Contraception (Final) Flashcards
1
Q
list some natural methods for non-hormonal contraception
A
- calendar (prevent pregnancy by knowing when you’re ovulating)
- basal body temperature
- cervical mucus method
- lactational amenorrhea
2
Q
this is the temporary postnatal infertility that occurs when a woman is amenorrheic and fully breastfeeding (< 4hr daytime and 6 nighttime) and the baby is < 6 months
A
lactational amenorrhea
3
Q
this is a barrier method; concern with allergies to latex or lanolin
A
condoms
4
Q
this is a barrier method; may be inserted up to 8 hours before sex. more resistant than external condoms. hypoallergenic (made of nitrile polymer)
A
internal condom
5
Q
this is a barrier method; may be isnerted up to 2 hours prior to sex and should leave in for at least 6 hours after sex. it is reusuable (for ab. 1-2 years). spermicide is REQUIRED for use. risk of TSS if left in for > 24 hours
A
diaphragm
6
Q
this is a barrier method; can be inserted up to 1 hour prior to sex and should leave in for at least 6 hours after sex. risk of TSS and vaginal discharge/odour if left in for > 48 hours. it is reusable for up to 1 year
A
cervical cap
7
Q
this is a barrier method; can be inserted anytime, should leave in for at least 6 hours after sex. contains spermicide (N9). single-use only. risk of vaginosis if left in for more than 30 hours
A
sponge
8
Q
this contains N9 which immobilizes or kills sperm. should be inserted 15 mins before sex. risk of abbrations/irritation, which can increase risk of infections
A
spermicide
e.g. VCF contraceptive foam & film
9
Q
this is less effective than N9. it helps seal the diphragm and lowers vaginal fluid pH which slows down sperm. may cause less vaginal irritation than N9. may be less effective at preventing pregnancy than a diaphragm + spermicide
A
lactic acid buffering gel
e.g. Contragel & Caya Gel
10
Q
this is the most effective method of emergency contraceptive. it creates a cytotoxic environment that produces an inflammatory response that prevents fertilization
A
copper IUD
11
Q
what is the onset of action for a copper IUD
A
effective immediately upon insertion
12
Q
what are the contraindications for a copper IUD
A
- pregnancy
- unexplained vaginal bleeding
- current STI’s
- PID
- unknown distorted uterine cavity
- post-sepsis
- active intrauterine disease
13
Q
what are the s/e of a copper IUD
A
mostly just inital pain and cramping or irregular bleeding due to inflammatory response. no hormones therefore not many other s/e :)
14
Q
what happens to FSH levels when a follicle is developing (during menstruation and follicular/proliferative phase)
A
FSH decreases
15
Q
what happens to LH levels when a follicle is developing (during menstruation and follicular/proliferative phase)
A
LH stays the same
16
Q
what happens to estrogen levels when a follicle is developing (during menstruation and follicular/proliferative phase)
A
estrogen stays the same
17
Q
what happens to progesterone levels when a follicle is developing (during menstruation and follicular/proliferative phase)
A
progesterone stays the same
18
Q
what happens to FSH levels when the follicle has matured, at the time of ovulation
A
FSH slightly increases
19
Q
what happens to LH levels when the follicle has matured, at the time of ovulation
A
LH levels spike
20
Q
what happens to estrogen levels when the follicle has matured, at the time of ovulation
A
estrogen levels increase
21
Q
what happens to progesterone levels when the follicle has matured, at the time of ovulation
A
progesterone levels stay the same
22
Q
what happens to FSH levels during the luteum/secretory phase, when the corpus luteum is developing
A
FSH levels stay the same
23
Q
what happens to LH levels during the luteum/secretory phase, when the corpus luteum is developing
A
LH levels stay the same
24
Q
what happens to estrogen levels during the luteum/secretory phase, when the corpus luteum is developing
A
estrogen levels are decreased but then start to increase again
25
what happens to progesterone levels during the luteum/secretory phase, when the corpus luteum is developing
progesterone levels spike
26
what happens to FSH levels during regression of the corpus luteum as the next cycle starts to begin
FSH levels slightly increase
27
what happens to LH levels during regression of the corpus luteum as the next cycle starts to begin
LH levels stay the same
28
what happens to estrogen levels during regression of the corpus luteum as the next cycle starts to begin
estrogen levels increase
29
what happens to progesterone levels during regression of the corpus luteum as the next cycle starts to begin
progesterone levels decrease
30
this hormone in hormonal contraceptives prevents the release of FSH and keeps the ovaries inactive
estrogen
31
this hormone in hormonal contraceptives supresses the mid-cycle peaks of FSH and LH, increases the thickness and decreases the volume of cervical mucus which helps decrease sperm motility, it inhibits the development of the uterine lining and may inhibit ovulation in some women
progesterone
32
what generation are the following progestins used in COC:
Norgestimate & desogestrel
3rd gen
33
what generation are the following progestins used in COC:
norethindrone & ethynodiol
1st gen
34
what generation are the following progestins used in COC:
levonorgestrel & norgestrol
2nd gen
35
what generation are the following progestins used in COC:
drospirenone & dienogest
4th gen
36
this generation of progestins is associated with the most androgenic activity therefore more androgen s/e such as weight gain, acne, etc.
