BC Flashcards
(78 cards)
1
Q
Oral Contraceptives (OCPs)
A
-HISTORY IS ESSENTIAL
COMPLIANCE IS IMPORTANT (can they remember to take a pill every day)
HEALTH CONSIDERATIONS (Some work better with certain OCPs)
-Combo of Ethinyl Estradiol (EE) and Progestin
-EE always same; Progestin varies
2
Q
Reproductive Cycle
A
- average 28 dys
- day 1, 1st day of period
- two phases: Follicular and Luteal
- without ovulation pregnancy cannot occur!
3
Q
Follicular Phase
A
- days 1-14/ or day 1 - ovulation
- anterior pituitary releases FSH which causes eggs to begin to mature
- start with 5-7, end up w/ 1 (maybe 2) dominant follicules
- follicules secrete estrogen which promotes growth of uterine lining
- when estrogen levels reach a certain point LH secreted from anterior pituitary finalizes follicule development, ovulation occurs
4
Q
Luteal Phase
A
- day 14-28/ or ovulation - next period
- site of ovulation becomes corpus luteum and secretes progesterone for impending pregnancy until a placenta takes over at 10 weeks
- if no fertilization, loss of feedback and CL disintegrates
- lack of progesterone causes shedding of uterine lining
5
Q
OCPs (PHASIC)
PTS
A
- 1st choice orthotricyclen – young women and non-smokers; Less effective in those who weigh 160 lbs (need more estrogen/progestin)
- Yasmin – Increases POTASSIUM and can cause MOOD SWINGS
- Seasonique – Best for short periods of time i.e. wedding; vacation
- Contraceptives DO NOT prevent STDs
6
Q
OCPs
CONTRA
A
- Hx of CV ischemia: MI/Stroke, Atrial Fib, Heart Failure, Previous blood clot (clotting cascade)
- Ovarian or breast cancer
- Smoker >35
- Pregnant
- Uncontrolled HTN
- Liver tumors/disease (NO OC)
- Undiagnosed vaginal bleeding
- Hx of Classic migraine (WITH aura)
7
Q
- (OCP) Monophasic:
- (OCP) Biphasic:
- (OCP) Triphasic:
A
(OCP) Monophasic:
- One level of hormones for the cycle
- Constant dose of estrogen and progestin for 21 days
(OCP) Biphasic:
- Two combos of estrogen/progestin
- Progestin increases in steps
- Estrogen is altered during cycle
(OCP) Triphasic:
- Three combo of estrogen/progestin
- Progestin increases in steps
- Estrogen is altered during cycle
8
Q
OCPs (Phasic)
MOA
A
- Combined estrogen/progestin work to suppress the release of FSH and LH
- Combined prevents ovulation;
- Always the same: Can prescribe ANY drug
9
Q
OCPs (Phasic)
PTS
A
- Hx: Migraine (no aura)
- Uterine fibroids
- Heavy menses
- HTN
- Fibrocystic breasts
10
Q
OCPs (Phasic)
SE
A
-Estrogen can cause blood coagulation by increasing platelet aggregation
11
Q
OCPs (Phasic)
Consider
A
- Causes endometrium to be less hostile to environment
- Start with low dose for lowest risk.
- HOWEVER, weight can be a factor. >160 lbs will need higher dose
12
Q
Progestins
A
- 4 generations
- vary amount
- Androgenic=testosterone
- more Androgenic=acne, bloating, hiruitism
- newer progestin have less androgenic
- not progesterone
- inhibits ovulation by supressing release of LH
- thickens cervical mucus (cleariod)
- hostile environment for implantation
13
Q
Estrogen
A
- Ethinyl Estradiol (EE)
- EE always same
- supresses FSH and LH
- decreases fertilization time
- estrogen may decrease production of milk
- fluctuations = migraine (classical w/ aura, no E)
- HX of Cancer, no Estrogen
14
Q
4 Generations of Progestins
A
- vary in amounts of ando; aldactone=Diuretic=Hypokalemia
- 1st=stop lining of uterus from growing; treats endometriosis
- 2nd=thickens uterine lining; doesn’t prevent ovulation. most ando
- 3rd-used in combo; least ando; high clot risk
- 4th=least ando; risk of hyperkalemia; aldosterone antagonist (Yaz, Yasmin); -Yasmin – Increases POTASSIUM and can cause MOOD SWINGS
15
Q
OCPs
Progestin Only
A
- “mini pill”
- Norethidrone (micronor, camila, errin, jolivette), Norgestral (overette)
- 99.5% effective; less effective than combo pill
- Thickens cervical mucus (makes it difficult for sperm to penetrate)
- Creates a more hostile environment for implantation
- Breastfeeding (estrogen may decrease production of milk)
- Needs to be taken exact same time everyday
- If missed, must use back up
- Progestin contraceptives have NO ESTROGEN so they are a choice for women with history of thromboembolic disease.
