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Endo/Repro Block2 > Contraception > Flashcards

Contraception Flashcards

1
Q

What is method effectiveness?

What is user effectiveness?

A

method: theoretical effectiveness if utilized perfectly

**user: **actual effectiveness when studied in a non-perfect world

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2
Q

What is natural methods of BC?

What is required for this to work?

A

avoid sex &/or ejaculation around time of ovulation to prevent conception

NEED: a female with regular cycles

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3
Q

How do we determine a woman’s fertie window?

A

Ovulation is 14 days PRIOR to 1st day of menses

  • subtract 18 days from length of shortest cycle
  • subtract 11 days from longest cycle

avoid intercourse 5 days b4 and 3 days after ovulation

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4
Q

Descirbe how the following can aid in ovulation tracking:

temp

cervical mucous

A

temp: raises basal temp at least 0.5 F due to progesterone [after ovulation]

mucous: @ ovulation = most abundant, watery, has consistency of egg whites

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5
Q

What is the best form of STI protection?

A

condoms!!

male is more effective than female

***most effectiveif used with spermicide [nonoxynol-9]

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6
Q

The diaphragm…what are some caveats to keep in mind with it?

A
  • needs to be fitted to pt by a trained doctor
  • decreases STI’s but does not prevent
  • ^^^ UTIs
  • MUST leave in at least 6 hrs post coitus, insert 2 hrs prior to coitus [<24 hrs total]
  • MUST be refit to pt if: greater than 10lb weight change, pregnancy since last fitting, pelvic surgery
  • MUST be pt who is comfortable doing a self exam
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7
Q

What are some caveats with the CERVICAL CAP method

A
  • similar to diaphragm; MUST be fitted by physician, be ok w/ self exams, & leave in 6 hrs post sex [max of 48 hrs]
  • harder to fit & use
  • usually an option if pt is having UTI problems w/ diaphragm
  • ^^ risk of toxic shock
  • ^^risk of cervical dysplasia????
  • BEST in primiparous women
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8
Q

How does the “sponge” work?

what are some caveats with this?

A

sponge: circular disc w/ nonoxynol9 [spermicide] in it, moisten w/ tap water & insert

  • leave in place up to 24 hrs
  • less effective than other methods
  • ^^rate of yeast infxn, UTIs, 7 TSS if left in place for extended period
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9
Q

What type [class] of contraception is spermicide classified as?

how does it work?

A

Actually is part of barrier method category

  • damages cell membranes of sperm & bacteria
  • Risks:
    • topical irritation
    • best if used with condom or diaphragm
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10
Q

How do the combined estrogen/progesterone BCs work?

A

1’ mechanism is E/P induced inhibition of midcycle LH surge–>inhibits ovulation

  • estrogen inhibits FSH
  • Progesterone inhibits LH
  • also prevents sperm penetration by changing cervical mucous consistency
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11
Q

what are the absolute contraindications for using a combo P/E BC?

A
  • previous thromboembolic event/stroke
  • Hx of CAD
  • Hx of E dependent tumor
  • liver disease
  • pregnancy
  • unDx’d abnormal uterine bleeding
  • smoker over 35 yo
  • migraine HA’s w/ neuro Sx’s
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12
Q

What are some relative contraindications for E/P use?

A
  • obesity
  • inherited thrombophilias
  • anticonvulsant therapy
  • migraine HA’s
  • HTN
  • Depression
  • Lactation
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13
Q

What are some benefits [aside from BC] of E/P combo?

A
  • Reduction in dysmenorrea
  • Reduction in menorrhagia
  • Reduction of ovarian, endometrial, and colorectal cancers
  • Improves acne
  • Improves benign breast disease
  • Improves osteopenia or osteoporosis
  • Decreases functional ovarian cysts
  • Decreases ectopic pregnancy rates
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14
Q

What are the risks of combo E/P?

A
  • ^^ thromboembolic event
  • breast cancer risks [controversial]
  • cervical cancer risk
  • medication interxns [antimicrobials like rifampin, anticonvulsants, HIV drugs, herbal produx like St. Johns Wort]
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15
Q

What are the forms of E & P in combo oral bC?

