Contraception & Infertility Flashcards
(109 cards)
1
Q
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
A
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
2
Q
Childbearing years are from __
A
between ages 15 to 44 years old
3
Q
Menstrual Cycle Phases:
A normal menstrual cycle ranges from 23-35 days (average = 28 days).
The start of bleeding (menses) is day 1 of the cycle. This indicates that the next cycle has begun. The remnants of the previous cycle (the thick, bloody endometrial lining) are sloughing off.
Menstruation typically lasts a few days (2-5 days). Changes in hormone levels cause the events that characterize the different phases of the menstrual cycle.
A
4
Q
Menstrual Cycle Phases:
During what phase dose menses occur?
A
Follicular phase
- when the estrogen and progesterone levels start off low.
5
Q
Menstrual Cycle Phases:
What are the phases of the Menstrual cycle?
1)
2)
3)
A
1) Follicular phase
2) Ovulatory phase
3) Luteal phase
6
Q
Menstrual Cycle Phases:
The first ~14 days of the menstrual cycle, also called the ____________.
What is happening here is ________
During the end of this phase, what happens?
A
Follicular phase
that every follicle in a woman’s ovary there is an egg (oocyte - immature)
- in this phase FSH is helping to spur on the development of the follicle. Helping it mature and grow.
Approaching the end of the Follicular phase there is this rise in estrogen.
This rise in estrogen leads to a surge in (LH) luteinizing hormone AND (FSH) follicle stimulating hormone.
When we see that LH surge and that FSH that peak, this tells us that it is going to trigger ovulation about 24-36 hours later.
7
Q
Menstrual Cycle Phases:
Ovulation:
A
- the release of the egg (ova) from the ovary.
8
Q
Menstrual Cycle Phases:
The start of ovulation begins the ___________.
____________ is dominant in this phase.
A
Luteal (last) phase, which lasts ~14 days.
Progesterone.
9
Q
Pregnancy Kits:
_____________ is released when a fertilized egg attaches to the lining of the uterus (called implantation).
A home urine test can detect pregnancy sooner if the women tests the __________________, when it is the highest.
A
(hCG) Human chorionic gonadotropin -
- detecting hCG in the urine or blood indicates pregnancy*
- first urine in the morning* when hCG is the highest
(hCG) human chorionic gonadotropin - tells us a woman is pregnant.
10
Q
Fertility Awareness and Test Kits:
Ovulation kits predict the best time for intercourse by detecting LH in the urine. For someone trying to get pregnant and conceive a child.
- LH surge -> release of oocyte (egg) from the ovary into the fallopian tube.
- The egg lives for 24 hours and sperm can survive for ~ 3 days.
A positive ovulation test?
A person wishing to conceive should have intercourse when the LH surge is detected, and for the following 2 days (based on sperm survival of ~3 days).
A
- test will detect if patient has an LH surge
- which means, patient is going to have ovulation in the next 24-36 hours
- so have intercourse for the next 2 days to give yourself the best chance of becoming pregnant
LH - tells us when we are going to ovulate.
11
Q
Preconception Health:
- focuses on steps to take to protect the health of the baby in the future.
- any woman planning to conceive (and all women of childbearing age) should:
1)
2)
3)
A
1) Increase their folic acid (folate, vitamin B9) consumption from a combination of dietary supplements and fortified foods (e.g. dried beans, leafy green vegetables, oranges). Before becoming pregnant.
- Folic acid supplementation: Adults are recommended to take 400mcg of dietary folate equivalents (DFE) per day to help prevent neural tube defects.
[During pregnancy this requirement increases to 600mcg DFE/day].
2) Lifestyle changes:
- No alcohol
- No illicit drugs
- Avoid smoking
- Keep vaccinations up to date
- Avoid toxic chemicals (hazardous drugs)
12
Q
Contraception:
Fertility-Awareness Based Methods-
A
- 24% failure rate
- not very effective
- non-pharmacologic option
- essentially knowing your cycle, know when you are ovulating and making sure you are not having sex in that window.
13
Q
Contraception:
- can be used until ready to conceive.
- a prompt return to fertility occurs when most contraceptives are discontinued.
- the only reversible contraceptive method that has a delay in return to fertility is the medroxyprogesterone injection.
A
Nonpharmacologic & OTC contraceptive methods:
14
Q
Contraception:
Male condoms-
Female condoms-
A
Male condoms:
- 18% failure rate
- a thin latex or plastic sheath worn on the penis.
- OTC
Female condoms:
- 21% failure rate
- has a closed end at the top, which is the part that gets inserted into the vagina.
- OTC
[Never recommend oil-based lubricant for use with latex or non-latex synthetic condom.] Only recommend water or silicone-based lubricants.
Condoms- are the ONLY method that provide some protection with STDs. As long as they are latex or synthetic.