- More Androgenics = more acni, bloating, hirsuitism
- Newer progestins have less androgenic activity
- Irregular spotting, no menses
- Amenorrhea
- hx of classical migraines (w/ aura)
16
Q
OCPs
Progestin Only
MOA
A
- Inhibits ovulation by suppressing release of LH
- Thickens cervical mucus (makes it difficult for sperm to penetrate)
- Creates a more hostile environment for implantation
17
Q
OCPs
Progestin Only
HORMONES
A
- Derivative of testosterone
- Drosperinone: exception because has aldosterone
18
Q
OCPs
Progestin Only
PTS
A
- Breastfeeding (estrogen may decrease production of milk)
- Hx of blood clots or VTE (venous thrombo embolism)
- Hx of classic migraine
- Smokers
19
Q
OCPs
Progestin Only
SE
A
- More Androgenics = more acni, bloating, hirsuitism
- Newer progestins have less androgenic activity
- Irregular spotting, no menses
- Amenorrhea
20
Q
OCPs
Progestin Only
CONSIDER
A
- Needs to be taken same time everyday
- If missed, must use back up
- Progestin contraceptives have NO ESTROGEN so they are a choice for women with history of thromboembolic disease.
21
Q
OCPs
How to pick
A
- start low dose (lowest risk of SE, 18-25mcg EE)
- low dose better for common migraine (no aura), fibroids, HTN, fibrocystic breasts
- normal dose 30-50 mcg EE
- Triphasic closest to normal cycle, start first
- if more than 160, need higher dose
- monitor weight gain
22
Q
OCPs
Monophasic
A
- EE/ Levonorgestral (Seasonique, Seasonale, Lybrel)
- constant level of hormones
- extended cycle regimens (period q 3 mnoths, 84 dys of EE/progestin
23
Q
OCPs
Start
A
- Quick Start (starts that day, backup for a minimum of 7 days, high risk of breakthrough bleeding 1st month)
- First Day Start (Most Common and Safest, starts first day of next period, NO BACKUP needed)
- Sunday Start (first sunday after period starts, NEED BACKUP for 7 DAYS)
24
Q
OCPs
Follow up
A
- monitor weight gain
- follow up 3 months to 1 yr
- ask about SE, breakthrough bleeding
- SE decrese w/ time (stick with it!)
- breakthrough bleeding early in cycle dy 1-10 or no period during placebo wk=MORE ESTROGEN
- breakthrough bleeding dy 10-21= need MORE or DIFFERENT PROGESTIN
25
OCPs
| RISKS
- migraines, headaches
- INCREASED RISK CVA
- BLOOD CLOTS
- htn
- mood changes
- GALLBLADDER DISEASE (cholesterol production up, progesterone down=affects motility of GI)
- acne
- bloating
- hair loss/ hiruitism
26
OCPs
| BENEFITS
- safe
- bleeding down, anemia down
- less cramping
- predictable cycle
27
OCPs
| ACHES
- Abdominal Pain
- Chest Pain
- Headaches
- Eye Problems
- Swelling/ Aching Legs
28
OCPs
| CANCER
- lower risk of ovarian and endometrial
- little increase risk of cervical
- not linked to breast
- HX of Cancer, NO ESTROGEN!
29
BC and BF
- progestin only pill
| - IUD
30
BC and Migraines
- Common (no aura)=low dose OCP
| - Classical (w/ aura)=no estrogen; Depoprovera ok
31
Ortho Evra “The Patch”
- a progestin (norelgestromin) and an estrogen (ethinyl estradiol)
- Worn for three weeks then one patch free week
- not as effective if you weigh more than 198
- transdermal
- no 1st pass effect=higher EE
32
Ortho Evra “The Patch”
| MOA
- Transdermal:
- inhibition of ovulation
- no 1st pass effect
33
Ortho Evra “The Patch”
| BENEFITS
- Can come off early
| - No need for daily pill, still easily reversible
34
Ortho Evra “The Patch”
| RISKS
- Can come off, decreasing efficacy
- More expensive
- Often visible
35
Depo Provera SQ and IM
- PROGESTERONE ONLY
- **NOT Recommended for women who want to conceive within 1-2 years!!!**
- Progestin only:
- Good with women Hx of blood clots and classical migraine
- weight gain
- High compliance bc EVERY 3 months
- Decreased bone density (increased with duration of use)
- May need BONE SCAN!
