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Flashcards in Contraception Deck (36):
1

Female reproductive cycle review

28 days; 2 phases-
Day 1= first day of menseS
Two phases:
FOLLICULAR
D 1-14
Anterior pituitary releases FSH which causes eggs to begin to mature
(Usually 5-7 eggs maturing but only 1 or 2 dominant follicles)
>> follicles secrete estrogen which PROMOTES GROWTH OF UTERINE LINING>> when estrogen levels reach a certain point LH is secreted from anterior pituitary, finalizing follicle development and OVULATION OCCURS!
LUTEAL PHASE
D 14-28 (ovulation until menses)
Site of ovulation becomes Corpus Luteum and secretes progesterone for an impending pregnancy until placenta could take over (ie about 10 weeks)
If no fertilization, there is a loss of feedback and CL DEGRADES
>> lack of progesterone >> shedding of uterine lining

2

Types of hormonal contraception

1. OCPs-
COCs (combined oral contraceptives)
Monophasic
Biphasic
Triphasic
-progestin only "mini pill"
2. IUD (mirena)
3. Other progestin-only implants (Depo Provera, Implnanon)

3

Oral contraceptives: combined OC's almost always contAin ethinyl estradiol (EE), and a progestin.
EE is always the same but the difference in progestins...

...is the androgen in activity
Aka: how much does it behave like testosterone
More androgenic= more acne, bloating, hirsuitism
Newer progestins have less androgenic activity

4

OC's: How do they work?

-combined estrogen / progestin work to suppress release of FSH and LH; without ovulation pregnancy cannot occur
1. Estrogen: suppresses LH AND FSH/speed ovum transport, decreasing fertilization time
2. progestin: in its ovulation by suppressing release of LH, THICKEN CERVICAL MUCUS (ie barrier), and creates a more hostile environment for implantation

5

OC's 4 types and main points on each

1. Monophasic : 1 level of hormone for cycle
2. Biphasic: 2 combos of estrogen/ progestin
3. Triphasic: 3 " " "" ""
Tripahsic: Has many different forms, either progestin or estrogen may increase or stay same
Progestin only: constant level of progestin
estrogen is almost always EE, but the type of progestin changes
Progestins are all derivatives of testosterone-
Either an estrane or a gonane does not describe pharmacological activity
Exception = drosperinone. A derivative of aldosterone.

6

OC's - how to pick one, how to dose

*start with low dose>> lowest risk side effects
(Low dose pills have 18-25 mcg EE, normal pills have 30-50 mcg)
**triphasic mimics normal cycle, so good place to start

7

Low dose pill better for:

History of common migraines (no aura)
Uterine fibroids
HX heavy menses
HTN
FIbrocystic blasts

8

If pt weighs more than 160#, how to dose:

Need pill with higher amounts estrogen and progesterone

9

If triphasic causes untoward side effects like mood swings, try...

Monophasic for extended cycle regimens:
Menses q 3 mo
84 days of EE/progestin
(seasonique, seasonale,Lybrel)

10

Are hormones variable in mono, bi and tri phasic? y / n

Hormones are viable with these preparations**

11

There are generations of progestins. The third gen, gonane, "Desogestrel/ Norgestimate," is....

Least adrenergic; increased risk for blood clots

12

Progestin only pills are good choices for:

1. Breastfeeding women( estrogen can decrease supply but not likely progestin)
2. Women with HX blood clots
3. HX of classical migraines

13

Some items to emphasize with Progestin only pills:

**must be taken same time every day- no room for error. If miss pill, use back up pill
- there are no placebo pills
-most women have irregular spotting but no menses
-amenorrhea common

14

Some name of progestin- only:

Norethidrone (Micronor, Camila, Errin, Jovlivette)
norgestrel (overette)

15

How to start OC's: quick start

Quick start=
Patient starts that day regardless of cycle
Needs back up method until next menses
Higher risk for breakthrough bleeding first month

16

How to start OC's: First Day Start

Pt starts first pill first day of next cycle
No back up method needed (good for someone unlikely to use back up method)

17

How to start OC's: Sunday start

pt starts first Sunday after period starts
Need back up birth control for 7 days

18

OC's
Follow up, pt counseling

Follow up in 3 months after start
Ask about side effects and breakthrough bleeding
Note- side effects decrease with use
Encourage pt to try for at least one month in order to choose better pill if need be