2nd gen - levonorgestrel and norgestrol
37
what estrogens are available in COCs
ethinyl estradiol and estetrol
38
In this type of combination birth control pill, each active pill contains the same amounts of estrogen and progestin.
monophasic
39
oral contraceptive pills have 3 different doses of progestin and estrogen that change approximately every 7 days.
triphasic
40
oral contraceptive pills that deliver the same amount of estrogen each day while progestin dose is increased halfway through cycle.
biphasic
41
what formulation (mono, bi or triphasic) should be used if using back to back hormone (no period)
monophasic
42
this COC contains a plant derived native estrogen - estetrol & drospirenone
Nextstellis
43
true or false: Nextstellis may be less effective in patients with a BMI > 30
true
44
true or false: pelvic exam, pap smear or STI screening are required before initiating COC
false
45
what are some risk factors that should be looked for when taking a patients medical hx prior to prescribing COC
- smoker
- obesity
- history of MI, stroke, angina or VTE
- uncontrolled HTN
- dyslipidemia
- uncontrolled DM
- migraine with aura
- hx of breast cancer
- hx of liver disease
- IBD
46
true or false: if a patient is less than 35 and smokes > 15 cigs/day, hormonal contraception should not be used
false - age < 35, the number of cigs does not matter
the advantages generally outweigh the risks
47
true or false: if a patient is >35 and smokes < 15 cigs/day, hormonal contraception should not be used
kinda true! - theoretical risks usually outweigh the advantages, take pt by pt
48
true or false: if a patient is > 35 and smokes > 35 cigs/day, hormonal contraception should not be used
true
unacceptable health risk
49
true or false: the risk of thromboembolism is greater in obese patients
true
50
which hormonal contraceptive option has weight gain as a possible side effect
depo-provera
51
true or false: ethinyl estradiol is an inhibitor of CYP 3A4
false - inducer, therefore lowers levels of CYP 3A4 substrate
52
true or false: ethinyl estradiol is a CYP 3A4 substrate, therefore inducers such as phenytoin will increase the metabolsim of ethinyl estradiol furthermore decreasing its effectiveness
true
53
true or falase: if a patient is on a strong CYP 3A4 inducer, then the preferref treatment is Depo-Provera q 12-13 weeks or LNG IUD
false - Depo Provera q 10 weeks or LNG IUD
q 12-13 weeks is normal regimen
54
when gathering a patients menstruation history, what are some questions you should ask?
- has the patients reached menarche
- when was their last period
- has the patient has unprotected sex since their last period
- does the patient have undiagnosed vaginal bleeding
55
what are the criteria that can rule out pregnancy
no signs or symptoms of pregnancy AND one of the following:
- exclusively breastfeeding, amenorrheic and < 6 months postpartum
- no intercoirse since last menses
- correctly using reliable contracpetion
- < 7 days after menses
- < 7 days after abortion or miscarriage
- < 4 weeks postpartum
56
what are the two options for conventional dosing for COC
1 tablet daily x 21/7, then 7 days of no pills
1 tablet daily x 28/7 (last 7 tablets are non-hormonal)
*can take continuously but should avoid multiphasic
57
what are some advantages of extended/continuous use COC
- decrease dysmenorrhea
- may improve other sxs associated with menstrual cycle
- convenient (delays or eliminates menstruation)
- good adherence
58
what are some disadvantages of extended/continuous use COC
- possible delay in the recognition of pregnancy
- unscheduled bleeding and spotting
59
if a patient misses their COC pill that they were supposed to take <24 hours ago, what should they do?
