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therapeutics > Ex 5. L2-3 Preventative Health/Nonhormonal Contraception (44-45) > Flashcards

Ex 5. L2-3 Preventative Health/Nonhormonal Contraception (44-45) Flashcards

1
Q

Different types of hormonal contraception

A

Levonorgestrel (IUD)
Shot
Implant
Pill
Vaginal Ring
Patch
Emergency Contraception

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2
Q

Estrogen hormones in contraceptives

A

-Suppress FSH production
-Increase sex-hormone binding globulin
-Prevent dominant follicle
-Increase binding of free androgens
Helps with acne

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3
Q

Progestin hormones in contraceptives

A

Prevent LH surge
-Inhibit ovulation

Thicken cervical mucus
-Inhibit sperm penetration/transport

Change of motility of fallopian tubes
-Impair transport of sperm/ova

Atrophy of endometrium
-Impair implantation

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4
Q

Common estrogens

A

Ethinyl estradiol (EE)
Estradiol valerate
Estetrol
Mestranol

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5
Q

Common Progestins

A

Norethindrone
Norethindrone acetate
Norgestimate
Drospirenone
Norgestrel
Levonorgestrel
Segesterone acetate
Ethnediol diacetate
Desogestrel
Etonogestrel
Dienogest

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6
Q

Side effects of too much estrogen

A

Bloating
Breast tenderness
Mood changes
Headache
Nausea
Heavy menses
Fibroid growth
Melasma
Vision changes
Cyclic weight gain

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7
Q

Side effects of not enough estrogen

A

Light menses
Vaginal Dryness
Spotting
No withdrawal bleeding

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8
Q

Estrogen dosing

A

Very low dose = < 20 mcg EE
We should NEVER be using high dose estrogen pills
Low dose = 20-35 mcg EE
Typically people have good experience in low dose range
High dose = 50 mcg EE

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9
Q

Progestin component

A

Progestational
-Prevent ovulation
-Lessen bleeding
-Desire high selectivity
androgenic
-Acne
-Hirsutism (male pattern hair growth)
-Desire lower activity
Antiestrogenic
-androgenic side effect
-Desire lower activity

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10
Q

Preferred lines of therapy for Progestin

A

First
Norethindrone
Ethynodiol diacetate
Noregestrel
Norethindrone acetate
second
Levonorgestrel
Third
Norgestimate
Desogestrel/Etonogestrel
Fourth
Drospirenone
Segesterone

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11
Q

Progestin characteristics

A

Prevent ovulation
Decrease bleeding
We want More selective

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12
Q

Androgenic characteristics

A

Acne
Hirsutism
Desire lower activity

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13
Q

Side effects of too much progestin

A

Acne
Hirsutism
Decreases sex drive
Depression
Increased appetite
Increase sex drive
Noncyclical weight gain
Less energy
Cholestatic jaundice
Yeast infections
Hair loss
Swelling in arms/legs

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14
Q

Side effects of not enough progestin

A

Breakthrough bleeding late in cycle
No withdrawal bleeding
Heavy menses

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15
Q

Potential benefits beyond pregnancy prevention

A

Decreased risk of endometrial cancer
Decreased risk of menstrual-related headaches
Decreased risk of ovarian cancer
Improvement in perimenopausal symptoms

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16
Q

Specific methods things to consider:

A

Efficacy
Hormonal content
Route/dosage form
Side effects
Return of fertility
Potential health benefits

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17
Q

Implant - Nexplanon (Etonogestrel)

A

Side effects: serious
-Mood changes
-Headaches
-Acne
Side effects: Common:
-Pain with insertion
-Irregular bleeding for first 6-12 months (no bleeding, regular periods, frequent spotting or bleeding)
Potential benefits
-Long term protection up to 3 years
-Nothing to remember to use on a regular basis
Return of fertility
-May be delayed or rapid return (within 6 weeks)
93% efficacy

18
Q

Levonorgestrel (LNG) (IUD)

A

Side Effects: Serious
-Uterine Perforation
-Infection
-Expulsion
Side Effects Common:
-Cramping with insertion
-Spotting for first 3-6 months
-Periods may become lighter or less frequent
Potential benefits:
Lighter periods; amenorrhea
-Lower risk of uterine cancer protection
-Safe to breastfeed
-Long term
return of fertility
-Immediate