A

Estrogen: ethinyl estradiol 10-50mcg

Progesterone:
–First Generation: norethindrone, norethindrone acetate, ethynodiol diacetate
–Second Generation: levonorgestel, norgestrel
–Third Generation: norgestimate, desogestrel
–Spironolactone analogue: drospirenone
–Latest iteration: dienogest

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16
Q

What are some androgenic SE’s?

What are some general SE’s?

A

Androgen SE: ^^LDL +/- decreased HDL, Acne, hirsutism

General SE: breast tenderness, N, HA, mood changes [-], irregular bleeding/spotting, weight change/fluid retention

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17
Q

Can you tell me about 1st & 2nd generation progestins?

A

Norethindrone- least androgenic of the grp

  • Slight improvement in lipid profile which is different than other 1st/2nd gen.
  • More androgenic than newer progestins

Levonorgestrel is the most widely perscribed

  • In many formulations including Plan B and extended cycle pills as well
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18
Q

How is 3rd gen different than others?

A

Norgestimate and desogestrel

  • Less androgenic effect
    • good choice for pts with dyslipidemia, acne or other possible androgenic SE’s
  • Higher thromboembolic potential
  • 2-3 X higher than first or second generation progestins
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19
Q

What is drspirenone?

A

a spironolactone analog!!!

  • both antimineralC & lower androgenic effects
  • benefits: improves weight stability/h2o retention & other androgen SE
  • downfalls: may ^^serum K+ [contraindicated in certain pts]

***new warning regarding VTE risk

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20
Q

What is dienogest?

A

latest & greatest Progestin

  • 4 phase
  • marketed for metromennorhagia
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21
Q

Whats the difference b/w …

monphasic

biphasic/triphasic

extended cycle?

A

_Monophasic _Same fixed dose for three weeks, then placebo week
Biphasic, Triphasic, +

  • Varying doses through first three weeks then placebo week
  • Similar SE profile to monophasics

Extended cycle (i.e. Seasonale / Lybrel)

  • Seasonale & Seasonique: 84 days fixed dose hormones then placebo week
  • Lybrel (Amethyst): Fixed dose of estrogen/progestin 365 days/yr
  • Breakthrough bleeding more common, but decreases over time
  • ? Whether increased amount of hormone exposure over time will lead to greater long term side effects
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22
Q

How do we prescribe the right pill?

A

–Start with low to moderate dose estrogen with most appropriate progestin considering co-morbid conditions
–Allow at least 2-3 cycles to assess
–Adjust based on side effects
–Follow-up based on side effects and co-morbid conditions

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23
Q

How/when should a pt take the pills?

How should the physician followup?

A

ADmin:
–First day of menses vs. Sunday start vs. quick start
–Same time of day every day
–Missed pills- what to do?
Follow up:
–Blood pressure check
Side effects and overall tolerance of pil

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24
Q

What is the quick start approach?

What are the benefits to this method?

A
  • If last menstrual period (LMP) was within the last 5 days, the method can be started immediately.
  • if LMP was > 5 days ago and a pregnancy tests (-), assess the last episode of unprotected sex to determine if EC required (or immediately insert copper IUD).
  • Instruct women who are using the pill, patch, ring, injection, or implant to use backup contraception for the first 7 days.

Benefits: Significantly improves the continuation rate for OCs. [Westoff]
•Produces better compliance at 3 months in adolescents. [Lara-Torre]
•Research shows that there are no significant differences in the number of bleeding-spotting days or any other bleeding parameter between the immediate and conventional starters

25
Q

What are some common SE’s to combo EP BC?

How do we Tx each one?

A

breakthrough bleeding:

  • in 1st 10 days, increase estrogen
  • after 10 days, increase progestin

no w/drawal bleed:

  • do preg test, continue pills
  • if pt wants menses to return, then ^^E

typical Hormone related SE’s

  • adjust approprote hormone component
26
Q

how does the nuvaRing [or any other brand vaginal ring] work?

