PHRM 825 Lecture 43-45: Hormonal Contraception Options/ Differences

roles of estrogen in contraceptives

suppress FSH production- prevent dominant follicle

increase sex- hormone binding globulin- increase binding of free androgens

roles of progestin in contraceptives

prevent LH surge- inhibit ovulation

thicken cervical mucus- inhibit sperm penetration/ transport

change motility of Fallopian tubes- impair transport of sperm/ ova

atrophy of endometrium- impair implantation

what are the common estrogens in contraceptives

ethinyl estradiol

estradiol valerate

estetrol

mestranol

side effects of too much estrogen

bloating, breast tenderness, mood changes, HA, nausea, heavy menses, cyclic weight gain

side effects of not enough estrogen

light menses

vaginal dryness

spotting

no withdrawal bleeding

low vs very low dose of estrogen

very low: <20 mcg EE

low: 20-35 mcg EE

high dose of estrogen

50 mcg EE

prevent ovulation

lessen bleeding

desire high selectivity

Progestational

Acne

Hirsutism

desire low activity

androgenic

androgenic side effects

desire lower activity

antiestrogenic

which two progestin components do we not want

androgenic and antiestrogenic

which progestins have the highest androgenic activity in order

1. levonorgestrel

2. norgestrel

3. norethindrone, norethindrone acetate, norgestimate, desogestrel/ etonogestrel

which progestin has the lowest androgenic and antiestrogenic activities

drospirenone

side effects of too much progestin

acne, hirsutism, decreased sex drive, depression, increased appetite, noncyclic weight gain, hair loss

side effects of not enough progestin

breakthrough bleeding

no withdrawal bleeding

heavy menses

other uses of contraception besides birth control

acne, hirsustism

regulation of cycle

endometriosis

PMS

dysmenorrhea

health benefits of contraceptives

-decreased risk of endometrial cancer

-decreased risk of ovarian cancer

-decreased risk of menstrual-related headaches

-improvement in perimenopausal symptoms

brand and generic name of the implant

nexplanon (etonogestrel)

side effects of implant

mood changes, HA, acne, pain w insertion, irregular bleeding for first 6-12 months

benefits of implant

long term protection (3 years)

nothing to remember

what progestin is in the IUD

levonorgestrel

side effects of IUD

infection, cramping, spotting within first 3-6 months, lighter periods

benefits of IUD

lighter periods, safe to breastfeed, long term, lower risk of uterine cancer, long term protection

copper IUD side effects

uterine perforation, infection, cramping, spotting for 3-6 months, heavier periods

brand name of copper IUD

Paragard

names of hormonal IUDs

Mirena, Skyla, Kyleena, Liletta

what progestin is in the shot

depot medroxyprogesterone acetate

routes of administration of the shot and doses for each route

150 mg IM

104 mg subcutaneous

side effects of shot

lower bone density, heavy bleeding, weight gain, acne, spotting between periods

benefits of shot

lower risk of uterine cancer

safe to breastfeed

lighter periods

side effects of combined pill

blood clots, stroke, nausea, spotting, change in mood or headaches

benefits of COC pill

improved acne

lessen ovarian/ uterine cancer risk

more regular, lighter periods

what are the four options for the combined pill

monophonic, biphasic, triphasic, four phasic

what progestins can be in the POP

norethindrone (mini pill)

norgestrel

drospirenone (4 mg)

what is the rule for taking POP

daily within 3 hours of the same time (important time frame)

side effects of POP (norethinedone and norgestrel)

headaches, bleeding, ectopic pregnancy, spotting

benefits of POP (norethinedone and norgestrel)

safe to breast feed

lack of estrogen related side effects

does drospirenone POP have placebo pills

no drospirenone POP does not contain placebo pills; it is a progestin-only pill that is taken continuously.

specific side effect of drospirenone POP

hyperkalemia

generic and brand names of disposable vaginal ring

etonogestrel and EE (Nuvaring, Eluryng)

frequency of administration of disposable vaginal ring

left in place for 3 weeks- removed for 1 week

new ring inserted after 7 days

side effects of disposable ring

blood clots, stroke, nausea, spotting, changes in mood or HA

benefits of disposable ring

improved acne

more regular, lighter periods

what is the generic and brand name of the reusable vaginal ring

Segesterone and EE (Annovera)

frequency of administration of reusable vaginal ring

left in place for 3 weeks- removed for 1

wash with mild soap/ warm water dry and reinsert

specific side effect of reusable ring

vulvovaginal infection/ candidiasis

how many times can the reusable ring be used

one device can be used up to 13 times

what the the brand name of the norelgestromin and EE patch

Xulane, Zafemy

what is the brand name of the levonorgestrel and EE patch

Twirla

what is the difference in appearance between the Xulane and Twirla patch

Xulane: thin, beige, square plastic with sticky back

Twirla: thin, beige, round plastic with sticky back

how to administer and frequency of administration of the patch

apply to upper outer arm, abdomen, buttock, or back

new patch every week for 3 weeks- patch free for 7 days

side effects of patch

blood clots, nausea, spotting, skin irritation, change in mood or HA

benefits of patch

improved acne, lower risk of ovarian and uterine cancer, more regular periods, don't have to remember daily

what are the three approaches to starting contraception

quick start

next period start

sunday start

when is backup method necessary when starting contraception and for how long

if more than 1-6 days after period start

use for 2-7 days

when must emergency contraception be taken and at what weight is it less effective

within 5 days

less effective if >165 pounds

when to restart contraception after emergency contraception

levonorgestrel: start/ resume immediately

Ulipristal acetate: start/ resume method five days after use

what to do if you missed a pill but it has been less than 48 hours vs 48 hours or more

less then 48 hrs: take late pill, no additional protection needed

48 hrs or more: take missed pills, use barrier methods for 7 days

when must barrier methods be used if delayed application or detachment of patch or delayed placement/ replacement of vaginal ring occurs