19
Q

Copper IUD

A

Side effects: serious:
-Uterine perforation
-Infection
-Expulsion
Side effects common:
-Cramping with insertion
-Spotting for first 3-6 months
-Periods may become heavier or stay about the same
Potential benefits:
-Lower risk of uterine cancer
-Long term
-Safe to breastfeed
Return of fertility
-Immediate
No hormones
if someone wants less painful/lighter menses, NOT FOR THEM
Can be used for 3-8 years

20
Q

Shot (Depot Medroxyprogesterone acetate)

A

How administered
-150mg IM or 104 SQ
Side effects: Serious
-Lower bone density
-Heavy bleeding
Side effects: Common
-Weight gain
-Change in acne, mood, or headaches
-Spotting between periods: no period
Potential benefits
-Lower risk of uterine cancer
-Safe to breastfeed
-Lighter, less painful periods; amenorrhea
Return of fertility
-Possible

21
Q

Pill-Combined (COC)

A

Side effects: serious
-Blood clots (estrogen related)
-Stroke
Side effects: common:
-Nausea, spotting and/or breast discomfort
-Change in mood or headaches
Potential benefits
-Improved acne
-Lower risk of ovarian/uterine cancer
-More regular, lighter, less painful periods
Return of fertility:
-Immediate

22
Q

Combined pill product info

A

Monophasic:
-Same dose throughout cycle
Biphasic
-Varying doses of EE or progestin
-Two strengths throughout cycle
Triphasic
-Varying doses of EE or progestin
-Three strengths: throughout cycle
Four phasic
-Varying doses of EE and progestin
-Four strengths throughout cycle

23
Q

POP - Norethindrone (“mini-pill) and Noregestrel (OTC)

A

**Frequency of admin*
-Daily, within 3 hours of the same time
-No placebo pills
Serious side effects
-Severe HA
-Heavy bleeding
-Ectopic pregnancy
Side effects: Common:
-Spotting and menstrual changes more common than combined pill
Potential benefits:
Safe to breast feed
Lack of estrogen related side effects
Return of fertility:
Immediate

BIG THING: have to be taken within three hours of the same time every day
-Outside of three hour range = missed dose

24
Q

POP - Drosperinone 4 mg (SLYND)

A

Frequency of admin:
Daily
No placebo pills in pack
Side effects: Serious:
Severe HA
Hyperkalemia
Side effects: Common
Spotting and menstrual changes more common than COC
Potential benefits
-Safe to breast feed
Lack of estrogen-related side effects
Return of fertility
-Immediate

25
Q

Monthly (Disposable) Vaginal Ring - Etonogestrel & EE (Nuvaring, Eluryng)

A

Frequency of admin
-Left in place for 3 weeks -> removed for 1 week
-New ring inserted after 7 days
Side effects: Serious
-Blood clots
-Stoke
Side effects: Common:
-Nausea, spotting, breast discomfort
Change in mood or headaches
Potential Benefits
Improved acne
More regular, lighter, less painful periods
Return of fertility: immediate

26
Q

Annual (Reusable) Vaginal ring: Segesrerone and EE (Annovera)

A

Frequency of admin
Left in place for 3 weeks -> removal for 1 week
Wash with mild soap/warm water, pat dry, and place in case
Reinsert to vagina (after cleaning)
Side effects: Serious
Blood clots
Stroke
Side effects: common
HA/migraine
Nausea vomiting
Vulvovaginal infection/candidiasis
Potential benefits
Improved acne
More regular, lighter, less painful periods
Don’t have to remember daily
Lower risk of ovarian/uterine cancer
Can use one device up to 13 times
Return of fertility
Immediate

27
Q

Patch - Norelgestromin & EE (Xulane and Zafemy)

A

How administered: Transdermal patch applied to upper outer arm, abdomen, buttock or back
Thin beige square plastic with sticky pack
Frequency of admin
New patch every 3 weeks -> patch free for 7 days
Apply new patch
Side effects: Serious
Blood clots (more estrogen than most combined pills)
Side effects: common
Nausea, spotting, breast discomfort
Skin irritation
Change in mood or headaches
Potential benefits
Improved acne
More regular, lighter, less painful periods
Don’t have to remember daily
Lower risk of ovarian/uterine cancer
Return of fertility
Immediate

28
Q

Patch - Levonorgestrel and EE (Twirla)