What hormones are involved?

A

Combo E/P too!!!

  • 15 mcg ethinyl estradiol & 120mcg of etonogestrel daily
  • wear intravaginally for 3 weeks, then out for one wk
27
Q

What should you do if the vaginal ring falls out?

What if you leave it in too long?

A
  • out <3hrs= rinse and replace
  • out >3hrs = replace and use backup contraception

How long in place?

  • in place 3-4 weeks, give a week off and then replace
  • if in place >4wks= one week off and use backup contraception for @ least 1 week once replaced
28
Q

How does vaginal ring compare to oral OCP’s?

A
  • comparable efficacy
  • lower dose of hormones
  • rapid return to ovulation
  • ease and convenience
  • eimlar SE’s and contraindications
  • Plastic NOT latex
29
Q

How do you use the Patch?

  • which hormones involved
  • when should a backup contraceptive be used?
A

Another combo E/P!

  • 20 mcg ethinyl estradiol & 150 mcg of norelgestromin daily
    • through the skin [butt, abd, arm, or torso– NOT breast]
  • change patch 1x wk for 3 weeks, then go 1 wk patch free
  • use backup method when:
    • on for >9days
    • off for >7days
    • falls off >24 hrs
30
Q

how does the patch compare to OCP’s

A
  • similar efficacy overall
  • greater fail rate in women >90kgs
  • better compliance
  • more breakthrough bleeding, breast discomfort, dysmenorrhea, site rxns
  • FDA warns that patch gives off more estrogen than most OCPs…
    • imlication for long term???
31
Q

How does P only BC work?

Why would we use these/who do they benefit?

A

1’ mechanism is inhibition of ovulation

-progestin effect also causes changes of cervical mucous–> decreased sperm transport and implantation

Pt’s who want effective contraception but want/need to avoid estrogen!!

  • medical contraindications to combo OCP
  • SE to combo options that are prohibitory
  • nursing
32
Q

Progesterone only BC and issues/SE’s to consider?

A
  • Irregular bleeding
  • Other SE’s from androgenicity
  • Duration of effect and return to fertility –>??
  • Chance of breakthrough ovulation if “pill missed ” with oral formulation
  • Effects on bone health
33
Q

What are the benefits of P only OCP?

  • How should a pt take the oral “minipill” drug?
A
  • eventual redxn on menses flow
  • NO ^^risk of stroke, MI or TE event
  • reduced risk of endometrial cancer and PID [w/ Depo/medroxyprogest. acetate]

Admin

  • 1st day menses vs. Sunday start vs. immediate
  • take daily like combo pill, at same time every day
    • ****timing **is critical –>must be taken w/in 3 hrs of normal time otherwise backup contraception is needed**
  • no w/drawal bleed week
  • highe failure rates
34
Q

How does the injectable form of P only work?

What is one of the major concerns/SE’s of this?

A

aka medroxyprogesterone acetate [DEpo-provera]

  • IM injexn every 3 months
  • start w/in 5 days of 1st menstrual day

SE’s BONE HEALTH!!!

  • bone resorption & redxn in BMD due to induced estrogen deficiency
  • will normalize in healthy pts once DMPA is discontinued
  • limit use to 2 years [recommended]
  • if longer, BMD needs 2 be followed, & Ca+ & w8 bearing exercise prescribed
  • *****BLACK BOX WARNING ??? idk what for
35
Q

P only implants…how do they work?

A
  • rods are implanted subQ under skin & removed once no longer effective
    • Implanon/nexplanon [etonogestrel]
      • 1 rod, lasts 3 yrs & FDA approved
    • Jadelle [levonorgestrel]
      • 2 rods, lasts 5 yrs (not available in US)
36
Q

What is the possible future of hormonal contraception?

A

MALE HORMONAL CONTRACEPTION!

  • still developing
  • hope to use testosterone +/- GnRH analogs or P to suppress spermatogenesis
37
Q

What is the definition of emergency contraception?

what is the main mechanism for EC’s?

