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Pharm III > Contraception > Flashcards

Flashcards in Contraception Deck (56):
1

Unintended pregnancy

Mistimed, unplanned or unwanted pregnancy at the time of conception
Typically occurs from inconsistent or incorrect use of effective contraceptives

2

Non-hormonal contraceptive methods

Periodic abstinence
Barrier methods
-Condom: male and female
-Diaphragm
-Cervical cap
-The last two barrier methods are prescriptions bc they need to be fitted
Spermicide

3

Combined hormonal contraceptives

Combined oral contraceptives
Patch
-Ortho Evra
-Xulane
Vaginal ring

4

Progestin only contraceptives

Progestin only pills
Long-acting injectable
-Depo-Provera (DMPA)
Implant
-Nexplanon
IUD
-Mirena
-Kyleena
-Skyla
-Liletta
-ParaGard
--Copper IUD

5

Progesterone MOA

Main contraceptive component
Blocks LH surge
Thickens cervical mucus
Slows tubal motility
Induces endometrial atrophy

6

Estrogen MOA

Suppresses FSH release which helps block LH surge
Primary role:
-Stabilizes endometrial lining
-Cycle control

7

Benefits of CHCs

Pregnancy prevention
Improvement in menstruation-related issues
Reduced risk of:
-Endometrial and ovarian cancer
-Endometriosis
-Ovarian cysts
-Ectopic pregnancy
-PID
Treat acne

8

Risks of CHCs

Alters lipid metabolism
-Progestin increases LDL, estrogen does opposite, net neutral
Increases BP
-Take baseline and monitor throughout therapy
Increased risk of:
-Breast CA?
-CVD
--MI and CVA
-VTE

9

Pt interview

Menstrual hx
-Regularity and cycle length
-Light or heavy menses
PE
-Height
-Wt
-BP
Pt preference
-Contraceptive hx
-Planning on conceiving
-Adherence
Monogamous relationship
-No hormonal contraceptive protects against HIV or STDs

10

R/o pregnancy

No s/sx of pregnancy and meets one of the following:
Less than or equal to 7 days after the start of normal menses
Not had sexual intercourse since start of last nl menses
Correctly and consistently using a reliable form of contraception
Less than or equal to 7 days after spontaneous or induced abortion
Within 4 wks postpartum
Fully or nearly fully breastfeeding

11

Category 4 CIs

Unsafe, benefits don't outweigh risks

12

Category 3 CIs

Risks probably still outweigh benefits

13

Category 2 CIs

Benefits outweigh risk, but there is still risk
A lot of category 2s apply to pt, still may not be the best product for them

14

Category 1 CIs

Go right ahead!!

15

What is in a category 4?

Age >35 yo and currently smoking greater than or equal to 15 cigarettes/day
Complicated solid organ transplant
Complicated valvular heart dz
Current breast CA
Hx of CVA
Hx of VTE with high risk for recurrence
Ischemic heart dz
Known thrombogenic mutations
Major surgery with prolonged immobilization
Malignant hepatoma or hepatocellular adenoma
Migraine HAs with aura
Severe cirrhosis
SLE with pos or unknown antiphospholipid antibodies
Uncontrolled HTN or HTN with vascular dz

16

What is part of a category 3?

Acute viral hepatitis
Age >35 yo and currently smoking <15 cigarettes/day
DM with vascular dz or DM >20 yrs duration
Hx of breast CA, but no evidence of dz for 5 yrs
Hx of cholestasis related to CHC use
Hx of VTE with low risk for recurrence
Hx of malabsorptive bariatric sx (oral therapies only)
Hx of HTN
IBD with increased risk for VTE
Multiple RFs for atherosclerotic CVD
MS with prolonged immobility
Superficial venous thrombosis
Symptomatic or medically treated gallbladder dz
Taking meds that induce liver enzymes and reduce efficacy of CHCs

17

Drug interactions of CHCs

Increase hepatic metabolism of CHCs:
Carbamazepine, phenytoin, primidone, topiramate, oxcarbazepine
Barbiturates
Protease inhibitors
-Fosamprenavir
Rifampin
Decreased by CHCs: lamotrigine

18

CHC use postpartum- not breastfeeding

Can use progestin only options immediately
Avoid first 3 wks
-Category 4
Avoid first 6 wks if risk factors for VTE
-Category 3

19

CHC use postpartum- breastfeeding

Can use progestin only options immediately
Avoid first 3 wks
-Category 4
Avoid during days 21-30
-Category 3
Avoid during days 30-42 if RFs for VTE
-Category 3

20

How do combined oral contraceptives differ from each other?

