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7006PHM Prof Pharm II > Contraception (COCs) > Flashcards

Contraception (COCs) Flashcards

1
Q

What are some COCs? (general) Name some pro’s/cons

A

Oral that contain both progestogen and oestrogen
- pros = regular, light, minimal pain period, control over period, improved acne/period disorders

  • cons = drug interactions, daily tablet, spotting, nausea, mood/weight change, BP inc, headache, inc stroke MI risk in smokers >35

Noova ring = COC hormonal vag ring

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2
Q

What are some progesterone only contraceptive methods?

A

Drosperidone tab = when COC C/I

Levonorgestrel or norethisterone tabs = when COC C/I

Medroxyprogesterone IM depot = 12 wkly injec

Etonogestrel implant = every 3 yrs, long term

Levonorgestrel IUD = long term (5 yrs)

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3
Q

What are some non-hormonal contraceptives?

A

Barriers = condoms (male/female), diaphragm

Copper IUD = unaffected by drugs, long term 5-10yrs

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4
Q

How do COCs prevent pregnancy? (general)

A

Inhibit ovulation

Reduce receptivity of endometrium to implantation

Thicken cervical mucous to form barrier to sperm

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5
Q

What are some indications for COCs?

A

Contraception
Acne
Menstrual disorders (e.g. dysfunctional uterine bleeding)
Endometriosis
PMS

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6
Q

Outline some COC Precautions

A

Migraine (can worsen), diabetes (effects glucose metabolism maybe)

BMI >30kg/m2 (inc VTE risk)

Cardiovascular health

Smokers (inc VTE risk, <35 support smoking cessation)

Surgery = inc thromboembolism risk, stop COC 4 wks before surgery, restart >2 wks post-mobilisation

Preg (estrogen can dec milk supply, use progest-only if must)

Post-partum = delay use until 21 days pp, or 42 day if high VTE risk

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7
Q

Outline some COC C/I

A

C/I patients w/ hormone sensitive breast cancer

Migraines w/ aura and/or >35 yrs

CV risk factors –> affects BP, inc stroke/MI

Hx VTE

Smokers >35yrs

end organ damage

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8
Q

How long do ADRs last for COCs?

A

Tolerance to ADR develop in first 3 months

Reduced risk of ovarian cysts, PID, dec ovarian/endometrial cancers

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9
Q

List some common ADRs for COCs

A

Mood changes (watch mental health)
N/V, headache
breast enlargement/tenderness
change in libido, inc BP, fluid retention
Chloasma (melasma, esp preg women)
acne, thrush

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10
Q

List some infrequent ADRs for COCs

A

Contact lense intolerance (+dry eyes)
Rash, hirsutism
Alopecia, altered lipid profiles
Hyperinsulinaemia (esp w/ levonorgestrel-containg COCs)
Insulin resistance

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11
Q

List some rare ADRs for COCs

A

VTE
Allergies, hypertension, stroke
Photosensitivity, jaundice, pancreatitis, liver cancer
Cervical cancer (inc w/ duration, declines to that of never users)
Breast cancer (small inc w/some, decline to never exposed after 10 yrs)

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12
Q

What influences the risk of VTE with COC use?

A

Dose of estrogen
type of progestogen
presence of other risk factors

Risk of VTE is higher in the 1st year of COC use, peak in 3 months

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13
Q

Which drugs types interact with COCs?

A

Drugs which increase CYP3A4 (progest, estro are metabolised by it)

Taking COC w/in 4 weeks of CYP3A4 inducers –> contraceptive failure

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14
Q

Which drug classes interact with COCs? (give e.g.)

A

Anti-epileptics = Carbamazepine, oxcarbazepine, phenytoin, phenobarbital, topiramate, primidone

Antibiotics = Rifampicin, Rifabutin, griseofulvin

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15
Q

Discuss the interaction between anti-infectives with COCs

A

No evidence that other anti-infectives alter COCs

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16
Q

What should be done if enzyme-inducing drugs are taken with COCs?

A

Use monophasic COC w/ levonorgestrel and ethinylestradiol AND inc COC dose to 50mcg ethinylestradiol

Two ways:
- 2 tablets of COC containing 30mcg or
- 1 tablet of 20 mcg and 1 tablet of 30mcg COC

Use additional contraceptive methods, reduce hormone free periods

Microgynon 50 ED is unsuitable as progestrogen dose is insufficient for contraceptive efficacy in this situation

17
Q

What is a monophasic COC regimen?

A

Each tablet contains same dose of oestrogen and progesterone

classified further by low, standard, high estrogen doses

18
Q

What is Multiphasic COC regimen?

