Chapter: Contraceptive/ Preg Flashcards
MENSTRUAL CYCLE PHASES
What are the phases of menstrual cycle?
The typical menstrual cycle lasts 23 to 35 days, with an average of 28 days. Day 1 of the cycle begins with the start of bleeding (menses), marking the shedding of the previous cycle’s thick, bloody endometrial lining.
Fertility Awarness: What role does the surge of luteinizing hormone (LH) play in the menstrual cycle, and how can ovulation kits assist individuals in timing intercourse for conception?
The surge of luteinizing hormone (LH) in the middle of the menstrual cycle triggers the release of the egg from the ovary into the fallopian tube. The egg remains viable for about 24 hours, while sperm can survive for up to 3 days. Ovulation kits, which detect LH in urine, help predict the best time for intercourse to maximize the chances of conception. It’s recommended to have intercourse when the LH surge is detected and for the next 2 days to align with sperm survival.
Pregnancy
How does human chorionic gonadotropin (hCG) serve as a marker for pregnancy, and what role does the timing of urine testing play in detecting hCG levels?
Human chorionic gonadotropin (hCG) is produced when a fertilized egg implants in the uterus. Its presence in urine or blood confirms pregnancy. Testing urine in the morning, when hCG levels are highest, can enable earlier detection of pregnancy using home tests.
Preconception health aims to safeguard the future baby’s well-being. All women of childbearing age, especially those planning to conceive, should:
- Take 400 mcg/day of folic acid to prevent neural tube defects, obtainable from fortified foods, supplements, or a diverse diet including beans, greens, and oranges.
- Cease smoking, illicit drug use, and excessive alcohol consumption.
- Maintain up-to-date vaccinations to prevent illnesses harmful to the baby, like toxoplasmosis.
- Avoid exposure to hazardous chemicals, including drugs listed by NIOSH.
EFFECTIVENESS OF CONTRACEPTIVE METHODS
NON-PHARMACOLOGIC AND OTC CONTRACEPTIVE METHODS
TEMPERATURE AND CERVICAL MUCUS
METHODS
Tracking body temperature and cervical mucus helps avoid pregnancy by identifying fertile days to abstain from intercourse. Basal body temperature predicts ovulation, typically ranging from 96-98°F before and 97-99°F during ovulation. This data, recorded on a calendar, predicts future ovulation. Natural Cycles, an FDA-approved app, assists in this tracking and prediction process.
NON-PHARMACOLOGIC AND OTC CONTRACEPTIVE METHODS
BARRIER METHODS
Barrier contraception methods like condoms, diaphragms, caps, and shields physically block sperm from reaching the egg, offering non-pharmacological options for contraception.
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Diaphragms, caps, and shields are soft latex or silicone barriers that cover the cervix to prevent sperm from passing through, and they can be used with or without spermicide. The Caya diaphragm, a single size option, doesn’t require fitting. Condoms, whether male or female, are over-the-counter and offer protection against many STDs (with latex or synthetic condoms, not “natural” sheepskin). Using nonoxynol-9 spermicide with condoms can increase STD/HIV transmission risk. Lubricants reduce friction and prevent condom breakage; water or silicone-based lubes are recommended, while oil-based ones are not.
HORMONAL CONTRACEPTIVES
HORMONAL CONTRACEPTIVES: General info - What are the mechanisms and differences between progestin-only and estrogen/progestin hormonal contraceptives? Also, what health benefits do they offer, and what information is provided in the Patient Package Insert (PPI) accompanying oral contraceptives?
Hormonal contraceptives inhibit FSH and LH production, preventing ovulation and altering cervical mucus to hinder sperm penetration. They include progestin-only options (pill, injectable, implant, and IUD) or estrogen/progestin combinations (pill, patch, and vaginal ring). Hormonal contraceptives offer health benefits such as reducing menstrual pain, irregularity, endometriosis, acne, ectopic pregnancy, and risk of certain cancers. They come with a Patient Package Insert (PPI) for safety information, proper use instructions, and guidance on missed pills.
ESTROGEN AND PROGESTIN COMBINATION ORAL CONTRACEPTIVES
What are the key components and variations in formulations of Combination Oral Contraceptives (COCs)?
Combination Oral Contraceptives (COCs) typically contain ethinyl estradiol (EE) and a progestin like norethindrone, levonorgestrel, or drospirenone. They come in monophasic, biphasic, triphasic, or quadriphasic formulations. Monophasic pills maintain consistent hormone levels, while multiphasic pills mimic hormone fluctuations during the menstrual cycle, with the number of phases indicating how often hormone levels change. For instance, “Tri-Sprintec” denotes a triphasic pill with three hormone cycles.