15
Q
Contraception:
Spermicide-
A
[nonoxynol-9] - spermicide used in this country.
- 28% failure rate
- can be used alone or with other barrier methods
- not very effective alone, preferred with other contraceptive methods
- Do not use with anal sex, causes irritation
- can increase risk of STD/HIV transmission
- OTC
16
Q
Contraception:
Phexxi-
A
(lactic acid, citric acid, and potassium bicarbonate, 1.8%, 1%, 0.4%)
- a prescription option (Rx)
- a vaginal gel that maintains an acidic pH (range 3.5-4.5), which is inhospitable to sperm and reduces their mobility.
- should NOT be used with vaginal rings or in those with a history of UTIs or urinary tract infections.
- comes in a box of #12 (5 gram) pre-filled single dose vaginal applicators.
17
Q
Contraception:
Rx
-Injectable-
Options include:
A
- 6% failure rate
18
Q
Contraception:
Rx
-Pill-
A
- 9% failure rate
(Natazia) - indicated for heavy menstrual bleeding.
19
Q
Contraception:
Rx
-Patch-
Options include:
A
- 9% failure rate
20
Q
Contraception:
Rx
-Ring-
Options include:
A
- 9% failure rate
21
Q
Contraception:
Rx
-Diaphragm-
Options include:
A
- 12% failure rate
22
Q
Contraception:
Rx
-Implant-
Options include:
A
- 0.05% failure rate
- is reversible
23
Q
Contraception:
Male sterilization
(Vasectomy)
A
0.15%
- permanent
24
Q
Contraception:
Rx
-Intrauterine Device (IUD)-
Options include:
A
- LNG 0.2% failure rate
- reversible
- Copper T 0.8% failure rate
- reversible
25
Contraception:
Female sterilization
(Hysterectomy)
0.5%
- permanent
26
Hormonal Contraceptives:
Estrogen and Progestin Combination Oral Contraceptives (COC):
- Most contain Ethinyl Estradiol (EE) AND a progestin [e.g. norethindrone, levonorgestrel (LNG), drospirenone]
-
There are different formulations of COC:
*-Monophasic: COCs have the same dose of estrogen and progestin throughout all the pills in the packet.
-Biphasic, Triphasic, and Quadriphasic pill packs: mimic the estrogen and progesterone levels during a menstrual cycle. The type of formulation (e.g. triphasic) refers to the number of times the amounts of the hormones change (e.g. three times).
27
Hormonal Contraceptives:
How do they work?
What does FDA require with these drug products being dispensed?
Options include:
- they work by inhibiting the production of FSH AND LH, which prevents ovulation*
- by inhibiting the production of FSH and LH, we don't get that surge of hormones approaching the end of the Follicular phase signaling ovulation. So no egg is released.
- they alter the cervical mucus, which inhibits the sperm from penetrating the egg.
(COC) combination oral contraceptives (estrogen/progestin)
-
-
-
(CHC) combined hormonal contraceptives (NOT oral)
- patch
- ring
-
-
(POP) Progestin Only Pill options
-
-
-
--- **a (PPI) Patient Package Insert with all oral contraceptives.**
28
Hormonal Contraceptives:
**Drospirenone**- a unique progestin, it is a mild potassium-sparring diuretic with lower androgenic activity. [so raises potassium]
- Less bloating, weight gain, PMS, symptoms, acne
- also associated with less acne, as they have anti-androgenic activity
Other progestins with LOW androgenic activity include:
-
-
-
--------------------------------------------------------------------------------------------------------------------
-
- norgestimate*[
- desogestrel [
- dienogest [
29
Hormonal Contraceptives:
Progestins include:
- norethindrone
- levonorgestrel (LNG)
--------------------------------------------------------------------------------------------------------------------
- drospirenone
-
-
--------------------------------------------------------------------------------------------------------------------
- norgestimate*[
- desogestrel [
- dienogest [
30
Hormonal Contraceptives:
Treatment of Other Indications- (besides pregnancy prevention)
What are other indications COC's are used for?
Other uses:
- dysmenorrhea (menstrual cramps, painful)
-
- premenstrual syndrome (PMS)
-
- acne (in females)
-
- anemia (by reducing blood loss)
-
- polycystic ovary syndrome (COCs are first line to regulate menses in those with PCOS) [PCOS- where infrequent, irregular or prolonged menstrual periods are common].
-
- endometriosis (when endometrial tissue grows outside of the uterus) - COCs are first line treatment for endometriosis.
-
- peri-menopausal symptoms (hot flashes, night sweats)
-
- menstrual-associated migraine prophylaxis
-
- heavy menstrual bleeding (menorrhagia)
31
Hormonal Contraceptives:
Progestin-Only-Pill (Mini-Pills):
- ONLY Progestin
- Contain NO estrogen
- 28-day packs (ALL pills are ACTIVE)
-
What is the MOA?