A

Progestogen, or estrogen and progestogen, content varies throughout pack

More complex, cyclic symptoms (fluid retention, PMS, etc)

No advantage over monophasic, difficult to change timing of w/drawal bleeds

19
Q

What types of estrogen is used in COCs?

A

Ethinylestradiol = synthetic estradiol derivative, more potent than natural form

Mestranol = synthetic estradiol, metabolised by ethinylestradiol

Estradiol = natural oestrogen

No clinical benefit between either

20
Q

Discuss the use of estradiol in COCs

A

Natural oestrogen

seen in Qlaira (estradiol valerate multiphasic), Zoely (17-b estradiol monophasic)

No change in libido, better tolerate in women with mood disorders

21
Q

Discuss the use of estradiol in COCs

A

Natural oestrogen

seen in Qlaira (estradiol valerate multiphasic), Zoely (17-b estradiol monophasic)

No change in libido, better tolerate in women with mood disorders

22
Q

Discuss the use of ethinylestradiol in COCs

A

Ethinylestradiol = synthetic estradiol derivative, more potent than natural form

- low dose --> 20mcg
- standard dose --> 30-35mcg 
- high dose --> 50mcg
23
Q

Discuss the use of Mestranol in COCs

A

Mestranol = synthetic estradiol, metabolised by ethinylestradiol

  • standrad dose 50mcg mestranol (=35mcg ethinylestradiol)
24
Q

What progesterone is used in COCs?

A

2nd Gen = levonorgestrel and norethisterone

3rd Gen = gestodene, desogestrel, cyproterone

4th Gen = drospirenon, dienogest, nomegestrol

25
Q

Discuss the use of 2nd generation progesterones in COCs

A

Levonorgestrel and norethisterone

Reduced risk of VTE compared to other COCs

COCs with 2nd gen progestogens are PBS subsidised

26
Q

Discuss the use of 3rd generation progestogens in COCs

A

Gestodene and desogestrel = less androgenic activity than levenorgestrel (2nd gen), greater VTE risk compared to 2nd gen

Cyproterone = progestogenic and andti-androgenic (treat androgenisation), highest VTE risk

NOT indicated in absence of androgenisation

27
Q

Discuss the use of 4th generation progesterones in COCs

A

Drospirenone = anti-mineralocorticoid activity (mild diuretic, K+ retention), anti-androgenic

Dienogest = anti-androgenic activity, VTE risk, no clear benefit over others

nomegestrol = anti-androgenic activity, no data about VTE risk (inc in HRT/MHT)

28
Q

What is the benefit of newer progestreogen components in COCs?

A

More beneficial on acne
Less hirsutism
Less weight gain

29
Q

What are some counselling points about COCs?

A

Active pills must be take consecutively w/ <36 hrs between doses

Hormone free interval must not exceed 7 days

Commence after menses to exclude preg, contraception provided 7 days after starting pill

30
Q

When is contraceptive efficacy affected with COCs?

A

2 or more active pills missed (>48 hrs between active pills)

Medications taken that interfere w/ COC effectiveness

Severe vom/diarrhoea persists >24 hrs

31
Q

Outline the 7 day rule for COCs

A

7 conseq days of active pill = reliably prevent ovulation

7 active pills may be omitted w/out ovulation (e.g. pill free period)

Missing more than 7 consec active pills = risk ovulation

Risk of preg greatest if missed pill is at the start or end of active pill cycle

32
Q

What is the advice given for missing a COC during the first week of active pills?

A

> 48 hrs since last active or first active >24hr late

Take EC if unprotected sex

Take most recent missed pill, discard any other ones –> continue pills as normal

use barrier protection for 7 days

33
Q

What is the advice given for missing a COC during the second week of active pills?

A

Safest time to miss

If >48 hrs since last active pill –> take most recent missed pill (discard others) –> use barrier protection for 7 days

No EC req

34
Q

What is the advice given for missing a COC during the third week of active pills?

A

> 48 hrs since active tablet –> take most recent active, discard other missed pills –> use barrier for 7 days

Skip hormonal free interval (discard inactive pills) –> straight on to new pack

35
Q

What is an extended pill regimen for COC?

A

Shorten or eliminate HFI –> reduce menses from every month to every 3-4 months

Seen in: seasonique, Yaz, Zoely

36
Q

What are the benefits of seasonique?

A

Extended pill regimen

Reduced breakthrough bleeding/improve cycle control, dec PMS, inc ovarian suppression

Period lasts 3 days during 7 monopills

7006PHM Prof Pharm II (24 decks)

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