32. Contraception & Infertility Flashcards Preview

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Flashcards in 32. Contraception & Infertility Deck (45):
1

A young female enters the pharmacy. She asks for the best over-the-counter option to protect against sexually transmitted infections (STis). Which of the following represents the best option for STI protection?

A. Latex male condom
B. Delfen Foam
C. Nonoxynol-9
D. Plan B One Step
E. Next Choice
 

A. Consistent and correct use of male latex condoms, or female condoms, can reduce (though not eliminate) the risk of STI transmission.

nonoxynol-9 - spermacide

Plan B One Step, Next Choice - emergency contraceptive (1.5mg levonorgestrel)

2

Chantelle started on the contraceptive Ortho Tri-Cyclen Lo five months ago. Initially, she had spotting over several weeks but was instructed by the pharmacist that she should get used to the formulation within 2-3 months. She feels the side effects are better, except that she continues to spot around days 7-8. What is the likely cause of the spotting?

A. Too much estrogen
B. Too little estrogen
C. Too much progestin
D. Too little progestin
E. Using a triphasic formulation
 

B. If low-dose estrogen pills are used, or if there is insufficient estrogen (the patient may be a fast metabolizer, or be using an enzyme inducer), then she may require a higher estrogen dose.

Picking formulations

Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine

Estrogen preferred when: no contraindication

Drospirenone preferred when: fluid retention/bloating, premenstrual dysphoric disorder (use Yaz or sertraline)

Spotting/"breakthrough bleeding": If early or mid cycle spotting then increase estrogen dose. If later in the cycle then increase progestin dose. Must wait 3 cycles before switching.

3

Carol has just been at the pharmacy to pick up a new prescription for combination oral contraceptives. The pharmacist has instructed Carol to be seen at once if she experiences severe chest pain, severe headache, a swollen or painful calf, vision problems, shortness of breath, is coughing up blood or has severe abdominal pain. The pharmacist understands that the use of estrogen may increase risk for these complications: (Select ALL that apply.)

A. Stroke
B. Deep vein thrombosis
C. Clotting
D. Migraine headaches
E. Heart failure
 

A, B, C. Keep in mind that many women use birth control pills safely for 20+ years with no complications. It is important to consider the rare events as well, and patients are instructed to be on the look-out for these signs of a severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).

4

A woman is using Alesse combination oral contraceptive pills. She does not enjoy getting a monthly menstrual cycle and has heard about new pill formulations where you get less periods. Choose the formulation/s which results in menstruation once every 3 months: (Select ALL that apply.)

A. Seasonale
B. Amethyst
C. Lybrel
D. Seasonique
E. Camilla
 

A, D. Seasonale, Seasonique and LoSeasonique are three month birth control pill formulations. They all have a 91-day pill regimen with 84 active pills. The difference is the placebo week: Seasonale has 7 days of placebo, and Seasonique has 7 days of low dose estrogen.

5

Nonoxynol-9 is the most commonly used spermicide and is present in the contraceptive sponge, film and vaginal spermicides. Choose the correct statements concerning nonoxynol-9. (Select ALL that apply.)

A. Nonoxynol-9 is prescription only.
B. Spermicide kills sperm, but does not reduce the risk of catching a sexually transmitted infection.
C. Some people are allergic to spermicides or get skin irritations from them; this is often mistaken for an allergy to the latex condom (which some people have as well).
D. If Nonoxynol-9 is used many times a day, or if it is used by people at risk for HIV, it can irritate tissue and increase the risk of contracting HIV and other sexually transmitted infections.
E. When used alone, spermicide is not very effective for pregnancy prevention; it is more effective when used with a condom or with a diaphragm.
 

B, C, D, E. Male-to-male intercourse and sex workers (including those in the porn industry) should not be using nonoxynol-9. If a female is at risk for pregnancy, she needs a more effective method, which can be used safely with condoms. Nonoxynol-9 will irritate the vaginal mucosa (or lining of the anus) and increase the risk of STi transmission. If spermicide is used alone (correctly) 15 of every 100 women will get pregnant/year.

6

Mark is sixteen years old. He wants to purchase emergency contraception for his girlfriend, who he says is 20 years old. Choose the correct statements. (Select ALL that apply.)

