive, weight gain, acne, oily skin,hirsutism

LOW HDL and HIGH LDL (same as progestin, opposite of est)

a pt comes in claiming she has nausea, breast tenderness, and increased blood pressure. labs show increased HDL and lower LDL

a. reduce estrogen dose

b. reduce progestin dose

c. reduce androgen dose

a. reduce estrogen

these are all estrogen side effects

a pt comes in with headache and fatigue, labs show low HDL and increase in LDL

a. reduce estrogen dose

b. reduce progestin dose

c. reduce androgen dose

b. reduce progestin

these are side effects of progestin

a pt comes in with late phase breakthrough bleeding (after 10 days). how do you adjust the CHC dose and which hormone do you target

late phase means theres not enough progestin to stabilize lining.

-increase progestin content

- can consider triphasic CHC with higher progestin dose at end

a pt comes in with early phase breakthrough bleeding (first 10 days). how do you adjust the CHC dose and which hormone do you target

first 10 days means theres not enough estrogen to stabilize endometrium in beginning of cycle

- choose pill with higher estrogen

a pt comes in with acne, hirsutism, depression, and fatigue from BC. how do you adjust the CHC dose and which hormone do you target

acne, hirsutism= too many androgens

depression, fatigue= too much progestin

-choose lower androgen content or find pill with anti-androgenic content

how should pts on CHCs be monitored

no monitoring necessary but should check if any side effects occurred

what age considerations should you make before prescribing birth control

increased risk of?

other options?

1. if >35: increased risk of VTE, stroke, and MI bc of estrogen

= USE LOWEST ESTROGEN DOSE

2. if >45: may opt for POPs, etonogestrel implant, levonorgestrel IUD, copper IUD (no estrogen)

(note CHCs and DMPA are not CI so could still be used just some risk)

for individuals >45 with risks from estrogen, what else could you prescribe

POPs, etonogestrel implant, levonorgestrel IUD, copper IUD (no estrogen)

individuals should NOT use CHCs if smoking >___ cigs and >__ years old

>15cigs and >35yo

use with caution if <15 cigs

If <35 and smoking, how much estrogen should be used?

if less than 35 years old and smoking, use 20mcg of estrogen

can women with HTN use CHCs

yes but can raise BP slightly

-use low dose CHC with well-controlled and monitored HTN

-AVOID if stage 2 uncontrolled (>140/90)

counseling regarding diabetes and CHC use

- progestins may slightlyyy affect carb metabolism but not a concern

- women with diabetes with vasc disease should NOT USE CHC OR DMPA

t/f: women with diabetes with vascular disease should not use CHC or DMPA

true (higher risk of thrombosis/ cardiovasc events)

how do progestins and estrogens affect dyslipidemia

progestins lower HDL and increase LDL

estrogens increase HDL and lower LDL (but can increase TG)

most low dose CHCs have no effect on lipids except for

levonorgestrel 0.15

which generation of progestins have a favorable lipid profile

3rd gen

how do CHCs and POPs affect dysmenorrhea/ menorrhagia

they lower both. extended and continuous cycles avoid bleeding and reduce symptoms

1/3 of pts on POPs have no bleeding (amenorrhea)

relate the risk of VTE to estrogen dose

35mcg has less risk than 50mcg

(but we dont know if 20 has less risk than 35)

== avoid estrogen dose >35mcg due to risk of VTE

avoid an estrogen dose greater than ______ due to VTE risk

>35mcg

risk of VTE might be higher in ______ generation CHCs containing which 3 meds

third

- gestodene

-desogestrol (2x)

- drospirenone

t/f: CHCs are contraindicated in women with a family history of VTE

false. CI if personal history of VTE

how do CHCs affect migraines? are headaches normal side effects? when is CHC CI

- may help or worsen

- headaches can happen during placebo week

-fluctuating hormones worsen a migraine= use monophasic or extended cycle

CI in migraine + aura (visual change, numb, weak) bc stroke risk

which CHCs are recommended in migraine prone individuals

monophasic or extended cycle (since headaches are common during placebo week)

which cancers can CHC lower risk of? increase?

lower risk of endometrial and ovarian cancer

might increase risk of cervical ectopy (not cancer) and breast cancer

CI IN PERSON HX OF BREAST CANCER

what hormonal contraception should you use in pts with SLE

POPs (CHCs worsen SLE symptoms and increase risk of VTE)

which contraception would you opt for

SLE:

sickle cell:

seizures:

postpartum+lactating 5 weeks:

SLE: POPs

sickle cell: DMPA

seizures: DMPA

postpartum+lactating 5 weeks: POPs. CHC often used after 6 weeks (estrogen lowers milk production)

what is the preferred hormonal contraception with patients for sickle cell disease

depot medroxyprogesterone DMPA)

how does obesity affect hormonal PK

higher body weight= increased BMR and enzyme rate= more hormone cleared and less in blood

more fat= more hormone sequestered and less absorbed transdermally= less in blood

LOWER EFFICACY

transdermal patches should not be first line in women weight over ___kg

90

which hormonal contraceptions are better suited for obese women

-DMPA (but can cause weight gain)

-levonorgestrel IUD

- higher dose CHCs

(implant and patches less effective)

when are CHCs contraindicated

Smokers: >15 cigs and >35yo

Breast Cancer

HTN stage 2 (>140/90)

