contraception

Question 1

the menstrual cycle is regulated by the complex hormonal system of the hypothalamic-pituitary-ovarian axis

Answer 1

• the hypothalamus controls pituitary gland function, which in turn exerts activity within the ovary
• GnRH pulses from the hypothalamus stimulate the release of FSH and LH, which regulate the secretion of estrogen and progesterone from the ovary

Question 2

ovarian phase cycles

Answer 2

1. follicular
2. ovulatory
3. luteal

Question 3

follicular phase

Answer 3

FSH stimulates several follicles in the ovary to develop w/ one ultimately becoming dominant
- the dominant follicle synthesizes enough estradiol to create negative feedback and decrease FSH levels

Question 4

ovulatory phase

Answer 4

• Estradiol levels peak and exert positive feedback to induce an LH surge -> facilitates release of the mature ovum
• Estrogen promotes proliferation of the endometrium and development of progesterone receptors in the endometrium

Question 5

luteal phase

Answer 5

Progesterone dominates
- Produced by the corpus luteum created from the LH-stimulated cells of the follicle

Progesterone and small amounts of estrogen released prevent new follicle development and proliferation of the endometrium

Question 6

endometrial cycle phases

Answer 6

1. proliferative
2. secretory
3. menstrual

Question 7

secretory phase

Answer 7

Endometrium becomes thick and cushion-like to prepare for implantation

If pregnancy does not occur -> the corpus luteum degenerates

Estrogen and progesterone levels decline rapidly

Question 8

menstrual phase

Answer 8

• Endometrial shedding
• The new cycle of hormonal release and inhibition starts again

Question 9

estrogens effects on other body systems

Answer 9

 Positively influences bone mass
 Increases serum triglycerides
 Improves HDL to LDL rations
 Stimulates coagulation and fibrinolytic pathways

Question 10

progesterone effects on other body systems

Answer 10

 Increases body temp
 Increases insulin levels
 May slightly depress the CNS

Question 11

first generation progestins

Answer 11

 Norethindrone
 norethindrone acetate
 ethynodiol diacetate
 women experience more spotting and breakthrough bleeding

Question 12

second generation progestins

Answer 12

 norgestrel
 levonorgestrel
 decreased breakthrough bleeding
 increasing androgenic activity (acne, hirsutism, and dyslipidemia)

Question 13

third generation progestins

Answer 13

 Desogestrel
 Norgestimate
 Offer less androgenic activity

Question 14

fourth generation progestins

Answer 14

Drospirenone
- Derivative of spironolactone
- mild diuretic effect

Question 15

Progestins are primarily responsible for the contraceptive effect in hormonal preparations

Answer 15

1. Exhibit a negative effect in the HPO axis
   –> suppress the H surge necessary for ovulation
2. Cause thickening of cervical mucus
3. Slow tubal motility
   —> delays transport of the ovum and sperm

4.Cause atrophy of the endometrium
–> preventing implantation

Question 16

estrogen component of hormonal contraception

Answer 16

• Improves efficacy by suppressing FSH release -> stops the development of a dominant follicle
• Adds to cycle control -> decreases irregular bleeding patterns

Question 17

tolerance of progestins

Answer 17

3rd and 4th generation progestins have fewer androgenic effects

Patients experience
* Less weight change
* Improved complexions
* Reduced mood swings

Question 18

major, but rare, adverse effects of COCs

Answer 18

 Cholestatic jaundice
 Benign haptic neoplasms
 Neurological migraines

Question 19

absolute contraindications for COCs

Answer 19

• Thromboembolic disorders
• Thrombophlebitis
• cerebrovascular disease
• coronary occlusion
• a past history of these conditions, or a condition that predisposes one to these conditions
• Abnormal liver function
• Known or suspected breast cancer
• Undiagnosed abnormal vaginal bleeding
• Tobacco use over the age of 35

Question 20

relative contraindications of COCs

Answer 20

– HTN
– Cardiac disease
– Migraine
– Diabetes
– Gallbladder disease
– History of cholestatic jaundice of pregnancy
– Uterine leiomyoma
– Epilepsy

Question 21

progestin implants

Answer 21

The etonogestrel implant (Nexplanon) provides contraception for up to 3 years
- The only implant currently available in the US

Question 22

Depot medroxyprogesterone acetate (Depo-Provera)

Answer 22

 A long-acting, injectable, progestin-only contraceptive
 One injection of 150mg IM is effective at suppressing ovulation for 12-13 weeks
 Thickens cervical mucus and atrophies the endometrium
 Will change bleeding patterns causing an increased number of days of spotting or amenorrhea
 Weight gain may be a concern
 Have a delay in return to fertility –> Average 9 to 10 months

Question 23

progestin-only pills (POPs)

Answer 23

Two formulations available
 norethindrone 0.35 mcg (Micronor and multiple generics)
 drospirenone 4 mg (Sylnd)

Question 24

primary contraceptive effect of POPs

Answer 24

through thickening of the cervical mucus and prevention of sperm penetration

Question 25

first day start

Answer 25

The first pill is taken on the first day of the menstrual period - No backup method is needed b/c ovulation will be suppressed within the first cycle

Question 26

sunday start

Answer 26

The first pill is taken on the Sunday following the start of menses - Backup method is recommended for the first 7 days - May offer the user the convenience of having the menses occur only during the week

Question 27

quick start method

Answer 27

The first pill is taken on the day of the office visit - Backup method is recommended for the first 7 days - Recommended to support achieving efficacy and pregnancy protection as quickly as possible

Question 28

Instructions for Missed Oral Contraceptives - missed one active pill

Answer 28

Take pill as soon as possible, taking two pills in 1 day if missed pill was day prior - No additional contraception needed

Question 29

Instructions for Missed Oral Contraceptives - missed two or more pills

Answer 29

Resume taking pill as scheduled - Use backup contraception for 7 days - Consider emergency contraception if in first week of pack

Question 30

Instructions for Missed Oral Contraceptives - missed two or more pills in week 3

Answer 30

Finish remaining pills and then immediate start new pack on next start day - Use backup contraception until 7 day of new pill pack taken