48 hours or longer

what to do if delayed application or detachment occurs during 3rd patch week or third week of ring use

omit the hormone free week by finishing the 3rd week patch/ ring and immediately starting a new one

what to do if patient is greater than 3 hours late on taking norethindrone or norgestrel pill

take late/ missed pill ASAP, continue daily pills, backup for 2 days

what to do if someone has irregular bleeding with contraception

take pills at the same time, ibuprofen 800 mg 3x a day x 5 days, may improve with continued use

what to do if someone has headaches with contraception

discontinue product if headaches get worse, OTC pain relievers, continuous product if during placebo

what to do if someone has nausea with contraception

take pills with food or at bedtime, continuous product if at start of cycle, may improve with continued use

what to do if someone has breast tenderness with contraception

supportive bra, OTC pain relievers, product with less estrogen

what to do if someone has acne with contraception

topical treatments, different pill formulation (less androgenic), combined product

acronym for serious side effects of combined methods

ACHES

what category of eligibility criteria for contraceptives means it is too dangerous for pharmacists to prescribe

3 or 4

which type of migraine is contraindicated for hormonal contraception and why

migraine with aura- mechanism of increased risk possible due to temporarily narrowed blood vessels

higher risk of stroke

drug interactions with contraceptives

antiretrovirals for treatment of HIV

anticonvulsant therapy (phenytoin, carbamepazine, barbiturates, oxcarbazepine)

antimicrobial therapy (antifungals, anti-parasitics, rifampin or rifabutin therapy)

SSRIs

St. John's Wart

myth associated with transgender men

hormonal testosterone protects them from pregnancy- they still have reproductive capabilities

Progestin only contraceptives for transgender men

do not interfere with testosterone use

norethindrone or drospirenone are options

implants, IUDs, shot

combination hormonal contraceptives for transgender men

controversial due to presence of estrogen in patients on testosterone during transitioning phase

no contraindications to current use

non-hormonal contraceptives for transgender men

copper IUDs- may increase menstrual bleeding

irreversible contraceptives for transgender men

tubal ligation- cut or tie fallopian tubes

excision of Fallopian tubes

emergency contraceptives options and frequency of administration

copper IUD- one insertion

levonorgestrel- one OTC dose as needed

ulipristal acetate- one Rx pill per cycle

which emergency contraceptive requires you to wait before restarting BC and how long do you wait

Ulipristal acetate- 5 days

interferes with sperm viability and function

most effective EC across all BMIs/weights

in office procedure

copper IUD

inhibits ovulation and leads to follicular rupture

effective up to 5 days; efficacy up to 194 lbs

interaction with hormonal contraception

ulipristal acetate

inhibits ovulation

less effective at weights greater than 165 pounds

labeled for 72 hours but can use up to 120 hours

levonorgestrel

at what duration of pregnancy can a medication abortion be used

up to 70 days (10 weeks)

can also be used for early miscarriage

how is a medication abortion executed

two drug regimen (mifepristone, then misoprostol)

selective progesterone receptor modulator

anti-progesterone (inhibits progesterone action)

decidual necrosis, cervical softening, increased uterine contractility

mifepristone (mifeprex)

prostaglandin EI analog

cervical softening

uterine contractions

misoprostol (cytotec)

dosing for medication abortion

1x 200 mg po of mifepristone

800 mcg buccally of misoprostol 24-48 hours later (2x200 mcg tablets in each cheek)

adverse effects from medicated abortion

bleeding/cramping

nausea, vomiting, diarrhea, headache, dizziness, hot flushes, chills

get help if: HEAVY bleeding + chills and fever

what type of BC can pharmacists prescribe

oral, patch, ring, injection

what must be done before a pharmacist can prescribe BC for a patient

birth control screening

pharmacist review

screen for pregnancy

check BP

determine eligible methods

contraceptive methods that can be prescribed by pharmacists

FDA approved for pregnancy prevention

self-administered

no progesterone receptor antagonists (ulipristal acetate)

what age must patients be to get BC from pharmacists

18 or older

how often does screening of patients have to occur when pharmacists are prescribing BC

every 6 months

what is the tiered effectiveness approach of counseling

giving patient chart of BC effectiveness

should NOT be the only form of counseling, use as conversation guide

one key question approach

would you like to become pregnant in the next year?

what does PHI-CARE stand for

past experience

health history

importance

counsel

autonomy

review

experience

how to limit coercion in contraceptive choice

present all option with pros/cons

visual decision aids to independently review

awareness of biases