What are the Key points with adherence for POP?
-
-
- prevent pregnancy by suppressing ovulation, thickening the cervical mucus to inhibit sperm penetration and thinning the endometrium.
- require good adherence.
- take at the same time everyday
- If greater than > or equal to 3 hours have elapsed from the regularly scheduled time, a back-up contraceptive is required for 48 hours.
- No placebo week
- No placebo days
32
Hormonal Contraceptives:
When would we use a "POP" Progestin Only Pill?
- in women who are breastfeeding. (Estrogen causes decreases in milk production)
- can be useful for women with a contraindication or intolerance to estrogen/ Can be started soon after delivery (3-6 weeks postpartum). It is not safe to use estrogen this early after delivery because of increased risk of thrombosis.
- women who have migraines with aura (estrogen increases the risk of stroke), progesterone only pills are safe to use in women who have migraines with aura.
-
-
- estrogen increases risk of stroke AND migraines with aura are associated with increased stroke risk. So you would be doubling that risk using an estrogen product.
33
Non-Oral Hormonal Contraceptives:
Contraceptive Patch: KEY NOTES TO KNOW
*- the patch has the same side effects, contraindications and drug interactions as (COCs) Combined Oral Contraceptives.
*- the patch causes HIGHER systemic estrogen exposure. It should NOT be used in anyone with clotting risk factors.
*- the patch is less effective in women greater than > 198 lbs or BMI > 30 kg/m2
*- Do NOT use the patch in women greater than > 35 years old who smoke.
- (Xulane) norelgestromin & ethinyl estradiol
- - - used to be called Orthoevra, no longer on market.
- (Twirla) levonorgestrel & ethinyl estradiol
34
Non-Oral Hormonal Contraceptives:
Contraceptive Patch
Key Counseling Points-
Apply patch transdermally for ONE week then remove. Do this for Weeks 1-3. Then no patch on for Week 4.
35
Non-Oral Hormonal Contraceptives:
Vaginal Contraceptive Rings: KEY POINTS TO KNOW
-
- the exact position of the ring does not matter.
- these are small flexible rings that are inserted in the vagina once a month.
- the vaginal rings have the same side effects, contraindications and drug interactions as oral contraceptives.
NuvaRing (etonogestrel & ethinyl estradiol)
EluRyng (etonogestrel & ethinyl estradiol)
Annovera (segesterone acetate & ethinyl estradiol)
36
Non-Oral Hormonal Contraceptives:
Vaginal Contraceptive Rings
Key Counseling Points-
NuvaRing (etonogestrel & ethinyl estradiol)
- the ring is to remain in place continuously for 3 weeks, then removed and disposed of. No ring for week 4.
-
-
EluRyng (etonogestrel & ethinyl estradiol)
- the ring is to remain in place continuously for 3 weeks, then removed and disposed of. No ring for week 4.
-
-
Annovera (segesterone acetate & ethinyl estradiol)
- vaginal ring is in for 3 weeks, then is removed for 1 week. Wash and store while it is removed for that one week, then reinsert. Used for one year.
- Is good for 13 cycles!!
37
Non-Oral Hormonal Contraceptives:
Injectable Contraception: KEY POINTS TO KNOW
-
- Can be given IM or SC every 3 months
- a progestin
-
-
-
What is MOA?
(Depo-Provera) - medroxyprogesterone acetate-DMPA
IM injection is 150mg.
(Depo-subQ Provera 104)
SC is 104mg.
- it causes thickening of cervical mucus and thinning of the endometrium
38
Non-Oral Hormonal Contraceptives:
Injectable Contraception
Key Counseling Points-
39
Non-Oral Hormonal Contraceptives:
(IUDs) Intrauterine Devices: KEY POINTS TO KNOW
-
- Long acting
-
(Mirena)- levonorgestrel
- 7 years
- approved for heavy menstrual bleeding
-
(Liletta)- levonorgestrel
- 6 years
-
-
(Kyleena)- levonorgestrel
- 5 years
-
-
(Skyla)- levonorgestrel
- 3 years
-
-
40
Non-Oral Hormonal Contraceptives:
(IUDs) Intrauterine Devices
Key Counseling Points-
41
42
Orilissa
elagolix
- FDA approved for moderate to severe pain associated with endometriosis.
43
Oriahnn
contains: (estradiol, norethindrone, and elagolix.)
- is indicated for heavy menstrual bleeding associated with uterine fibroids.
- NOT a contraceptive (not intended to prevent pregnancy).