A. The levonorgestrel EC pill that contains two 0.75 mg tablets can be purchased by Mark as an OTC product.
B. Mark can purchase Plan B One-Step, since it does not have age restrictions.
C. Plan B contains ethinyl estradiol which provides some protection against Chlamydia.
D. Mark can purchase Plan B One-Step, since it does not have sex restrictions.
E. The parents of both individuals should be contacted regarding this request.
 

B, D. Plan B One-Step is OTC with no sex or age requirements as of June 2013. The FDA has requested that Plan B One-Step be placed in the aisle with other family plannings, such as condoms and spermicide.

The two-step products require prescription.

7

A woman is hoping to become pregnant. Choose the correct statement. (Select ALL that apply.)

A. If a couple is attempting pregnancy, it should occur in about 25% per month, and most become pregnant within a year.
B. Males are not contributory to infertility; it is always the females, and largely due to the health of her eggs.
C. Women attempting to become pregnant should begin to take folic acid at a recommended daily intake of 400-800 mcg daily.
D. Any women trying to conceive should be started on an ACE inhibitor, as these can increase fertility.
E. If pregnancy has not occurred within six months time, the couple should be referred to a clinician specializing in infertility.
 

A, C. Ovulation is the most fertile time; when the ovulation predictor kit is positive, it has detected luteinizing hormone, indicating that the egg will soon be released. The sperm need to travel to the fallopian tubes, where fertilization can take place.

8

Which of the following products requires that the pharmacist dispense a patient package insert (PPI) with each prescription and refill? (Select ALL that apply.)

A. LoSeasonique
B. Diaphragms
C. Norethindrone mini-pill (progestin only pill)
D. Delfen Foam
E. Yasmin
 

A, C, E. Inform the patient that the PPI has important safety information and instructions on how to use them properly and what to do if pills are missed. The FDA requires that the patient package insert accompany each package dispensed to the patient.

9

Which of the following birth control pill formulations is a multiphasic formulation?

A. Nor-QD
B. Loestrin 24-Fe
C. Apri
D. Aviane
E. Ortho-Novum 7/7/7
 

E. As indicated by the name, the Ortho-Novum 7/7/7 has three different weeks of hormone levels-they change over time.

Birth Control Nomenclature:

0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)

Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)

Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)

Fe, contains iron

Progestin only, often have "nor" in the name for norethindrone or "pro" found in HRT products for progestin

10

A pharmacist remembers that he was taught in school to warn patients using oral contraceptives about watching for severe leg pain, chest pain or trouble breathing. This is due to a risk of:

A. Clots
B. Hemorrhagic strokes
C. Severe depression
D. Liver cancer
E. Breast cancer
 

A. The thrombogenic risk associated with estrogen has been reduced over the years the pill has been available since the estrogen content used today is much lower than in previous years. Nonetheless, it is still present, particularly in high-risk women who may not be candidates for the pill. If a woman has any history of clotting disorders (DVT, MI, Stroke, PE) she is contraindicated from any estrogen use, including as hormone therapy when she is older.

Keep in mind that many women use birth control pills safely for 20+ years with no complications. It is important to consider the rare events as well, and patients are instructed to be on the look-out for these signs of a severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).

11

Greg is dispensing Next Choice to a young woman. Greg is aware that nausea is the primary side effect of the EC pills. He asks if she gets easily nauseated, and she replies that she does and states that she vomits easily. Choose the correct recommendation for managing the nausea:

A.He can recommend two tablets of the OTC version of Compazine one hour before the EC is taken.
B. The nausea medication will make her "wired" and could cause insomnia.
C. She will need to get a prescription for a trimethobenzamide suppository.
D. She can use two 25 mg tablets of meclizine an hour before she uses the EC.
E. Emergency contraception pills do not cause nausea since they contain no estrogen.
 

D. The usual recommendation for nausea from the EC pills is OTC meclizine (Bonine, Dramamine "Less Drowsy") but the catch is that these are sedating and, if the patient is going to drive home from the pharmacy, it may be unsafe.

OTC Compazine does not exist, it requires a prescription.

12

Which of the following are correct statements concerning missed pills with an estrogen-progestin birth control pill formulation? (Select ALL that apply.)

A. Back-up methods could include condoms and a spermicide (such as foam).
B. The spermicide contains levonorgestrel.
C. Back-up contraception is generally needed if two or more consecutive hormonal pills are missed.
D. If a single pill is missed anywhere in the packet, the forgotten pill needs to be taken when noticed and the next pill is taken the next day, which may mean taking two pills on the same day.
E. If a single pill is missed in week 1 or 2 the woman should continue the same packet until it is all taken, and use back-up until a new packet is started.
 