take 1 active pill ASAP and continue pack as usual
60
if a patient misses their COC pill that they were supposed to take >24 hours ago, what should they do?
see product monograph
61
true or false: progestin only pills must be taken within a 3 hour window daily for 28 days with NO hormones free interval
true
62
true or false: when starting a POP, 2 days of backup is required if you start on day one of menses
false - no back up required
63
true or false: when starting a POP, 2 days of backup is required if you start >5 days after onset of menses
false - backup required for 7 days
64
true or false: when starting a POP, 2 days of backup is required if starting on another day other than day 1 of menses or <5 days after onset of menses
true
65
true or false: if a dose of POP is missed or delayed by > 3 hours, the patient should use backup for 48 hours
true
66
true or false: if patient has episode of diarrhea/vomiting within 3 hours of taking POP dose, they should use back up for 48 hours
true
67
what are some s/e associated with POP
specific for progestin:
- shorter menstrual cycle
- androgenic s/e (e.g. acne, weight gain)
any hormone:
- breast tenderness
- h/a
- nausea
- mood disturbances
68
what are some CI's to using POPs
- current breast cancer
- avoid with active systemic lupus and conditions associated with malabsorption
69
this type of oral contraceptive is usually prescribed when estgrogen is contraindicated or less appropriate
- common in post partum because doesnt affect milk supply and doesnt increase risk of blood clot
progestin only
70
what is the dosing regimin for the vaginal ring
insert one ring q 3 or 4 weeks
71
true or false: backup is needed if starting the vaginal ring on day 1 of menses
false
72
true or false: backup is needed if starting the vaginal ring immediately
true
73
when would a patient require backup in terms of missed dose of the vaginal ring
- removal for > 3 hours
- > 48 hours delayed insertion
- inserted for more than 28 days
74
what are some s/e of vaginal ring
- h/a
- vaginitis
- leukorrhea
other: nausea, breast tenderness
75
what are some advanatges of the vaginal ring compared ot oral contraceptives
- daily action not required therefore increased compliance
- better for patients who have trouble taking oral medications due to adherence or issues with GI absorption
- less nausea, acne, emotional effects and unscheduled bleeding than COC
- shorter duration of menstrual bleeding than with patch
76
what is the dosing for the transdermal patch
apply one patch once weekly x 3 weeks than one week patch free
77
true or false: backup is required when starting the patch on day 1 of menses
false
78
true or false: backup is required if starting the patch immediately
true
79
when would a patient require backup in terms of missed dose of the patch
- patch detached > 24 hours
- first patch delayed by >24 hrs
- > 7 day hormone free interval
80
what are some s/e associated with the transdermal patch`
- breast sxs
- h/a
- nausea
- application site reactions
81
true or false: the transdermal patch is less effective in those > 90kg
true
82
what is the dosing for Depo-Provera
one injection IM every 12-13 weeks
83
true or false: backup is needed if starting depo-provera immediately
yes - 7 days
84
true or false: backup is needed if starting depo in first 5 days of menses
false
85
when would a patient require backup if they missed a dose of depo-provera (think of timeline you get dose)
if injection interval is >14 weeks, use backup for 7 days
86
what are some common s/e associated with depo-provera
- Irregular bleeding for first few months
- amenorrhea after one year
- weight gain (often seen in 1-3 months; if no weight gain after 3 months prob wont happen)
- bloating
- mood changes
- h/a
87
true or false: pharmacists can prescribe and administer depo provera
true
88
true or false: depo provera is a type of comibined hormonal contraceptive
false - progestin only
89
what are some contraindications for depo-provera
- breast cancer
- unexplained vaginal or urinary tract bleeding
90
true or false: there is a delay in fertility once you stop taking depo provera
true - 6-12 months
91
what is the dosing for hormonal IUDs
inserted into the uterus by healthcare provider once q 5 years
92
true or false: backup is needed if getting IUD inserted on within 7 days of menses
false
93
true or false: backup is needed if getting IUD inserted immediately
true
94
true or false: hormonal IUDs are a combined hormonal contraceptive
false - progestin only
95
what are some CIs associated with progestin only iUD
- pregnancy
- unexplained vaginal bleeding
- current STI's
- PID
- unknown distorted uterine cavity
- post-sepsis
- active intrauterine disease
^ same as copper IUD +
- breast, cervical or endometrial cancer
96
what are some s/e associated with progestin only IUD
- irregular bleeding in first 3-6 months
- amenorrhea or decrease in amount of menstrual bleeding
- expulsion of IUD
- pain/cramping following insertion
97
true or false: pharmacists can prescribe IUDs