- Decreases HDL, increases LDL and total cholesterol
- If dose missed, PREGNANCY test is MANDATORY and must be NEGATIVE
- when given w/in 5 days of period immediately effective
36
Depo Provera SQ and IM
| BENEFITS
- Progestin only:
- Good with women Hx of blood clots and classical migraine
- Minimal drug interactions
- High compliance bc EVERY 3 months
37
Depo Provera SQ and IM
| RISKS
- Weight gain
- Decreased bone density (increased with duration of use)
- May need BONE SCAN!
- Decreases HDL, increases LDL and total cholesterol
38
Depo Provera SQ and IM
| CONSIDER
- If dose missed, PREGNANCY test is MANDATORY and must be NEGATIVE
- Spotting common first few month, most patients amenorrheic
- NOT recommended beyond 2 years
39
Nuva Ring
- 0.12 mg etonogestrel and 0.015 mg EE
- NO BF
- Good for patients who are non smokers and less than 35 years of age
- Bypasses first pass effect
- Absorbed through vaginal mucosa (tampons do NOT affect absorption)
- Can be removed up to 3 hours with no need for back up birth control
- Convenient, no need to remember daily pill
- Effective
- Less chance of breakthrough bleeding
- If out longer than 3 hours, BACK UP METHOD NEEDED FOR 7 DAYS!!
- Increase Risk of Blood Clots
- Can be left in for 4 weeks (note that women may not have menses)
- If left beyond 4 weeks, CHECK PREGNANCY TEST
40
Nuva Ring
| MOA
- Bypasses first pass effect
| - Absorbed through vaginal mucosa (tampons do NOT affect absorption)
41
Nuva Ring
| BENEFITS
- Can be removed up to 3 hours with no need for back up birth control
- Convenient, no need to remember daily pill
- Effective
- less chance of breakthrough bleeding
42
Nuva Ring
| RISKS
- If out longer than 3 hours, BACK UP METHOD NEEDED FOR 7 DAYS!!
- Vaginitis
- Same risk as OCPs, contains ESTROGEN
- Women may be uncomfortable inserting ring
- Some C/O feeling ring when inserted or during intercourse
- Increase Risk of Blood Clots
43
Nuva Ring
| CONSIDER
- Good for patients who are non smokers and less than 35 years of age
- Start within 5 days of LMP
- Ring left in for 3 weeks then out for 1 week
- Can be left in for 4 weeks (note that women may not have menses)
- If left beyond 4 weeks, CHECK PREGNANCY TEST
- NO BF
44
Implanon/Nexplanon
- 68 mg etonogestrel
- Inserted within 5 days of LMP
- Nexplanon-easier insertion, can be located w/ x-ray
45
Implanon/Nexplanon
| MOA
- Implanted rod
| - Inserted in upper arm, medial surface 6-8 cm from elbow in bicep groove
46
Implanon/Nexplanon
| BENEFITS
- Rarely can migate
| - Provides contraception for 3 years
47
Implanon/Nexplanon
| RISKS
- Cause weight gain
- Spotting
- Acne
- Mood Changes
48
IUDs
- Paraguard, Mirena
- can cause perforation
- expulsion can occur
- check for strings monthly
- effective immed if placed w/in 5 days of LMP
- BF OK
- Speculum search before US
- good for young people bc nothing to remember
49
Mirena
| MOA
(Progestin)
- Plastic: Some inflammation, but also atrophies uterine lining
- Suppresses LH and ovulation
50
Mirena
| Benefits
Good for 5 years
51
Mirena
| RISKS
Spotting common but eventually becomes amenorrheic
52
Paragurd
| MOA
Copper wire; local inflammation reaction to prevent implantation
53
Paragurd
| BENEFITS
- ParaGard contains no hormones of any kind
| - only non-hormonal birth control method around
54
Paragurd
| RISKS
May have heavy bleeding and cramping during the first few weeks
55
Emergency Contraceptive
- Contains 1.5 Levonorgestrel (progestin)
- Thickens cervical mucus, may prevent ovulation, implantation, if ovulation has already occurred
- Available OVER THE COUNTER (Cost prohibitive)
- DOES NOT work if patient is already pregnant
- Take as soon as possible after unprotected intercourse
- Can provide prescription which will reduce cost and covered by most insurances
- IUD can be used as an Emergency Contraceptive
56
Emergency Contraceptive
| MOA
- blocks ovulation
- Thickens- cervical mucus, may prevent ovulation, implantation, if ovulation has already occurred
- Take as soon as possible after unprotected intercourse
57
Emergency Contraceptive
| BENEFITS
- Available OVER THE COUNTER (Cost prohibitive)
| - PLAN B more EFFECTIVE than YUZPE (estrogen based)
58
Emergency Contraceptive
| RISKS
- DOES NOT work if patient is already pregnant
- No known harm to fetus if taken when pregnant
- YUZPE has ESTROGEN: will need to prescribe Meclizine or Reglan
59
Best PT for Nuvaring?