A, C, D. Most women miss early due to not picking up the refill. Pills taken daily can be hard to remember for many and a different formulation may be useful.

13

Certain medications taken concurrently with birth control pills can reduce the contraceptive's efficacy. Which of the following medications, if taken with birth control pills, could cause this problem and require back-up contraception or a different method of contraception with long-term therapy? (Select ALL that apply.)

A. Rifampin
B. Carbamazepine
C. Erythromycin
D. Azithromycin
E. Mycophenolate
 

A, B, E.

Decreases hormone efficacy:

ABX: rifampin, rifapentine, rifabutin

Anticonvulsants: barbiturates, carbamazepine, oxcarbazepine, phenytoin, topiramate, felbamate

St. John's wort, several protease inhibitors and NNRTIs, bosentan (Tracleer), mycophenolate (CellCept), mycophenolic acid (Myfortic)

14

Which combination oral contraceptive product comes in a patch formulation?

A. Mircette
B. Ortho Evra
C. NuvaRing
D. Lybrel
E. Yasmin
 

B.

Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.

15

Which of the following birth control pill formulations is not a mini-pill?

A. Camila
B. Nor-QD
C. Errin
D. Cyclessa
E. Nora-BE
 

D. "Cycle" in the name indicates changing hormone dose. The POPs have the same dose of a progestin only, taken daily.

Birth Control Nomenclature:

0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)

Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)

Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)

Fe, contains iron

Progestin only, often have "nor" in the name for norethindrone or "pro" found in HRT products for progestin

16

The following are contraindications to the use of estrogen therapy, in any dose or formulation. (Select ALL that apply.)

A. History of myocardial infarction
B. History of deep vein thrombosis
C. Unexplained vaginal bleeding
D. History of pregnancy
E. History of cerebrovascular accident
 

A, B, C, E. There are other contraindications

Contraindications & Boxed Warning: Clotting, Hormone-dependent cancer anywhere in the "reproductive" tissues and liver cancer, cigarette smoke and serious cardiovascular events.

Keep in mind that many women use birth control pills safely for 20+ years with no complications. It is important to consider the rare events as well, and patients are instructed to be on the look-out for these signs of a severe complication from estrogen-containing oral contraceptives (ACHES): ABDOMINAL PAIN (severe). CHEST PAIN (severe), shortness of breath, coughing up blood. HEADACHE (severe), numbness of lips, tongue, arm or leg. EYE PROBLEMS - vision loss, blurring, flashing lights SEVERE LEG PAIN - redness, swelling of calf or thigh. These could be signs of a thrombotic event (MI, DVT, PE).

17

If a patient finds that she cannot tolerate estrogen for any reason, which products might be used as alternatives? (SelectALL that apply.)

A. Nor-QD
B. Intrauterine device
C. Depo-Provera
D. Ortho Evra
E. Seasonique
 

A, B, C. Depo-Provera contains the progestin medroxyprogesterone; it is an acceptable option as there is no estrogen. The shot lasts for three months. Depo-Provera decreases bone density. About half the women using the shot stop menstruating and the rest have light menstrual bleeding.

Birth Control Nomenclature:

0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)

Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)

Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)

Fe, contains iron

Progestin only, often have "nor" in the name for norethindrone or "pro" found in HRT products for progestin

18

When do patients begin a Seasonale or Seasonique packet?

A. Start on the Sunday after the period has started.
B. Start on the Monday after the period has started.
C. Start on the Tuesday after the period has started.
D. Start on the Wednesday after the period has started.
E. Anytime is acceptable.
 

A. Most pills (including these formulations) are started on the Sunday following the period. Most couples are more likely to have intercourse on the weekends and with a "Sunday starter" the bleeding during the placebo week will occur on weekdays (it generally starts on Monday).

19

Holly is a 30 year-old woman who just had a baby. She has been prescribed the progestin-only mini-pill, Nor-QD. Her doctor told her that she will use this type of birth control pill until she is done breastfeeding her baby. Which of the following counseling points on the "mini pill" should be relayed to the patient?

A. The mini pill can be started at any time.
B. Use another method of birth control for the first 7 days.
C. If more than 6 hours have elapsed from the regularly scheduled time you take your pill, you could get pregnant.
D. This method offers better protection against pregnancy than estrogen and progestin combination pills, for most women.
E. This formulation causes more nausea than most estrogen and progestin combination pills.
 