19

OC's
breakthrough bleeding

For BB early in cycle day 1-10 or no mense during placebo week>> need more estrogen support

For BB later in cycle day 10-21>> need more, or a different type of progestin

20

Risks of OC's

1. Increased migraine severity
2. Increased risk CVA
3. Headaches
4. Blood clots
5. HTN
6. Mood changes
7. Gallbladder disease
8. Acne
9. Bloating
10. Hair loss / hirsuitism

21

Benefits of OC's

Overall very safe
Decreased menstrual bleeding so decreased risk anemia
Decreased cramping
Predictable cycle

22

Contraindications of OC's

1. HX CV ischemia - MI, CVA
2. A fib
3. Heart failure
4. Previous blood clot
5. Ovarian/ breast CA
6. Smoker > 35 yo
7. Pregnant
8. Uncontrolled HTN
9. Liver tumors / disease
10. Undiagnosed vaginal bleeding
11. HX classical migraine (I.e., with AURA)

23

Danger signs on OCS

A: abdominal pain ( hepatic/ gallbladder)
C: chest pain (PE)
H: H/a ( CVA)
E: eye problems
S: swelling in legs / aching in LE (DVT)

24

OC's and CA RISK

Overall decrease risk (ovarian, endometrial) but NOT GIVING TO PTS with CA
40-80% less risk ovarian ca than with nonusers
Protective benefit most clear with monophasics
50-60% less risk endometrial cancer
* risk also decreases with increased length of use
Protective benefit continues 20years after last use
* slight increased risk cervical cancer
**ocs not clearly linked to increased risk breast cancer!
Breast cancer Dx in OC's users tended to be less advanced more localized

25

Depo Provera: benefits

Benefits:
- progestin only so CAN USE in women with classical migraine, ?blood clots
-minimal drug iteractions
-high compliance (only given every 3 mo)

26

Depo Provera : risks

-weight gain
-decreased bone density (worse with longer use)
- decreases HDL AND increases LDL AND TCHOL
** not recommended to use more than 2 yr

27

Nuva Ring - how it works, how to use

Lower dose/ bypasses 1 st pass effect
Absorbed via vaginal mucosa
Tampons do not affect absorption
Ring left in 3 weeks (can be left in 4 weeks but might not have a period)

28

Nuva Ring - how to start, what to do if mess up

Start within 5 days LMP
NO BACK UP METHID NEEDED
(But if left in more than 4 weeks, check a pregnancy test prior to rein steering new ring)
Can be removed for up to 3 hours with no back up birth control
BUT! If out more than 3 hours,>>7 days back up method needed

29

Nuva ring benefits

Convenient
Effective
Less chance of breakthrough bleeding

30

Nuva Ring risks

Vaginitis
Same as OC's
(Has estrogen)
Some PTS complain it is uncomfortable

31

Depo Provera - how it works, how to give

SubQ progesterone only
When admin withi 5 days of LMP IMMEdiately effective
- given every 3 months
- if dose is missed must get pregnancy test!

32

Who is Depo Provera not ideal for?

For anyone wanting to conceive within 1-2 years

33

Ortho Evra THE PATCH- how admin, how it works, high
and low points

= transdermal form of contraception, thought to be easier than pill but still easily reversible
- worN 3 weeks/ 1 week off
- higher levels of EE - no first pass effect
$$$ can be pricey
-can be visible
-can come off early

34

Implanon: how given, how it works,other tidbits

-implanted rod (upper arm) containing etonogestrel
- inserted within 5 days LMP
**contraception =3 years
Side effects: weight gain, acne, mood changes
Rarely migrates

35

IUDS: the what the how et

Copper wire inserted causes local inflammation to prevent implantation
- can have spotting after insertion,increased cramping
Mirena is plastic - causes some inflammation but also a trophies uterine lining and suppresses LH AND Ovulation
* 5 year life/ most women become ammenhorreic
Either IUD CAN CAUSE PERF esp with insertion
-expulsion can occur too, encourage women to check for strings
-placed within 5 days LMP Then effective immediately

36

Give an overview of the contraceptives

1. The pill (monophasic, bi, tri)
2. Patch/ Nuva Ring
3. Deposit shot
4. IUD
5. Emergency contraception