44
Lysteda
tranexamic acid
(antifibrinolytic)
- is a nonhormonal treatment for menorrhagia**
oral formulation
45
Natazia
(estradiol valerate and estradiol valerate/dienogest) tablets
-
-
-
Each blister pack contains 28 round, biconvex, film-coated tablets in the following order:
Natazia (estradiol valerate and estradiol valerate/dienogest) tablets provide an oral contraceptive regimen consisting of 26 active film-coated tablets that contain the active ingredients specified for each tablet below, followed by two inert film-coated tablets:
*
2 dark yellow tablets each containing 3 mg estradiol valerate
*
5 medium red tablets each containing 2 mg estradiol valerate and 2 mg dienogest
*
17 light yellow tablets each containing 2 mg estradiol valerate and 3 mg dienogest
*
2 dark red tablets each containing 1 mg estradiol valerate
*
2 white tablets (inert)
46
Contraception and menstrual periods:
*Most (COC) Combined Oral Contraceptives have 28 days (4 weeks) of pills
-- 21-24 pills are "ACTIVE" containing hormone
-- the remainder are inactive (placebo) pills, or contain iron or folate
-- during week 4 (when taking inactive pills) --------> MENSES occurs
*Extended-cycle COCs have 84 days (12 weeks) of active hormone pills
-- Bleeding "MENSES" occurs every 3 months
-- Seasonique
*Continuous contraception ------------> suppresses menses altogether
-- Amethyst
47
**Extended-cycle (COCs) Combined Oral Contraceptives:
- have 84 days (12 weeks) of active hormone pills PLUS either
[7 days of very low estrogen pills OR 7 days of placebo pills.]
- bleeding "MENSES" occurs every 3 months
- a lot of women like this, less bleeding and less frequent periods they have disrupting their lives.
What are examples of extended-cycle COCs?
- (Seasonique) - levonorgestrel + ethinyl estradiol
84 light blue-green tablets, each containing 0.15 mg of levonorgestrel and 0.03 mg ethinyl estradiol.
7 yellow tablets each containing 0.01 mg of ethinyl estradiol.
--------------------------------------------------------------------------------------------------------------------
- (Jolessa)- levonorgestrel + ethinyl estradiol
is an extended-cycle combination oral contraceptive consisting of 84 pink active tablets each containing 0.15 mg of levonorgestrel, a synthetic progestin and 0.03 mg of ethinyl estradiol, an estrogen, and 7 white inert tablets (without hormones).
--------------------------------------------------------------------------------------------------------------------
- (Camrese)-[levonorgestrel/ethinyl estradiol tablets & ethinyl estradiol tablets]
is an extended-cycle oral contraceptive consisting of 84 light blue-green tablets each containing 0.15 mg of levonorgestrel, a synthetic progestogen and 0.03 mg of ethinyl estradiol, and 7 yellow tablets containing 0.01 mg of ethinyl estradiol.
--------------------------------------------------------------------------------------------------------------------
- (Camrese Lo)
is an extended-cycle oral contraceptive regimen of 84 orange tablets each containing 0.1 mg levonorgestrel and 0.02 mg ethinyl estradiol, followed by 7 yellow tablets each containing 0.01 mg ethinyl estradiol.
--------------------------------------------------------------------------------------------------------------------- (Amethia)
an extended-cycle oral contraceptive consisting of 84 white tablets each containing 0.15 mg of levonorgestrel, a synthetic progestogen and 0.03 mg of ethinyl estradiol, and 7 light blue tablets containing 0.01 mg of ethinyl estradiol.
48
**Continuous contraception:
- suppresses menses altogether
What are examples of Continuous contraception?
- Amethyst (levonorgestrel 0.09mg and ethinyl estradiol tablets 0.02mg)
90 mcg levonorgestrel and 20 mcg ethinyl estradiol) is available in a 28-tablet dispenser, arranged in 4 rows of 7 active tablets.
- No INACTIVE pills (taken continuously), so NO period occurs.
49
**Select Contraceptive Types: **
- if product name contains- "Lo"
like (e.g. Loestrin), this means ________
- the product has a low level of estrogen.
- less than or equal to 35mcg (0.035mg) of estrogen
other examples include:
Camrese Lo
Loryna
Ortho Tri-Cyclen Lo*
Lo Loestrin Fe
50
**Select Contraceptive Types: **
- if product name contains- "Fe"
like (e.g. Loestrin Fe), this means _________
- the product includes an iron supplement in the dosing regimen.
other examples include:
Lo Loestrin Fe
Junel Fe
Microgestin Fe
Minastrin 24 Fe
51
**Select Contraceptive Types: **
- if product name contains- "24"
like (e.g Loestrin 24 Fe) this means _________
- the product has a SHORTER PLACEBO time**
- there is 24 active pills of hormone + 4 inactive (or Fe iron) pills
other examples include:
Minastrin 24 Fe
Loestrin 24 Fe
52
**Select Contraceptive Types: **
- if product name contains- Tri or 7/7/7/
like (e.g. Tri-Sprintec, Nortrel 7/7/7/) this means _____
- the product has 3 DIFFERENT HORMONE STRENGTHS for each "phase" or week
other examples include:
--------------------------------------------------------------------------------------------------------------------
(Trivora)
-Six blue tablets containing 0.05 mg of levonorgestrel and 0.03 mg of ethinyl estradiol.