A. Progestin-only pills (The mini-pill, or POPs) are used primarily by women who are lactating, since estrogen decreases milk supply. Progestin-only pills are occasionally used by patients who have contraindications to estrogen (such as a clotting disorder) or who cannot tolerate the estrogen side effects. They must be taken at about the same time each day or pregnancy can occur.

Starting POP: Start at any time, takes 2 days to gain protection. All come in 28-day packs and all pills are active. POPs need to be taken exactly around the same time every day; if 3 hours have elapsed from the regular scheduled time, back up is needed for 48 hours after taking the late pill. If dose is missed, patient could be pregnant and EC may be suitable.

Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine

20

Holly is a 30 year-old woman who has been using Nor-QD for contraception since she had her baby. Holly was primarily breast-feeding, but she stopped when the baby was seven months. The baby is now eight months old. Holly knows that she needs to be switched to a pill that includes estrogen but she has been too busy to see the doctor. She forgot to take her Nor-QD this morning and had intercourse later that evening. Is she at risk for pregnancy?

A. No, unless she has missed 2 consecutive pills.
B. No, unless she has missed 3 consecutive pills.
C. No, unless she has missed 4 consecutive pills
D. Yes, pregnancy could result, and the patient may wish to use emergency contraception.
E. This cannot be determined because it depends on the date of the last menstrual cycle.
 

D. Patients must take the pill at the same time of day; if three hours have elapsed from the regular scheduled time, back up is needed for 48 hours after taking the late pill. If a dose is missed, and sexual intercourse has taken place, pregnancy could result, and the patient may desire emergency contraception.

Starting POP: Start at any time, takes 2 days to gain protection. All come in 28-day packs and all pills are active. POPs need to be taken exactly around the same time every day; if 3 hours have elapsed from the regular scheduled time, back up is needed for 48 hours after taking the late pill. If dose is missed, patient could be pregnant and EC may be suitable.

21

Jane has just received the Ortho Evra patch at the pharmacy. It is a good choice for her because she sometimes forgets to take the pill. Counseling points for Ortho Evra should include all of the following recommendations: (Select ALL that apply.)

A. The patch provides some protection from sexually transmitted infection, but not as much as condoms.
B. Ortho Evra cannot be used in women with a history of blood clots, or > 198 pounds.
C. One patch is placed on the upper outer arm, abdomen, buttock or back-when applying press firmly for ten seconds.
D. If the patch is left off for more than 36 hours, you may not be protected from pregnancy.
E. Start the patch on the first Sunday after the period begins or apply during the first day of the period.
 

B, C, E. The patch has reduced efficacy if off for longer than 24 hours.

Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.

22

What is the primary reason that Yaz and Yasmin became best-selling drugs (and this reason could also be considered a "side effect" of the drug)?

A. They prevent pregnancy more than some of the older formulations.
B. They prevent monthly bleeding.
C. They lower potassium.
D. They cause less headaches.
E. They do not contribute to pre-menstrual and water-weight gain.
 

E. There is no pre-menstrual and water-weight gain with these products, which has made them best-sellers. However, these formulations can elevate clotting risk. There also seems to be fewer PMS and menstrual symptoms with Yaz.

Picking formulations

Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine

Estrogen preferred when: no contraindication

Drospirenone preferred when: fluid retention/bloating, premenstrual dysphoric disorder (use Yaz or sertraline)

Spotting/"breakthrough bleeding": If early or mid cycle spotting then increase estrogen dose. If later in the cycle then increase progestin dose. Must wait 3 cycles before switching.

23

The pharmacist is dispensing the Ortho Evra contraceptive patch to Sue-Ellen. The patient's vitals today include a blood pressure of 106/68 mmHg, pulse 72 BPM, height 5'6" and weight 212 pounds. Select the correct statement:

A. A new patch is applied daily.
B. This patient is not a good candidate to use the Ortho Evra patch.
C. The patch has a low risk of blood clots compared to the orally administered contraceptives.
D. One patch stays on for three weeks; on the fourth week the patch is left off.
E. The patch should be applied to either breast.
 

B. The patch is not recommended for women over 198 pounds due to lower efficacy. The patch is linked to a higher risk of blood clots than low-dose oral contraceptives.

Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.

24

A young female enters the pharmacy. She is using birth control pills. She asks if she is protected against HIV and other STIs. Which advice should be provided? (Select ALL that apply.)