Significant risk?

A

prevention of pregnancy w/in 72-120 hrs of unprotected sex or failure of a contraceptive method

MOA: depends on time w/in menstrual cycle…

  • can inhibit ovulation OR
  • prevent fertilization

****greater possibility of post-fertilization effect [endometrial changes inhospitable to fertilized ovum]

38
Q

Will a hormonal EC abort an established pregnancy?

A

NO

39
Q

What is the main hormone of Plan B?

HOw effective is Plan B?

What is the difference b/w 2 step & 1 step?

A

MOA: P only

effectiveness:

  • 95% effective if used w/in 24hrs of unprotected sex
  • 89% if used w/in 72hrs

Two Step: 1 tablet w/in 72 hrs of unprotected sex, take 2nd tablet 12 hrs later

One step: take w/in 72 hrs of unprotected sex

***Available OTC to ALL ages since June 2013

40
Q

What is different about Ella EC?

A

newest formulation of EC that uses P agonist/antagonist

  • can use up to 120 hrs [or 5 days] after unprotected sex!!!***
  • SE’s: HA, N, abd discomfort, dysmenorrhea, fatigue, dizzy
41
Q

COmbo pill packs of EC…

how are they taken?

major SE?

A

combo pill packs = E + P

  • depending on E/P dose, take 2-4 pills w/in 72 hrs and repeat dose in 12 hrs
  • may cause N!! premedicate if necessary
42
Q

What are some issues to remember about EC?

What is the biggest one?

A
  • can reduce risk of pregnancy by 75-95%
  • politically controversial
  • state/pharmacy variability in availability

****BIGGEST issue is: **remember to counsel **repro age sexually active women about this option

43
Q

What is the MOA and duration of effectiveness for each of the following:

Copper IUD [Paragaurd]

Mirena

Skyla

A

copper IUD: pre-fertilization effect

  • induces foreign body rxn in endometrium–>inflam response–> prevents sperm 4m reaching fallopian tubes
  • lasts 10 years!!

Mirena (slow release P: levonorgestrel)

  • inhibits ovulation & sperm survival/implantation
  • lasts 5 yrs
    • ***other benefits: decreases menses blood loss & relieves dysmenorrhea

Skyla: low dose levonorgesterel, lasts 3 yrs, approved for nulliparous women

44
Q

Who are good candidates for copper IUD?

For LNG IUD (mirena, skyla)

A

copper:

  • want more regular periods
  • no hormones
  • no Hx of dysmenorrhea, or menorrhagia

LNG IUD:

  • ok w/ irregular bleeding
  • ok w/ amenorrhea
  • Hx of dysmenorrhea or menorrhagia is ok
45
Q

Do IUDS cause PID?

A

NO, incidence is similar to general population

  • risk is ^^only during 1st month after insertion
  • preexisting STI at time of insertion, not iud itself, ^^risk
  • RULE OUT GC/Chlamydia prior to insertion
  • IUDs DONT cause infertility
46
Q

What are contraindications for IUDs?

A
  • pregnancy
  • congenital or acquired uterine cavity malformation
  • acute STD, cevicitis or vaginitis
  • postpartum endometritis or infected abortion w/in 3 months
  • known or suspected uterine or cervical neoplasia
  • unresolved abnormal pap
  • genitl bleeding of unknown cause
  • acute liver disease
  • immunodeficiency states
  • Hx of previously inserted IUD that hasnt been removed, allergy of Cu+, known or suspected breast carcinoma
  • artificial heart valves
  • Wilsons disease [for paragaurd]
  • sensitivity to levonorgestrel
47
Q

Is sterilization permanent?

how is tubal ligation performed?

how is vasectomy performed?

A

You should consider it permanent…although som reversible procedures exist they have limited success and come with many issues

tubal ligation: laparoscopic procedure or during Csxn/postpartum

  • most SE’s are related to surgery
  • post tubal ligation: ^^risk for ectopic pregnancy [if preg does happen] & decreased risk of ov.Ca

Vasectomy: in dr office under local anesthesia

  • safe & effective [and cheaper than female sterilization]
  • multiple diff techniques
48
Q

What are non-surgical methods of tubal ligation?