Diabetic w vasc disease

Stroke, CAD, MI, VTE

Migraine + aura

SLE--> use POPs

Postpartum 21 days

when is a women fertile again after using CHCs

usually takes 1-2 weeks for ovulation to occur (pretty quick) regardless if monthly or extended CHCs

-get med attention if >6 months

when is a women fertile again after using POPs

there is no delay since women still ovulate during use of POPs

when can women start estrogen containing contraception post partum? why shouldnt they start immediately?

cant start <21 days bc DVT risk

recommended to start after 42 days postpartum (but may be harder to breastfeed-> opt for POP until about 6 weeks, ideally wait 6 months)

when does ovulation begin postpartum

about 4 weeks

in regards to breast feeding, when is it recommended to start contraception to not mess up milk production

6 weeks

but steroid hormones pass into milk. ideally wait 6 months postpartum while breastfeeding

which hormonal contraception is recommended for breastfeeding mothers and why

POPs recommended bc estrogen inhibits prolactin= less milk for baby

when can IUD be used postpartum

immediately. can be placed right after birth or abortion (unless septic)

t/f: all forms of contraception can be started immediately after 1st or 2nd trimester abortion (unless septic)

true

the ______ the dose of a hormone, the greater risk drug interaction will affect efficacy

lower (bc less buffer)

how do abx/antifungals affect contraception efficacy

they dont

DI: anticonvulsants (phenobarbital, primidone, carbamazepine, felbamate, phenytoin, topiramate, oxcarbazepine)

MOA: lower contraceptive effect by inducing metabolism of hormones (both est and POP)

rec: avoid using together. use DMPA or high dose estrogen

DI: lamotrigine

MOA: lower effect of lamotrigine

rec: increased seizure risk. avoid combo

DI: griseofulvin

MOA: lower effect on contraception

rec: use backup method

DI: non nucleoside reverse transcriptase inhibitors (efavirenz, nevirapine)

MOA: lower contraceptive effect

rec: use diff contraception

DI: protease inhibitors (ritonavir, amprenavir, denavir, nevirapine)

MOA: lower contraception effect

rec: use alternate

DI: rifampin

MOA: lower contraception effect

rec: use backup

DI: st johns wort

MOA: lower contraception effect

rec: use alternate

CHC pills need to be used for _________ days to prevent ovulation

7 consecutive days

when can a pt start a pack/patch/ring

1. first sunday after period (period free weekends)= use backup for 7 days

2. first day of next period= dont need to use backup

3. quick start= use back up for 7 days. start immediately if not pregnant

when should patients expect bleeding ("pill period") after their last pill or removal of a patch/ring

1-3 days after

what if pt has been bleeding for 10 days. should she wait for "pill period" to be over before starting next cycle of hormones

no. start next cycle after 28 days of previous even if "pill period" not complete

how should pts take POPs

-take pill every day at exact same time

- there is no hormone free interval. every pill is active

(remember removing estrogen is what triggers bleeding. also ovulation is not suppressed in POPs)

when is the most risky time to miss a dose of CHC

just before or after hormone free interval (7 days of therapy for full efficacy)

Miss early → ovulation not fully suppressed; miss late → hormone drop triggers ovulation

miss 1 pill of CHC

when do you take a pill?

do you need backup? EC?

take it as soon as you remember

dont need backup

dont need EC unless if you missed other doses in month

miss 2+ pills of CHC

when do you take a pill?

do you need backup? EC?

take asap. continue pill pack and throw out missed pills.

if in last week: skip placebo pills; start new pack

if in first week: dont skip placebo, consider EC

-use backup for 7 days and until you take 7 active pills

SO: Take ASAP, continue pack, skip placebo if last week, backup 7 days, consider EC if first-week miss

what if you miss <7 days of pills but you used an extended cycle contraceptive for >21 days

take asap. dont need backup, can consider EC

what if you miss >7 days of pills but you used an extended cycle contraceptive for >21 days

take asap. use backup for 7 days and until you take 7 more pills. can consider EC

what time frame do you have for progestin only pills before you have to use a backup method for 2 days

>3hrs late= use backup for 2 days and consider EC

how do you use xulane patch

-apply patch to butt, back, abdomen, or upper arm (not breasts)

-apply on same day of week and wear for 7 days; repeat for 3 weeks

NO PATCH 4TH WEEK= withdrawal bleeding

- rotate patch site

- avoid lotion, cream, makeup, tight clothing

- repress detached patch

what do you do if patch/ring is off for less than 2 days

apply new patch/ring asap. dont need backup. can use EC if patch fell off early on

what do you do if patch/ring is off for more than 2 days

apply new patch/ring asap and keep the same day you change it out/remove

if in 3rd week, skip hormone free week and start new patch. or use backup.

use backup for 7 days WITH the active patch on

how do you apply nuvaring

squeeze ring together and insert intravaginally. if it hurts push it in further

-after 3 weeks, remove ring on same day as insertion

-remove ring 4th week= withdrawal bleeding

depo-provera MOA

-suppressed gonadotropin release

-suppressed ovulation

when do you initially inject depo shot? do you need backup? how long is it effective for?

-initial injection within 7 days of your period starting (dont need backup)

- if shot is >7 days from period start then use backup for next 7 days

- effective for 3 months

can you use depo shot while breastfeeding

yes. start 1 month after delivery ideally

t/f: depo shot is recommended in women with seizures

true. may decrease seizure rate