A. Birth control pills reduce the risk of gonorrhea.
B. Birth control pills reduce the risk of chlamydia.
C. Birth control pills reduce the risk of HIV.
D. Birth control pills do not protect against sexually transmitted infections.
E. The best protection against STIs is abstinence; the second-best protection is to use condoms (in addition to another contraceptive method, for efficacy against pregnancy).
 

D, E. Birth control pills, patches and rings are intended to prevent pregnancy. They do not protect against transmission of HIV (AIDS) or other sexually transmitted diseases (STIs), including chlamydia, genital herpes, genital warts, gonorrhea and syphilis.

25

Which of the following represent possible advantages of using continuous birth control formulation such as Lybrel orAmethyst? (Select ALL that apply.)

A. Long period of time without menstrual cycle bleeding and "period-related" effects, such as moodiness.
B. Lower risk of pregnancy with missed pills.
C. No withdrawal effects, such as physical and emotional symptoms, that can occur with other formulations during the hormone-free interval.
D. Reduced risk of acquiring sexually transmitted infections, such as gonorrhea and chlamydia.
E. Avoidance of clotting risk.
 

A, C.

26

Carol comes into the pharmacy to pick up a prescription for Sarafem for premenstrual dysphoric disorder (PMDD). Which birth control formulation is approved for PMDD?

A. Yasmin
B. Yaz
C. NuvaRing
D. Ortho Evra
E. ParaGard
 

B. When the placebo period is shortened or low dose estrogen is given during the placebo period, then physical and emotional withdrawal symptoms are improved. Many women experience low mood when they have swings in hormone levels and certain formulations can help stabilize mood.

Sarafem (fluoxetine)

Picking formulations

Progestin preferred when: breastfeeding, elevated clotting risk, estrogen contraindication, aura migraine

Estrogen preferred when: no contraindication

Drospirenone preferred when: fluid retention/bloating, premenstrual dysphoric disorder (use Yaz or sertraline)

Spotting/"breakthrough bleeding": If early or mid cycle spotting then increase estrogen dose. If later in the cycle then increase progestin dose. Must wait 3 cycles before switching.

27

A pregnancy test kit is positive if this hormone is present in the urine:

A. Parathyroid hormone
B. Luteinizing hormone
C. Progesterone
D. Ethinyl estradiol
E. Human chorionic gonadotropin
 

E. If a case indicates human Chorionic Gonadotropin positive (hCG+), the patient is pregnant and teratogenic drugs should be discontinued, if possible.

If a case is +hCG, the patient is pregnant and teratogenic drugs should be discontinued, if possible. Alcohol, ACE inhibitos, angiotensin receptor blockers, benzodiazepines, carbamazepine, ergot-derivatives, isotretinoin, leflunomide, lithium, methimazole, nafarelin, NSAIDs, paroxetine, phenytoin, phenobarbital, propylthiouracil, quinolones, ribavirin, tazarotene, tetracyclines, topiramate, valproic acid, misoprostol, methotrexate, statins, dutasteride, finasteride, warfarin, lenalidomide and thalidomide.

28

With a regular estrogen-progestin birth control pill formulation, when is the highest risk time for pregnancy if a pill is missed?

A. Week 1 and week 3
B. Week 1 and week 2
C. Week 2 and week 3
D. Week 3 and week 4
E. All the weeks are equally risky for pregnancy
 

A. While there is no time that is 100% foolproof to miss pills, missed pills on either side of the placebo week is the highest risk.

Highest risk during the beginning and ending of placebo week.

29

Select the correct statement concerning the Ortho Evra patch:

A. Apply the patch on the first Sunday following the beginning of your menstrual period or on the first day of your period.
B. Apply the patch the day you receive it from the pharmacy; timing with the patch is not important.
C. Apply the patch on the third Monday of the month, regardless of your menstrual cycle.
D. Apply the patch exactly five days after the period has started.
E. Apply the patch exactly ten days after the period has started.
 

A. Instruct patients: If this is the first time you are using this medication, apply the patch on the first Sunday following the beginning of your menstrual period or on the first day of your period. If your period begins on a Sunday, begin on that day.

Ortho evra patch is placed on clean, dry skin of buttocks, stomach, upper arm, or upper torso once a week for 21 out of 28 days. Do not apply to breasts. If patch becomes loose or falls off <24 hours, MAY still be covered if they put it back on. If >24 hours then back up method for 1 week. Less effective in women >198 pounds.