What is a caveat of this type?

What is a major contraindication for NSTL?

A

transcervical implants!!!

Essure: microinserts placed into proximal fallopian tubes–>expand & tissue grows around them=occlusion

Adiana: low level radiofrequency delivered to fallopian tubes= lesion

  • microinserts placed in fallopian tubes

**although less invasive [faster recovery w/ less discomfort], 3 mo backup contraception is needed

Contraindication: woman who has delivered a baby, miscarried, or had an abortion w/in **6wks for Essure **or 3 months for Adiana

49
Q

What are the adverse side effect for vasectomy?

What should be part of follow up for vasectomy?

A

SE: mostly procedure related

Follow up: MUST have semen analysis to assure no motile sperm***

  • approx 20 ejaculations or 3 months following?
  • need to use other form of contraception until cleared

**risk/benefit ratio is in favor of vasectomy over tubal ligation

*****3 months of other form of contraception should be used

50
Q

What is an immediate form of EC?

A

insert a copper IUD

51
Q

What are the 3 targets of hormone contraception?

A
  1. Ovary = 1’ MOA
    • GnRH & LH/FSH suppression hence inhibition/delay of ovulation [no follicle development & no LH surge]
    • combo E/P = 95-99% effective
    • low level P only: 50% med & high level Ponly preps 94-99%
  2. Cervix = backup
    • viscosity of cervical mucous doesn’t promote sperm transit into uterus
    • all preps do this. P ^^ viscosity most
  3. Uterus = back up of the back up
    • causes thin endometrial lining, not supportive of preg if fertilized inspite of 1 or 2
    • all methods likely do this
52
Q

Describe hormone levels of women on BC compared to:

non-preg menstruating female

a pregnant female

A
53
Q

One more time: summary of MOA for hormonal contraceptives?

A
  1. No ovarian cycle
  2. Inhospitable cervical mucous
  3. Lackluster uterus
54
Q

39 yo G2P2 postpartum visit

nursing still, healthy

Doesnt know if she wants another child…contraception options?

A

DON’T offer: combo E/P drugs since nursing

DO: P only [minipill] unless (+) she doesnt want another kid–> then talk about TL etc

**stay away from Depo??

55
Q

17 yo in for PE

sexually active [2 previous partners, current BF of 4 mo]

uses condoms “when remember”

generally healthy [irr menses, mild depression in past w/o meds]

contraception options?

A

Possibilities:

  • Depo might be good for her–>delays return to fertility
  • IUD would be a good long-term option

***BIGGEST thing: educate her about protxn, condom use, STI prevention

56
Q

25 yo med student

long term relationship [1 previous partner]

no Hx of STIs

HX of migraine HAs, otherwise very healthy

wnats to get thru boards b4 talking marriage/future

CONTRACEPTION OPTIONS?

A

IUD are great options here

CAUTION: E might b an issue here–>due to migraines–> if no aura, then could do a combo pill but must monitor it

57
Q

44yo G3p3003

married w/ Hx of fertility problems (now “done” having kids)

overweight, no Hx of STIs

mild HTN controlled w/ ACEi

hypercholE–>on statin

CONTRACEPTION OPTIONS?

A

POSSIBILITIES:

  • TL or vasectomy are great option
  • if financial issues/sterilization concerns= could do P only
    • watch androgenic effects on lipids
  • could do Paragaurd –> watch for really heavy periods

CAUTION: HTN is an issue for E use

58
Q

37yo G4P4

3rd marriage

Hx of PID @ age 23

smokes 1.5 p/day

depression–>takes SSRI

uses condoms

CONTRACEPTION OPTIONS?

A

POSSIBILITIES:

  • paragaurd
  • implant

NO:

  • E since over 35 and smoker
  • P +/- E, both can have mental health implications/changes–> monitor

***counsel on STI protxn

59
Q
A

Endo/Repro Block2 (11 decks)

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