false - b/c we cannot insert them
98
true or false: there is a delay in fertility once an IUD is removed
false - fertility may return immediately
99
this medication may be used for women with a narrow cervical canal who will be getting an IUD inserted
misoprostol
100
this medication may be used for post-insertion pain of an IUD
oral NSAIDs
101
what is the dosing for the subdermal implant
inserted subdermally q 3 years
102
true or false: backup is needed if starting implant within 5 days of menses
false
103
true or false: backup is needed if starting implant immediately
true - 7 days
104
what are some CI's for the subdermal implant
- < 18 y/o
- pregnancy
- current or past hx of thrombosis
- liver tumors / liver disease
- abnormal vaginal bleeding
- breast cancer
105
what are some s/e assoicated with the subdermal implant
- changes in menstrual bleeding
- mood swings
- weight gain
- h/a
- acne
- breast tenderness
- abdominal pain
- post insertion site pain or reaction
- chloasma (yellow rash on face)
106
true or false: pharmacists can prescribe subdermal implant
false - b/c we cannot insert it
107
true or false: the subdermal implant tends to be less effective in people who are overweight
true
108
true or false: a medical blood pressure check up is required after insertion
true - RPh can do this!
109
true or false - there is a delay in fertility after removal of implant
true - but only 7-14 days thus recommend immediate backup
110
this is the use of a druf or device to prevent an unwanted pregnancy that may occur after unprotected sex
emergency contraception (EC)
111
what are some indications for emergency contraception
- no contraceptive method used or incorrect use
- condom slip or break
- displacement of cervical cap or diaphragm
- removal, displacement or missing IUD
- missed COC, especially in the first week of pack or if starting a new pack late
- > 3 hours late taking POP
- removed intravaginal contraceptive ring for > 3 hours during an in ring week
- removed patch for > 24 hours during a patch week
- > 14 week interval between depo shots
- ejaculation on external genitalia
- sexual assault
112
this emergency contraceptive contains Levonorgestrel 1.5mg. it inhibits ovulation and fertilization
non prescription EC e.g. Plan-B, Contingency One)
113
in what time period is Levonorgestrel 1.5mg the most effective
within 24 hours (still has decent efficacy up to 72 hours)
114
what are some s/e of Levonorgestrel EC
- nausea
- vomiting (may take gravol 1 hr before taking)
- dizziness
- fatigue
- headache
- breast tenderness
- lower abdominal pain
- spotting/breakthrough bleeding
- altered timing of next cycle
115
true or false: pharmacists can prescribe Levonorgestrel EC
true - but can get oTC
116
if a patient vomits within this time period of taking Levonorgestrel EC, when should they repeat the dose
2 hours
117
true or false: hormonal contraception initiation needs to be delayed after EC use
false - can be started the day of or day after EC use
118
true or false: if a patient has a contraindication to COC they cannot use hormonal EC
false - b/c risk of having a clot in pregnancy is much higher than one dose of EC
119
true or false: Levonorgestrel EC is the best choice of EC for patients who are breastfeeding
true
120
this type of EC delays ovulation. it is a selective progesterone receptor modulator
ulipristal acetate EC
121
in what time period is ulipristal acetate EC the most effective
up to 5 days post intercourse
122
if a patient vomits within this time period of taking ulipristal acetate EC, when should they repeat the dose
3 hours
123
what are some s/e associated with ulipristal acetate EC
same as levo
- nausea
- vomiting (may take gravol 1 hr before taking)
- dizziness
- fatigue
- headache
- breast tenderness
- lower abdominal pain
- spotting/breakthrough bleeding
- altered timing of next cycle
124
what is a *possible* CI to using ulipristal acetate
preferably avoid in pateints who have used hormonal contraception or levo EC in the past 7 days
125
true or false: ulipristal acetate is less effective in people with BMI > 30
false - best oral EC in these patients
126
true or false: resuming hormonal contraception or initiation needs to be delayed after ulipristal use
true - do not initiate or resume regular hormonal contracpetion for at least 5 days after taking ulipristal
127
true or false: ulipristal is safe to use in breastfeeding
false - it is recommended to pump and discard milk for one week after taking ulipristal
128
this is the most effective EC. it is effective up to 7 days post intercourse; continues long term contraception after insertion
copper IUD
129
true or false: copper IUD is less effective in patients with a BMI > 30
false - most effective option for these patients
130
true or false: copper IUD is a safe EC option in breastfeeding
true
131
this is a method of emergency contraception that uses a combination of ethinyl estradiol and levonorgestrel, specifically 1 mg of norgestrel (or 0.50mg of levonorgestrel) and 100 mcg of ethinyl estradiol ASAP and again in 12 hrs.