30

A pharmacist will counsel a patient beginning a combination oral contraceptive for pregnancy prevention. Which of the following are correct counseling statements? (Select ALL that apply.)

A. The FDA requires that the patient package insert be dispensed the first time the patient receives the medication. With refills it is not required.
B. If you have had any type of clotting disorder, such as a DVT, you cannot use this product.
C. Cigarette smoking with this medication must be kept under 20 cigarettes daily.
D. If you take any new medications or over-the-counter medicines, check with one of the pharmacists first to see if they are safe to use with your birth control pills.
E. The most common side effects are nausea, light bleeding between periods (talk with your doctor if this does not go away after three months), and possibly some weight gain and breast tenderness.
 

31

Andrea is a 28 year old female with lupus-induced nephropathy. Her renal function has declined and is currently estimated at a creatinine clearance of 23 mL/minute. Her serum potassium is 4.8 mEq/L. Her medications include lisinopril 10 mg twice daily, methotrexate once weekly, a vitamin D supplement and simvastatin. Andrea has met a young man and went to her physician to get a contraceptive method. Andrea should not receive any of these contraceptive options: (Select ALLthat apply.)

A. Mirena
B. Condoms and foam
C. ParaGard
D. Yaz
E. Yasmin
 

D, E. When dispensing drospirenone containing products, check for potassium sparing agents or an elevated potassium level (the safe range is 3.5-5 mEq/L). Reduced renal function will increase the risk of hyperkalemia. Check the BUN and SCr to make sure they are not elevated. Potassium is renally excreted.

32

Judy has just received a NuvaRing at the pharmacy. It is a good choice for her because she sometimes forgets to take the pill. Counseling points for the NuvaRing should include all of the following recommendations: (Select ALL that apply.)

A. Insert the ring between days 1 and 5 of menses and leave in for three weeks; remove at the end of three weeks.
B. The ring can be removed for up to 24 hours without risk of pregnancy.
C. The ring can be stored at room temperature for up to four months.
D. The ring does not protect you from sexually transmitted diseases.
E. NuvaRing cannot be used in women with a history of blood clots, stroke, heart attack or in women over age 35 who smoke.
 

A, C, D, E. The ring is refrigerated at the pharmacy but can be kept at room temperature by the patient. If the ring is removed or accidentally left out for more than three hours, contraceptive efficacy is reduced. The time limit for the ring to be out is three hours; some couples will want the ring removed during sex. For most people, the ring is not felt during intercourse.

33

A patient has vomited out the first dose of Plan B (0.75 mg). The pharmacist should tell her to retake the dose (after taking anti-nausea medicine first) if she has vomited within this time period after having taken the EC tablet/s:

A. 60 minutes
B. 90 minutes
C. 2 hours
D. 3 hours
E. 4 hours
 

C. If the patient vomits within two hours after taking levonorgestrel pills, they should take an anti-emetic and then take then another full dose of levonorgestrel.

34

Mark has entered the pharmacy to get emergency contraception (EC) for his girlfriend. Which statements regarding EC are correct? (Select ALL that apply.)

A. If the period is more than a week late, a pregnancy test should be taken.
B. A patient must be over 17 years of age to purchase Plan B One Step over the counter.
C. Emergency contraception is a form of contraception that prevents pregnancy after sexual intercourse.
D. Plan B One Step contains one 0.75 mg tab of levonorgestrel.
E. The levonorgestrel EC formulations are indicated for use up to 3 days after unprotected intercourse.
 

A, C, E. Plan B One Step and generic formulations contain one 1.5 mg tab of levonorgesterol and Next Choice and Plan B contain two 0.75 mg tablets. Plan B was discontinued in 2009.

35

Chantelle is using an estrogen-progestin oral contraceptive. She is started on Trileptal for seizures by her primary care physician. Despite perfect adherence with the daily birth control pills, she became pregnant within a few months of starting the Trileptal. What is the likely cause of the pregnancy?

A. The Trileptal decreased the absorption of the birth control pills.
B. The Trileptal increased the absorption of the birth control pills.
C. The Trileptal induced the metabolism of the birth control pills.
D. The Trileptal inhibited the metabolism of the birth control pills.
E. There is no interaction between Trileptal and birth control pills; the pregnancy is a mystery.
 

C. Enzyme inducers lower birth control pill concentrations and ovulation can result. Other drugs interact for a variety of other reasons.