-Five white tablets containing 0.075 mg of levonorgestrel and 0.04 mg of ethinyl estradiol.
-Ten pink tablets containing 0.125 mg of levonorgestrel and 0.03 mg of ethinyl estradiol.
- (placebo) Seven peach inert tablets. The peach inert tablets are unscored, round in shape with "WATSON" debossed on one side and "P1" on the other side.
--------------------------------------------------------------------------------------------------------------------
(Tri-Sprintec)
7 gray, round, flat-faced, beveled-edge, unscored tablets debossed with stylized b on one side and 985 on the other side contains 0.18 mg norgestimate, USP and 0.035 mg ethinyl estradiol, USP
7 light blue, round, flat-faced, beveled-edge, unscored tablets debossed with stylized b on one side and 986 on the other side contains 0.215 mg norgestimate, USP and 0.035 mg ethinyl estradiol, USP
7 blue, round, flat-faced, beveled-edge, unscored tablets debossed with stylized b on one side and 987 on the other side contains 0.25 mg norgestimate, USP and 0.035 mg ethinyl estradiol, USP
7 white, round, flat-faced, beveled-edge, unscored tablets debossed with stylized b on one side and 143 on the other side contains inert ingredients.
- estrogen strength same each week)
--------------------------------------------------------------------------------------------------------------------(Nortrel 7/7/7)
(norethindrone and ethinyl estradiol tablets: 0.5/0.035 mg, 0.75/0.035 mg, and 1/0.035 mg
- estrogen strength same each week
53
**Select Contraceptive Types: **
- if product name contains- "Nor"
like (eg Nora-BE) this means ______
- the product contains the progestin [norethindrone]
other examples include:
Nortrel 7/7/7
54
**Select Contraceptive Types: **
- if product name contains- "Pro"
like (eg Depa-Provera) this means ______
- the product contains a progestin
other examples include:
55
Adverse Effects of Hormonal Contraceptives: Estrogen
What might a woman expect when starting an oral contraceptive or any hormonal product.
Common and nonspecific side effects include:
-
-
-
How can we take care of SE?
side effects of estrogen are very common and non-specific*
These include:
- stomach upset, nausea*, breast tenderness*/fullness, bloating*, weight gain*, elevated blood pressure* (not a huge increase maybe ~5-8 mmHg)
--------------------------------------------------------------------------------------------------------------------Reducing the estrogen dose, less side effects but a dose too low can cause breakthrough bleeding (spotting).
- any nobody wants to have random bleeding when they are not expecting it, is bothersome.
- - - Lower estrogen = Less side effects but more breakthrough bleeding (spotting)
56
Adverse Effects of Hormonal Contraceptives: Estrogen
If a woman has spotting early to mid-cycle, then ________________
A higher dose of estrogen is needed in product.
57
Severe and Rare issues associated with Estrogen:
- - (recognizing symptoms of thrombosis):
what might you think of to recognize a clot?
**remember; ACHES**
A
C
H
E
S
[estrogens are known to cause thrombosis (a clot).]
-ACHES-
-
A- abdominal pain (mesenteric or pelvic thrombosis)
-
C- chest pain (sharp, crushing or heavy pain can indicate a heart attack. Shortness of breath can indicate a PE (a blood clot in the lungs).
-
H- headache (sudden and severe with vomiting or weakness/numbness on one side of the body can indicate stroke)
-
E- eye problems (blurry vision, flashing lights or partial/complete vision loss can indicate a blood clot in the eye)
-
S- swelling or sudden leg pain (can indicate a DVT- a blood clot in the leg)
58
Adverse effects of Hormonal Contraceptives: Progestin
What might a woman expect when starting an oral contraceptive or any hormonal product.
Common and nonspecific side effects include:
-
-
-
How can we take care of SE?
- progestin can cause breast tenderness, headache, fatigue and depression
59
Adverse effects of Hormonal Contraceptives: Progestin
If a woman is having Late-cycle breakthrough bleeding, then ____
A higher dose of progestin in the product is needed.
60
Adverse effects of Hormonal Contraceptives: Progestin
Which progestin has a slightly higher risk of clotting and should NOT be used in women with clotting risk?
- drospirenone
61
Adverse effects of Hormonal Contraceptives: Progestin
which progestin can also increase (K) potassium levels AND should NOT be used in those with kidney, liver or adrenal gland disease?
What is the normal range for potassium (K)?