yuzpe regimen
132
in what timeline is the yuzpe regimen effective
within 72 hours post intercourse
133
if a patient vomits within this time period of using yuzpe regimen EC, when should they repeat the dose
2 hours
134
this medication is used for medical termination of a developing intrauterine pregnancy with a gestational age up to 9 weeks as measured from the first day of the last menstrual period in a presumed 28 day cycle
Mifegymiso
135
what is the dosing for Mifegymiso for the termination of pregnancy
mifeprisone PO followed by misoprostol bucally 24-28 hrs after
136
this medicaiton in Mifegymiso blocks progesterone receptors, causing the endometrium to no longer sustain the growing embryo; the lining of the uterus then breaks down, and bleeding begins. is also triggers an increase in PG levels and dilates the cervix
Mifepristone
137
this medication in Mifegymiso induces contractions, relaxes the cervix leading to evacuation of the intrauterine content
misoprostol
138
when should a patient be followed up with a physician after taking mifepristone
7-14 days
139
true or false: return to fertility is delayed after taking Mifegymiso
false - return to fertility expected immediately
140
what are the red flags for prescribing any type of hormonal contraceptive
- history of breast cancer
- severe liver disease
- liver cancer
- active viral hepatitis
- at high risk for heart attack or stroke - SLE
- undiagnosed vaginal bleeding
141
what are the red flags for prescribing estrogen, that would result in a prescription for POP, LARC or DMPA
- diabetes with microvascualar disease OR >20 years
- uncontrolled hypertensions SBP >160 or DBP > 100 or hypertension with vascular disease
- migraine with aura
- DVT/PE risk
- complicated vascular disease
142
patients under what age need to be referred for prescribing of contraception
under 12
143
this medication is not recommended for patients under the age of 18 due to a possible impact on bone mass in people who are still growing
depo-provera
144
based on the product monograph of these three types on hormonal contraceptive, they are not recommended for those under the age of 18
patch
implant
ring
145
the pediatric society recommends this form of contraception no matter what age
IUD
146
the canadian contraception consensus guidelines recommend this method of contraception in post partum individuals regardless of breastfeeding status
progestin only
147
although the risk of VTE us the same in breastfeeding and non-breastfeeding women, the use of _______ is generally not recommended before 6 months post-partum in women who are breastfeeding
CHC
148
what should you do if a patient is started on a CHC, and they have complaints of increased acne
switch to higher EE or a progestin with less androgenic activity
149
what should you do if a patient is started on a CHC and they have complaints of increased bloating
switch progestin to drospirenone which has weak postassium sparing diuretic effects
150
what should you do if a patient is started on a CHC and they have complaints of breast tenderness, weight gain or headaches
switch to lower EE dose or progestin with less androgenic activity
151
what should you do if a patient develops migraines ir their migraines worsen after being on a CHC, what should you do
switch to progestin-only contraceptives
152
what should you do if a patient is started on a CHC and they have complaints of nausea
switch to a lower estrogen dose
153
what should you do if a patient is on a CHC but they're having breakthrough bleeding early in their cycles (after a 3 month trial)
switch to a higher estrogen dose
154
what should you do if a patient is on a CHC but they're having breakthrough bleeding late in their cycle (after 3 month trial)
switch to a higher progestin dose or a progestin that has higher progestin activity
155
what are some options for a patient who is having breakthrough bleeding who is on a progestin only contraceptive method
- switch to low dose COC x 1-3 days
- add estrogen x 10-20 days (oral conjugated estrogen or estradiol)
- add NSAIDs x 5-7 days
- add tranexemic acid 2-3 tabs 3-4 times a day for several days; routine use is not recommended
156
which progestin generation has the most progestrone and androgen effects
second
157
which first generation progestin thst has higher progesterone effects but less androgen effects
a) norethindrone
b) ethynodiol diacetate
norethindrone