Decreases hormone efficacy:

ABX: rifampin, rifapentine, rifabutin

Anticonvulsants: barbiturates, carbamazepine, oxcarbazepine, phenytoin, topiramate, felbamate

St. John's wort, several protease inhibitors and NNRTIs, bosentan (Tracleer), mycophenolate (CellCept), mycophenolic acid (Myfortic)

36

Choose the correct statement concerning Lybrel.

A. Lybrel is another formulation of progestin only pills.
B. Lybrel is associated with more PMS symptoms compared to other birth control formulations.
C. Lybrel causes less clotting than other birth control formulations.
D. Lybrel comes as continuous pills; no placebo/off week.
E. Lybrel causes less spotting compared to other birth control formulations.
 

D. Lybrel is continuous pills with no monthly cycle. Lybrel comes in 28 day packets, but there is no placebo week and the packets are taken continuously.

37

Which of the following contraception formulations would have a higher risk of clotting than the Loestrin Fe 1.5/30 formulation? (Select ALL that apply.)

A. Ortho Evra
B. Yaz or Yasmin
C. A 35 mcg ethinyl estradiol/norethindrone formulation
D. The mini-pill (POP)
E. Condoms and foam
 

A, B, C.

The progestin drospirenone, as well as the Ortho Evra patch (due to higher systemic estrogen level) are linked to a higher risk of blood clots and best avoided in at-risk women.

Birth Control Nomenclature:

0.5/35 (or similar), usually called monophasic formulation (progestin/estrogen)

Tri or 7/7/7 or Cycl-, triphasic formulation (multiphasic)

Lo, low estrogen <35mcg (when you go below this, there could be spotting because estrogen maintains endometrium lining)

Fe, contains iron

Progestin only, often have "nor" in the name for norethindrone or "pro" found in HRT products for progestin

38

Ruth has started to use the oral contraceptive Ortho Tri-Cyclen. Which of the following side effects are not expected from the use of this product?

A. Breast tenderness
B. Hair loss
C. Bloating
D. Elevated blood pressure
E. Breast fullness
 

B. Estrogen can cause nausea, breast tenderness/fullness, bloating, weight gain or elevated blood pressure. The blood pressure increase may be noticeable in a woman with hypertension. Both diabetes and hypertension are "relative contraindications" to the use of birth control pills. If the blood pressure, or the diabetes, is well-controlled, then the pill may be appropriate (preferably a low estrogen formulation). If not, then it is not prudent to use estrogen-containing products.

Adverse effects due to estrogen: nausea (may help to take in evening or at bedtime), breast tenderness/fullness, bloating, weight gain or elevated blood pressure. Almost everything in pharmacy is dose-related. If low-dose estrogen pills are used, or if insufficient estrogen, then early or mid-cycle breakthrough bleeding can occur and may require higher estrogen dose (wait at least 3 cycles before switching).

 

Adverse effects due to progestin: generally less SE than estrogen, but does cause late-cycle breakthrough bleeding. Other events include "mental – they don't feel right", fatigue, breast tenderness, headache.

39

A 24 year-old female patient uses the following medications on a daily basis: Ortho Tri Cyclen (for contraception), sertraline (for depression) and buspirone (for anxiety). She complains of nausea and weight gain. Which of the following statements represents the most appropriate course of action?

A. Change the sertraline to citalopram.
B. Change the Ortho Tri Cyclen to Ortho Tri Cyclen Lo.
C. Change the buspirone to alprazolam.
D. Add meclizine, as needed.
E. Add loratidine, as needed.
 

B. Estrogen can cause nausea, breast tenderness, bloating and weight gain in any formulation (for contraception or hormone therapy). If she finds this method useful for contraception, it may be a good option to use a formulation with lower estrogen content. If this is done and she experiences spotting she may need to go back to the higher estrogen formulation.

Adverse effects due to estrogen: nausea (may help to take in evening or at bedtime), breast tenderness/fullness, bloating, weight gain or elevated blood pressure. Almost everything in pharmacy is dose-related. If low-dose estrogen pills are used, or if insufficient estrogen, then early or mid-cycle breakthrough bleeding can occur and may require higher estrogen dose (wait at least 3 cycles before switching).

 

Adverse effects due to progestin: generally less SE than estrogen, but does cause late-cycle breakthrough bleeding. Other events include "mental – they don't feel right", fatigue, breast tenderness, headache.

40

Ruth has started to use the oral contraceptive Ortho Tri-Cyclen. There are some antibiotics/antifungals that can reduce the efficacy of birth control pills. Which of the following medications would not interact with oral contraceptives?