- drospirenone
[3.5-5 mEq/L]
62
Adverse effects of Hormonal Contraceptives: Progestin
Which progestin can cause a loss in bone mineral density?
AND what do teens and young women who are still accumulating bone mass, should they be counseled on with this product?
injectable depot medroxyprogesterone acetate
Patient should take Calcium and Vitamin D
63
64
**Risks of Hormonal Contraceptives**:
Boxed Warnings: What are the Boxed Warnings for each of the following?
ALL estrogen containing products (pills, patch, ring)
-
Estrogen + Progestin transdermal patch
-
Depo-Provera
-
ALL estrogen containing products (pills, patch, ring)
- DO NOT USE in women greater than 35 years of age AND smoke due to the risk of serious cardiovascular events.
-
Estrogen + Progestin transdermal patch
- INCREASED risk of VTE (DVT/PE) compared to COCs
-
Depo-Provera
- Loss of bone mineral density with long term use (increased risk of developing osteoporosis) [making sure patient is on enough calcium and vitamin D]
65
**Risks of Hormonal Contraceptives**:
Do NOT Use Estrogen in women with what conditions?
VERY specific contraindications to not be using estrogen*
- History of DVT/PE*, stroke*, CAD*, thrombosis of heart valves or acquired hypercoagulopathies.
-
- History of breast*, ovarian* or liver cancer*; liver disease; uncontrolled hypertension (e.g. > 160/100 mmHg)
-
- Severe headaches or migraines with aura* (especially if > 35 years of age); diabetes with vascular disease; unexplained uterine bleeding [ we would want to figure this out first before dispensing product, could be cancer],
-
66
Considerations for Drug Selection:
If patient has Acne or Hirsutism (unexpected hair growth), then use _____
a progestin that has lower androgenic activity (norgestimate- Sprintec) or a progestin that has NO androgenic activity - [drospirenone-Yaz, Yasmin]
67
Considerations for Drug Selection:
If patient is breastfeeding, then use _________
- a progestin only pill (POPs) or nonhormonal contraception
68
Considerations for Drug Selection:
If patient has an estrogen contraindication (including clotting risk), then use ___
- a progestin only pill (POPs) or nonhormonal contraception
69
Considerations for Drug Selection:
If patient has migraines with aura, then use ___________
a progestin only pill (POPs) or nonhormonal contraception method
70
Considerations for Drug Selection:
If patient is having fluid retention/bloating, then use
a product containing drospirenone [Yaz, Yasmin]
71
Considerations for Drug Selection:
If patient is overweight, then use
- choose any method and counsel patient about the possibility of reduced effectiveness with the contraception patch. Do NOT use DMPA if trying to avoid further weight gain.
72
Considerations for Drug Selection:
If patient is having heavy menstrual bleeding, then ___
trialing a COC with only 4 placebo pills (rather than 7 placebo pills) or continuous/extended regimens will minimize bleeding time.
- the COC Natazia and the IUD levonorgestrel releasing Mirena are indicated for heavy menstrual bleeding.
73
Considerations for Drug Selection:
If patient has high blood pressure and it is not well controlled, then use ___
a progestin only pill (POPs) or nonhormonal contraception.
74
Considerations for Drug Selection:
If patient wishes to avoid monthly cycle/menses, then use _______
an extended (91-day) or continuous formulations.
an alternative would be to use monophasic 28-day formulation and skip placebo pills.
75
Considerations for Drug Selection:
If patient is having mood changes or disorder, then use ________
a monophasic COC--- extended cycle or continuous with drospirenone is preferred.
76
Considerations for Drug Selection:
If patient is having nausea, then ______
have patient take at night; consider decreasing estrogen dose (which will have less GI symptoms but may increase spotting around menses) OR switch patient to POP, vaginal ring or nonhormonal method (ideally after 3 month trial)
77
Considerations for Drug Selection:
If patient is postpartum, then _________
Patient CANNOT use combined hormonal contraception for 3 weeks or 6 weeks if patient has additional risk factors for VTE.
Patient can use POP starting at 6 weeks and nonhormonal method during this time.
78
Considerations for Drug Selection:
If patient has (PMDD) Premenstrual Dysphoric Disorder, then
Use Yaz or antidepressant.
79
Considerations for Drug Selection:
80
Considerations for Drug Selection:
81
Considerations for Drug Selection:
82
POP or Non-hormonal method:
Use in women who are _______
- breastfeeding
- 3-6 weeks postpartum
- contraindication to estrogen
- migraine with aura
- uncontrolled BP
83
Drospirenone Containing Product:
Use in women who _______
- have acne
- fluid retention/bloating
- mood changes or disorder
- (PMDD) Premenstrual Dysphoric Disorder (Yaz is indicated for PMDD) or [alternative antidepressant]
84
Other considerations:
For Mood changes or disorders:
monophasic, extended or continuous-cycle COC
"won't have those big shifts in hormones, receiving a constant dose or hormone."