ESTROGEN AND PROGESTIN COMBINATION ORAL CONTRACEPTIVES
What distinguishes drospirenone from other progestins in Combination Oral Contraceptives (COCs)
Drospirenone, a distinct progestin found in some COCs, mitigates common adverse effects associated with oral contraceptives. Its mild potassium-sparing diuretic properties reduce bloating, PMS symptoms, and weight gain. Additionally, drospirenone-containing products are linked to reduced acne due to their anti-androgenic activity. Other progestins with low androgenic activity include norethindrone and desogestrel. Drospirenone can increase risk of hyperkalemia!! so use with caution in drugs that increase K+ (ACEi/ARBs)
What are some other uses of COCs (besides preganacy prevention)
COCc serve various purposes beyond pregnancy prevention. They effectively manage dysmenorrhea (menstrual cramps), premenstrual syndrome (PMS), acne (in females), and anemia by reducing blood loss. COCs are also used to alleviate peri-menopausal symptoms like hot flashes and night sweats, as well as menstrual-associated migraine prophylaxis.
For conditions like polycystic ovary syndrome (PCOS), (often presents with irregular menstrual periods), COCs are the first-line treatment. PCOS can also cause symptoms like hirsutism, acne, excessive weight, insulin resistance, and fatigue.
Furthermore, COCs are the primary treatment for endometriosis, a condition affecting 10-20% of women where endometrial tissue grows outside of the uterus. COCs help reduce symptoms such as dysmenorrhea and heavy bleeding associated with endometriosis.
Additionally, specific medications like Elagolix (Orilissa) are FDA-approved for moderate to severe pain associated with endometriosis. The COC Natazia and the levonorgestrel-releasing IUD Mirena are indicated for heavy menstrual bleeding (menorrhagia). Oriahnn, containing estradiol, norethindrone, and elagolix, is indicated for heavy menstrual bleeding associated with uterine fibroids, although it’s not a contraceptive. Lysteda, an oral formulation of tranexamic acid, serves as a nonhormonal treatment for menorrhagia.
What are Progestin-only pills (POPs), and how do they differ from combination pills?
Progestin-only pills (POPs) are estrogen-free contraceptives taken daily for 28 days. They prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and thinning the endometrium. POPs are suitable for breastfeeding women and those intolerant to estrogen, often initiated soon after childbirth. Strict adherence is crucial, with a three-hour window for pill intake. They’re also used for migraine prevention, especially in women with migraines accompanied by aura, where estrogen poses stroke risks.
NON-ORAL HORMONAL CONTRACEPTIVES: Contraceptive Patch
Contraceptive patches have similar side effects, contraindications, and drug interactions as combined oral contraceptives (COCs), but they expose the body to higher levels of estrogen systemically. They’re not recommended for individuals at high risk of blood clotting (such as those over 35 who smoke, have cerebrovascular disease or prior blood clots, postpartum women, or those with a BMI over 30). Xulane and Zafemy might be less effective in women weighing over 198 pounds.
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Patch can be apply to clean, dry skin of buttocks, stomach, upper arm or upper torso
NON-ORAL HORMONAL CONTRACEPTIVES: Vaginal rings, Injectable, IUD
Vaginal Contraceptive Rings: These rings, inserted monthly, share side effects, contraindications, and drug interactions with oral contraception. Their position within the vagina is not critical.
Injectable Contraception: Depot medroxyprogesterone acetate (DMPA), administered every 3 months via intramuscular (IM) or subcutaneous (SC) injection, suppresses ovulation, thickens cervical mucus, and thins the endometrium…. injection have lower drug interactions since it bypasses first-pass metabolism
Intrauterine Devices (IUDs): Long-acting and reversible, some IUDs contain hormones to achieve contraception.