A. St John's wort
B. Smoking
C. Rifampin
D. Topiramate
E. Levofloxacin
 

E. Levofloxacin does not interact with birth control pills. Use back-up (condoms and spermicide) while using an interacting medication.

Decreases hormone efficacy:

ABX: rifampin, rifapentine, rifabutin

Anticonvulsants: barbiturates, carbamazepine, oxcarbazepine, phenytoin, topiramate, felbamate

St. John's wort, several protease inhibitors and NNRTIs, bosentan (Tracleer), mycophenolate (CellCept), mycophenolic acid (Myfortic)

41

An ovulation predictor test kit is positive if this hormone is present in the urine:

A. Progesterone
B. Follicle-stimulating hormone
C. Thyroid-stimulating hormone
D. Luteinizing hormone
E. Ethinyl estradiol
 

D. Ovulation predictor test kits are used to increase the chances of pregnancy; if positive, the luteinizing hormone (LH) surge has occurred and it is best to have intercourse the day of the LH surge and for two days afterwards.

LH surge is what causes ovulation and release of the egg.

42

A pharmacist is filling a prescription for clomiphene for a woman who is attempting pregnancy. Which of the following statements regarding clomiphene are correct? (Select ALL that apply.)

A. This medication can cause hot flashes, which may be bothersome and can make you feel sweaty and flushed, including during sleep.
B. This medication can cause nausea.
C. This medication is a selective estrogen receptor modulator.
D. This medication is a synthetic form of estradiol.
E. If you are going to be sitting or lying down for a long period of time, such as in an airplane, get up regularly and walk and exercise your calves.
 

A, B, C, E. This medication is a selective estrogen receptor modulator (SERM); which are estrogen agonists in some tissues, and estrogen antagonists in others. Raloxifene is another SERM.

Infertility Drugs

clomiphene (Clomid, Serophene): a selective estrogen receptor modulator (SERM). SE: hot flashes, ovarian enlargement, abdominal bloating/discomfort, blurred vision, headache, fluid retention. Best treatment for hot flash is estrogen.

43

Greg is dispensing ulipristal to a young woman. What are the differences between ulipristal and levonorgestrel?

A. Ulipristal is indicated for up to 10 days after unprotected intercourse.
B. Ulipristal and levonorgestrel EC products are both over-the-counter to people 17 and older.
C. Ulipristal does not cause nausea.
D. Ulipristal is pregnancy category C.
E. Ulipristal can prevent implantation in the uterus.
 

E. Ulipristal (Ella) requires a prescription. Ulipristal works primarily by delaying ovulation, but it may also prevent implantation in the uterus-this mechanism is more controversial than levonorgestrel.

Ella (ulipristal) can also be used up to 5 days after intercourse, while levonorgestrel is only indicated for 3 days after intercourse.

44

If a woman takes levonorgestrel EC while pregnant, what is expected to happen? (Select ALL that apply.)

A. The EC could cause infertility.
B. The EC will terminate the pregnancy.
C. The EC could cause birth defects.
D. The EC will not affect her future fertility, nor will it terminate an established pregnancy.
E. She will need to consider how the unprotected sex occurred, in order to reduce future risk.
 

D, E. EC will not end an existing pregnancy or cause birth defects. EC contains the same hormones as regular birth control pills, and women's bodies also produce these hormones naturally during pregnancy. Exposure to EC does not threaten an existing pregnancy.

45

A young woman went on a weekend trip with her boyfriend and forgot her pill packet. She missed taking her birth control pills during days 18th-20th. The woman has come into the pharmacy to get her next month's packet, which is ready for pick-up. Choose the correct advice the pharmacist should relate to the patient:

A. Report at once to the doctor to get a pregnancy blood test.
B. Continue to take the old packet, take the placebo week as usual, and begin the new packet on time. Try not to miss future pills.
C. Use back-up contraception for 14 days.
D. Use back-up contraception for 30 days, then start the new packet.
E. Do not use the "placebo week" (or sugar or "dummy" pills); go ahead and begin the new packet.
 

E.

If pills were missed in the last week of hormone pills, days 15-21 of a 28-day pack, omit the hormone-free week by finishing the hormone pills in current pack and start a new pack the next day. If unable to start a new pack, use back-up until hormonal pills from a new pack are taken for seven consecutive days.

Decks in Pharmacy Class (61):