85
Other considerations:
For menorrhagia (heavy menstrual bleeding):
Natazia, or Mirena IUD
- both are indicated for this condition.
Could also consider COCs with only 4 placebo pills (rather than 7 placebo pills) or continuous/extended regimens will minimize bleeding time.
86
Drug Interactions with Hormonal Contraceptives:
*Check package labeling to avoid missing an interaction.
- recommend back up contraception method if needed (condoms/spermicide)
Drugs that decrease hormonal contraception efficacy.
**Strong Inducers**:
- rifampin (requires a back-up method for 6 weeks after discontinuation), rifabutin, rifapentine.
- Anticonvulsants (e.g. phenytoin, carbamazepine, oxcarbazepine, primidone, lamotrigine, topiramate, barbiturates, perampanel)
- St. John's wort
- Tobacco
- ritonavir-boosted protease inhibitors (PIs), bosentan (Tracleer), mycophenolate (CellCept, Myfortic)
-
Risks with Hepatitis C treatments:
Drospirenone Drug Interactions:
- the inducers help induce the metabolism of substrate drugs. Reducing the level of the drugs.
Viekira, Mavyret, & Tecnive products are contraindicated with ethinyl estradiol containing products. The combination causes liver toxicity.
- If patient is on an ace inhibitor, angiotensin receptor blocker, and spironolactone (aldosterone antagonist) then the risk of Hyperkalemia is even greater if being put on drospirenone.
87
Starting Birth Control: Combination Oral Contraception
- It takes ~7 days of treatment to achieve efficacy
- Requires back-up (non-hormonal contraception) for 7 days
----------------------------------------------------------------------------------------------------------------
-1) Start today ("quick start method"): maximizes protection from unintended pregnancy.
---------------------------------------------------------------------------------------------------------------
-2) "Sunday start method" preferred by women: Start the Sunday after onset of menstruation.
---------------------------------------------------------------------------------------------------------------
-3) COCs can also be started on the first day of menses "her period". If started within 5 days after the start of the period, no back-up method of birth control is needed; protection is immediate. If NOT within 5 days of menses, then use back-up method for 7 days.
2) Sunday start method: This is commonly used if the patient prefers that menstruation occur during the week and is complete before the following weekend.
- this method requires back-up (nonhormonal) contraception for 7 days.
--------------------------------------------------------------------------------------------------------------------
Late or Missed Pills:
88
Starting Birth Control: Progestin-Only-Pills
-
- Takes ~48 hours to achieve efficacy. Protection begins after 2 days.
- requires a back-up method for 48 hours when you start.
- Start any time: all come in 28-day packs and all pills are active.
- Must have good compliance taking pill every day at the same time within a 3-hour window.
Late or Missed Pills:
-
- If you miss dose from your 3-hour timing window, then you have to use a back up method for 48 hours.
Late or Missed Pills:
- Start as soon as remembered
- If more than one COC pill is missed, back-up contraception is required.
89
Late or Missed Pills - Instructions for Typical formulations:
For (COCs) Combined Oral Contraception pills-
- - If 1 late or missed pill AND it has been less than < 48 hours since last dose, THEN _________
Is Back up contraception method required?
Emergency contraception needed?
- Take miss pill as soon as possible AND take next dose on schedule (even if that makes 2 pills in 1 day*).
- Back up contraception is NOT required
- Emergency contraception is NOT usually needed if you just missed one pill
BUT if the missed doses are earlier in the same cycle or in Week 3 of the previous cycle. [Then maybe can consider it]
90
Late or Missed Pills - Instructions for Typical formulations:
For (COCs) Combined Oral Contraception pills-
-- If 2 missed pills AND it has been 48 hours or greater since the last dose, AND missed pills were during Week 1 or Week 2, THEN ___
Back up contraception method required?
Emergency contraception needed?
- Take the most recent missed pill as soon as possible (discard any other missed pills). Take next dose on schedule (even if that makes 2 pills in 1 day).
- If you missed 2 pills. YES, back up non-hormonal contraception is required for 7 days.
- Can consider (EC) Emergency Contraception if 2 missed pills were during Week 1 AND if had unprotected sex in last 5 days.
91
Late or Missed Pills - Instructions for Typical formulations:
(POPs) Progestin Only Pills
- - If greater than > 3 hours past scheduled time to take pill, Then ___
Back up contraception method required?
Emergency contraception needed?
Take pill as soon as possible and take next dose on schedule.
Back up non-hormonal contraception is required for 48 hours (2 days).
Can consider (EC) Emergency Contraception if unprotected sex in last 5 days.