Based on individual hormones and doses of hormones, number of active pills, phases

21

Estrogens- hormones

Ethinyl estradiol (EE)
Mestranol
-Less potent than EE
Estradiol valerate

22

Progestins 1st gen

Ehynodiol diacetate
Norethindrone
Norethindrone acetate

23

2nd gen progestins

Levonorgestrel
Norgestrel

24

3rd gen progestins

Desogestrel
Norgestimate

25

4th gen progestins

Dienogest
Drospirenone

26

Drospirenone

Structurally related to sprironolactone
-3 mg of drospirenone = 25 mg of spironolactone
Antimineralcorticoid and antiandrogen effects
-May result in less wt gain

27

AEs of drospirenone

Hyperkalemia
Jury is out on increased VTE risk

28

Usual regimen of combined oral contraceptives

21 active pills
7 placebo

29

Extended cycle regimens, combined oral contraceptives

24 active pills, 4 placebo
26 active pills, 2 placebo
84 active pills, 7 placebo

30

Continuous cycle regimen, combined oral contraceptives

Always active pills
Skipping placebo pills

31

When would you want to utilize extended or continuous cycle regimens for combined oral contraceptives?

Decrease menses
Anemia
Dysmenorrhea
Endometriosis
Menstrual migraines
Desire for decreased menses

32

Monophasic combined oral contraceptives

Same levels throughout cycle
Preferred regimen

33

Biphasic combined oral contraceptives

Hormones change once during cycle

34

Triphasic combined oral contraceptives

Hormones change twice during cycle

35

Four-phasic combined oral contraceptives

Hormones change three times during cycle

36

Initial dosing of combined oral contraceptives

Pts without comorbid conditions
EE 20-35 mcg
Older progestin
-Levonorgestrel
-Norethindrone

37

Counseling for combined oral contraceptives

Adherence
Adverse effects
-Usually improve after first 3 mos
D/c therapy if experience ACHES
Abdominal pain
Chest pain
HAs
Eye problems
Severe leg pain
Missed dose management
Starting therapy

38

Monitoring and f/u

No routine f/u required
Advise f/u when:
-Experiencing adverse effects
-Want to change contraceptive method
-Need to replace or remove contraceptive method
Assess at routine visits
-BP
-Changes in health status
-Pt satisfaction
-Wt

39

AEs of excess estrogen in CHCs

Bloating
Breast tenderness
HA
Nausea
Dysmenorrhea
Menorrhagia

40

AEs of excess progestin in CHCs

Acne
Bloating
Breast tenderness
Changes in mood
HA
Fatigue
Hirsutism
Increased appetite
Oily skin
Wt gain

41

AEs of estrogen deficiency in CHCs

Amenorrhea
Decreased libido
Early or mid-cycle breakthrough bleeding
Vasomotor sx

42

AEs of progestin deficiency in CHCs

Dysmenorrhea
Menorrhagia
Late cycle breakthrough bleeding

43

What is the #1 reason pts stop their contraceptives?

Breakthrough bleeding

44

How to manage estrogen excess in combined oral contraceptives

Decrease estrogen
Consider progestin only methods
Avoid patch
Consider vaginal ring
For dysmenorrhea
-Consider extended cycle or continuous cycle
-Consider NSAIDs

45

How to manage estrogen deficiency in combined oral contraceptives

Increase estrogen

46

How to manage progestin excess in combined oral contraceptives

Decrease progestin
For acne, oily skin or hirsutism:
-Consider less androgenic progestin

47

How to manage progestin deficiency in combined oral contraceptives

Increase progestin
Consider progestin only methods
For dysmenorrhea:
-Consider extended cycle or continuous cycle
-Consider NSAIDs

48

Patch

Releases EE 35 mcg and norelgestromin 150 mcg per day
-Warning regarding increased exposure to estrogen: increased VTE risk?
Same CI and precautions as CHCs
Avoid in pts weighing >90 kg
-Decreased efficacy

49

Counseling for the patch

Apply to abdomen, buttocks, upper torso, or upper arm
New patch each week for three wks
-Patch free 4th wk
Adverse effects similar to CHCs
-Skin irritation

50

Vaginal ring

Releases EE 15 mcg and etonogestrel 12 mg per day
-Inserted and left in place for 3 wks
-Removed for 1 wk
Same CIs and precautions as CHCs
Adverse effects similar to CHCs
-FB sensation
-Vaginal sx

51

Advantages of CHCs

Highly effective
Protect against endometrial and ovarian CA
Favorable effects on bone mass
Fertility returns quickly after stopping
-Approximately 1-2 wks
Menstrual cycle benefits

52

Disadvantages of CHCs

Adverse effects
-Breakthrough bleeding: common during first 3-6 mos
DO NOT protect against HIV or STDs
Efficacy dependent on adherence

53

Role of progestin only therapy

Breastfeeding
Pts who do not tolerate estrogen containing contraceptives
Pts with medical conditions in which estrogen is not recommended
-Category 4 and 3

54

Progestin only pills

No placebo, 28 days of norethindrone 0.35 mg
Decreased efficacy compared to CHCs
Needs to be taken same time every day
-Missed dose >3 hrs, use backup contraception for 2 days

55

When to avoid progestin only pills

Breast CA
Hx of malabsorptive bariatric surgery
Malignant hepatoma or hepatocellular adenoma
Severe cirrhosis
SLE with pos or unknown antiphospholipid antibodies

56

DIs- progestin only pills

Increased hepatic metabolism due to:
Carbamazepine, phenytoin, primidone, topiramate, oxcarbazepine
Barbiturates
Rifampin