General Tips for Contraceptive Names
■ “Lo” indicates < 35 mcg E; less E causes less estrogenic side effects. Ex: Loestrin
■”Fe” indicates an iron supplement included. Ex: Loestrin Fe
■ “24” indicates a shorter placebo time: 24 active + 4 placebo = 28 d cycle. Ex: Minastrin 24 Fe
Study Tip Gal: Pills
Monophasic Formulations: List the drug names and what they include
Study Tip Gal: Pills
Biphasic, Triphasic Formulations: List the drug name and what they include
Ortho Tri-Cyclen Lo, Tri-Sprintec, Nortrel
7/7/7, Trivora, Velivet
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Formulations with “phasic” in the name indicate that the hormone doses are delivered in “phases”;
one or both of the hormone doses change during the active pill days
Study Tip Gal: Pills
Quadriphasic Formulations: List the drug name and what they include
Natazia
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Hormone dose changes over the 21-24 days to mimic menstrual cycle (four phases of estradiol valerate and progestin dienogest)
Study Tip Gal: Pills
Extended Cycle Formulations: Name of Drugs and what they include
Jolessa, Seasonique, Camrese, Camrese Lo, Amethia
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Period occurs every 3 months
Joelssa: 84 days of EE + LNG followed by 7 days of placebo
everything else: 84 days of EE + LNG followed by 7 days of low dose EE
Study tip gal: Pills
Continuous Formulations: Drug name, what does it include
Amethyst - No inactive pills (taken continuously); no period occurs; 28 days of EE + LNG with no placebo pills
Study tip gal: Pills
Drospirenone Containing Formulations: Drug name, Notes
Yasmin 28, Yaz, many others
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Mild potassium sparing diuretic to reduce bloating and other effects; C/I in renal or liver disease; monitor potassium and kidney function
Study tip gal: Patch
Transdermal patch: drug name and note/ sig
Xulane, Twirla
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Has higher AUC than pills; Weeks 1-3: apply once weekly; week 4: off
Study tip gal: Ring
Vaginal Ring: drug name and note/ sig
Nuvaring
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Lower AUC than pills
Nuvaring, Annovera Insert monthly: in x 3 weeks; remove x 1 week
Study tip gal: POP
Progestin-Only Pill (The Mini-Pill/POP)
Errin, Camila, Nora-BE, Slynd
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Errin, Camila, Nora-BE contain a fixed dose of norethindrone; take active tablet daily (no placebo
days); “Nor” in the name indicates it contains norethindrone
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Slynd is drospirenone -only
Study Tip Gal: Injection
Injection: name, notes
Contains depot medroxyprogesterone (DMPA); injected every 3 months (150 mg IM or 104 mg SC)
“Pro” in the name indicates it contains a progestin
Adverse Effects Due to Estrogen
Estrogen Side Effects: Nausea, breast tenderness, bloating, weight gain, and elevated blood pressure are common with estrogen. Lower estrogen doses are more tolerable, but insufficient estrogen may cause breakthrough bleeding. If spotting occurs early or mid-cycle, consider switching to a higher estrogen dose after waiting three monthly cycles.
Serious Adverse Effects: Rare but include thrombosis, such as heart attack, stroke, and DVT/PE. Risk increases with age, smoking, diabetes, hypertension, prolonged bed rest, and obesity. Higher estrogen doses, like with Xulane patch, elevate clotting risk. Consider risks of unintended pregnancy; clot risks are higher during pregnancy and postpartum.
Adverse Effects Due to Progestin
Progestin Side Effects: Breast tenderness, headache, fatigue, and depression. Late-cycle breakthrough bleeding may require a higher progestin dose.
Drospirenone Risks: Has a slightly higher clotting risk and may increase potassium levels. Avoid in women with clotting risk or kidney, liver, or adrenal gland disease. Check potassium levels, ideally within the normal range of 3.5-5 mEq/L.
Depot Medroxyprogesterone Acetate: Can lead to bone mineral density loss, particularly concerning for teens and young women still building bone mass. Ensure adequate calcium and vitamin D intake.
RISKS OF HORMONAL CONTRACEPTIVE
Skipped or Missed Pill…what to do?
If multiple COC pills are missed, backup contraception is needed. If missed pills are in the third week, skip the hormone-free week and start the next package immediately, with seven days of backup contraception.
Emergency Contraceptives: what are the 3 different options and when would you use them?
Emergency contraception (EC) prevents pregnancy after unprotected intercourse, available in hormonal or nonhormonal forms. The copper IUD (Paraqard) is the most effective if inserted within five days. Oral EC options include levonorgestrel (Plan B One-Step) and ulipristal acetate (Ella), effective within five days with efficacy decreasing over time. Earlier use improves effectiveness. Higher doses of combination oral contraceptives are less common due to lower efficacy, increased nausea/vomiting, and more contraindications.
The old pregnancy categories were deemed confusing and overly simplistic, often leading to misinterpretation by physicians. The updated labeling aims to offer more detailed benefit/risk information for prescription drugs, aiding patients and clinicians in making informed decisions. What does the updated label look like?
Teratogens are hazardous drugs according to USP Chapter 800; Teratogenic drugs should be discontinued prior to pregnancy…list some of these drugs?
- Some drugs with significant teratogenic risk have REMS requirements
- Consult reliable and current resources, such as Briggs’ Drugs in Pregnancy and Lactation, when prescribing or dispensing medications to pregnant women
Select Conditions and Preferred Management During Pregnancy
Infection
Select Conditions and Preferred Management During Pregnancy
Needing Anticoagulation: VTE or Mechanical Heart Valve