-forgetful (young)?
60
Nuvaring out for more than 3 hrs
BACK UP METHOD NEEDED FOR 7 DAYS!!
61
>160 lbs
-orthotriclen not good
62
Know that if a patient has started oral contraceptives and start to spot
- If within first 1-10 days MORE ESTROGEN
| - If 10-21 days, MORE PROGESTIN
63
why you don’t prescribe DEPO
-**NOT Recommended for women who want to conceive within 1-2 years!!!**
-Weight gain
-Decreased bone density (increased with duration of use)
May need BONE SCAN!
-Decreases HDL, increases LDL and total cholesterol
-Spotting common first few month, most patients amenorrheic
-NOT recommended beyond 2 years
64
using Mirena
-Either can cause perforation, especially with insertion
-Expulsion can occur, most common in first month
-Advise women to check strings monthly
-If cannot feel strings, NEED EVAL
-Placed within 5 days of LMP, effectively IMMEDIATELY
Plastic: Some inflammation, but also atrophies uterine lining
-Suppresses LH and ovulation
Good for 5 years
-Spotting common but eventually becomes amenorrheic
65
relationship between estrogen and blood coagulation
- clotting cascade
| - blood clots
66
5 absolute contraindication to COMBINED ORAL CONTRACEPTIVE THERAPY
- history of blood clots, history of ischemic MI, a fib
- history of ovarian cancer
- history of ischemic stroke
- smoker >35
- uncontrolled HTN
67
A DECREASE in estrogen in oral contraceptives will lead to
INCREASE in bleeding/spotting.
68
Family history of breast cancer
NOT a contraindication. Educate the risks.
69
ESTROGEN
DECREASES FSH AND LH
70
BF BC
PROGESTERONE ONLY
71
4TH GENERATION PROGESTERONE
YAZ/YASMIN
HYPERKALEMIA
ALDOSTERONE ANTAGONIST
72
BLEEDING DAYS 1-10
MORE ESTROGEN
73
QUICK START
START THAT DAY
| BACK UP WHOLE MONTH
74
ESTROGEN AND CLOTTING CASCADE
Estrogen containing oral contraceptives increase the plasma concentration of clotting factors II, VII, X, XII, factor VIII, and fibrinogen. Estrogen, like many lipophilic hormones, affects the gene transcription of various proteins. Thus, estrogen increases plasma concentrations of these clotting factors by increasing gene transcription.Higher doses of estrogen appear to confer a greater risk of venous thrombus formation. This can be explained by a greater degree of nuclear receptor binding and overall activation of gene transcription for these clotting factors.
75
5 CONTRA
- Hx of CV ischemia: MI/Stroke, Atrial Fib, Heart Failure, Previous blood clot (clotting cascade)
- Ovarian or breast cancer
- Smoker >35
- Pregnant
- Uncontrolled HTN
- Liver tumors/disease (NO OC)
- Undiagnosed vaginal bleeding
- Hx of Classic migraine (WITH aura)
76
DEPO PROVERA
BONE DENSITY
77
NUVA RING
OUT LONGER THAN 3 HRS, BACKUP 7 DAYS
78
IUD
WOMAN CHECKS STRING MONTHLY
| IF SHE CANT FIND, COMES IN FOR PELVIC EXAM