A

How administered: Transdermal patch applied to abdomen, buttock or upper torso (excluding breast)
Thin beige round plastic with sticky back (larger than others)
Frequency of admin
New patch every 3 weeks -> patch free for 7 days
Apply new patch
Side effects: Serious
Blood clots
Side effects: common
Nausea, spotting, increased weight
Skin irritation
Change in mood or headaches
Potential benefits
Improved acne
More regular, lighter, less painful periods
Don’t have to remember daily
Lower risk of ovarian/uterine cancer
Return of fertility
Immediate

29
Q

General approaches to starting contraception

A

Quick start
-Start anytime it is reasonably certain person is not pregnant
-If more than 1-6 days after period, use backup method for 2-7 days
Next period start
-Start within 1-6 days of period start
-No backup method required
Sunday Start
Start on Sunday after period starts
-If more than 1-6 days after period start, use backup method for 2-7 days

30
Q

How to handle late/missed doses

A

Drospirenone oral pill
See “late or missed COC recommendations**
Norethindrone or norgestrel oral pill
Any number of pills is > three hours late; take late/missed pill ASAP; continue daily pills, backup needed for two days
Progestin only injection:
-Less than or equal to two weeks late (15 weeks) receive injection, no backup method
-More than two weeks (>15 weeks): receive injection if reasonably certain person is not pregnant, backup method for 7 days, consider emergency contraception
Patch
-<24 hours: try to get patch to stay on
-No tape, no extra adhesive
If does not work, use new one
-Ok to do up to 48 hrs
Ring:
Rinse w/cool water and reinsert within 48hrs - anything longer sort of like starting over

31
Q

Starting contraception: Changes

A

When changing hormonal methods
-Switch method at any time or when due for next injection
-No backup needed if no gaps in tx
Emergency contraception
-Within five days of unprotected vaginal intercourse
-Levonorgestrel: More effective the sooner it is used; may be less effective is >165 pounds
Restarting after emergency contraception:
-Levonorgestrel: start/resume method immediately; backup method for seven days
Ullipristal acetate: start/resume method five days after use; backup method until seven days of use

32
Q

Q: A patient calls your pharmacy around 10:00AM and says that she forgot to take her COC yesterday afternoon, which she usually takes around 1:00 pM. She tell you she only forgot one pill. What should she do?

A

Take her pill ASAP; no backup needed

33
Q

Q: Would you give different advice if the patient was taking a norethindrone mini-pill? If so, what would you tell the patient? (missed dose)

A

Take her pill ASAP, and use a form of backup for 2 days

34
Q

Q: Jessica comes to your pharmacy to pick up a new prescription for Annovera. How would you counsel the patient on how to clean the ring?

A

Wash with mild soap and warm water when you remove for the hormone-free week. Keep in the case until ready to re-insert

35
Q

Common SE and how to address

A

Irregular Bleeding
-Take pills at same time
Ibuprofen 800mg 3x a dat x 5 days
-May improve with continued use
Headaches
D/C product if headaches get WORSE
OTC pain relivers
Continuous product if during placebo
Nausea
-Take pills with food or at bedtime
-Continuous product if at start of cycle
-May improve with continued use
Breast tenderness
-Supportive bra
-OTC pain relivers
-Products with less estrogen
Acne
-Topical treatments
-Different pill formulation (Less androgenic)
-Combined product (if able)

36
Q

Serious side effects of combined methods

A

A = abdominal pain
C = Chest pain (SOB, cough)
H - HA
E - Eye problems (double/blurry vision)
S - Severe leg pain

37
Q

Cautions with combined

A

A LOT to consider
Contraindications:
<21 days post partum
Cirrhosis
VTE
Diabetes and vascular disease
etc.

38
Q

COC and antibiotics

A

Controversial
Potential mechanisms
-Altered intestinal flora
-Increased nausea/vomiting/diarrhea as a side effect of antibiotic
Altered metabolism
Recommend backup plan!!

39
Q

Q: You prescribed EE 50 mcg/Norethindrone 1mg (Ovcon-50) daily for a 27 yo about 3 months ago. She comes back for her refill today with complaints of significant nausea, breast tenderness and mood changes. She wonders if COC is to blame. What do you suggest?

A

27 y/o high dose estrogen - choose a lower dose of estrogen
ALl of SE listed are to do with estrogen

40
Q

Q: AN 18 y/o was recently started on EE 20mcg/Levonorgestrel 0.1 mg (Aviane-28) daily. She has noticed that she consistently has some spotting around days 5-6 of the pill pack. What do you suggest?

A

18 y/o - increase estrogen (NOT to 50, maybe 30 instead of 20)

therapeutics (49 decks)

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