92
Late or Missed Pills - Instructions for Typical formulations:
For (COCs) Combined Oral Contraception pills-
-- If 2 missed pills AND it has been 48 hours or greater since the last dose, AND
missed pills was during Week 3, then ___
Back up contraception method required?
Emergency contraception needed?
Skip the Hormone Free Week (Week of Placebo Pills) AND Start next pack of pills right after
- If you missed 2 pills. YES, back-up nonhormonal contraception for 7 days.
- If 2 missed pills during Week 2 or Week 3: Can consider (EC) emergency Contraception
93
94
Patient Counseling for Non-Oral Formulations:
Xulane Contraception Patch:
-
- a thin, beige color, plastic patch
- place on clean, dry skin of buttocks, stomach, upper arm, or upper torso.
- Do NOT apply to breasts.
- apply once weekly for 7 days (for weeks 1, week 2 and week 3).
-** Start on day 1 (no back-up needed) or Sunday (back-up needed for 7 days)**
- If the patch becomes loose or falls off for > 24 hours during the 3 weeks of use, or if > 7 days have passed during the 4th week where NO patch is required, there is a risk of pregnancy. A back-up method should be used for one week after starting a new patch.
95
Patient Counseling for Non-Oral Formulations:
NuvaRing Vaginal Contraception Ring:
-
- the ring is inserted into the vagina once a month
- Exact position does not matter.
- ring is kept in place for 3 weeks of use and is then removed for 1 week, before replacement with a new ring.
-
- Start on Day 1 of menstrual bleeding**
-** If inserted on Days 2-5, a back-up method of contraception is required for 7 days**.
Notes to Pharmacist:
- Store for up to 4 months at room temperature (refrigerate prior to dispensing)
- The ring is effective for up to 4 weeks and, though not FDA approved, can be kept in place to prevent a period**.
-
- If the ring is kept in place for greater than > 4 weeks, confirm no pregnancy, then insert a new ring and use back up contraception until the new ring has been in place for 7 days.
96
Long-Acting Reversible Contraceptives:
(IUDs) Intrauterine devices
[Hormonal IUDs]: contain levonorgestrel.
- Mirena: inserted into the uterus for up to 5 years; approved for heavy menses
- Skyla: inserted into the uterus for up to 3 years;
[Copper-T IUD]
- Paragard: inserted for up to 10 years, can be used for emergency contraception or regular birth control.
[Implant]
Nexplanon: a plastic rod implanted subdermally in arm, releases etonogestrel for 3 years.
Mirena- 7 years for prevention of pregnancy
- FDA approved for menorrhagia (heavy menstrual bleeding) for ~ 5 years
- about 20% of women will become amenorrheic
-
Liletta- 6 years
-
Kyleena- 5 years
-
Skya- 3 years
-
(all contain levonorgestrel)
----------------------------------------------------------------------------------------------------------------------------
97
Emergency Contraception (EC):
- is any form of contraception, hormonal or nonhormonal, that is used after unprotected intercourse to prevent pregnancy.
Types of (EC) Emergency Contraception:
1) ParaGard IUD
-
2) (Ella) ulipristal
-
3) (Plan B) levonorgestrel
-
----------------------------------------------------------------------------------------------------------------------------------
- How well does each work?
How soon do I have to use it?
How do I use it?
Where can I get it?
1) ParaGard (copper) IUD
- 99.9% effective
- must be placed by a medical provider within 5 days.
- is placed in the uterus by a doctor or nurse
- from a doctor, nurse or at a clinic.
- Do not prevent implantation of a fertilized egg. (So, they do NOT cause an abortion and they do not terminate an established pregnancy).
2) (Ella) ulipristal
- an oral option that requires Rx (prescription)
- less effective in women weighing greater than > 195 lbs (88.6 kg) or if BMI > 30 kg/m2.
- works better the sooner you take. ASAP within 5 days.
- From a doctor, nurse, or at a clinic.
-
3) (Plan B) levonorgestrel
- an oral option that's OTC
- works better the sooner you take. ASAP within 3 days
- At a pharmacy, no prescription is needed.
-
[These don't protect against Sexually Transmitted Diseases]
98
Who May Benefit from (EC)?
Emergency Contraception (EC):
Contraceptive failure:
- condom breaks
- missed oral contraceptive pills
- displacement of a barrier method (e.g. diaphragm)
No contraceptive used:
- Unplanned intercourse
- No contraception available
Sexual assault
99
Emergency Contraception (EC):
(Plan-B) levonorgestrel:
MOA:
Primary side effects:
- packaged as one tablet of 1.5mg levonorgestrel
- reduces the risk of pregnancy by up to 89% if started within 72 hours (3days) after unprotected sex.
- the sooner you take it the higher the efficacy.
- is OTC with no age restrictions.
- no requirement to sign a registry, patient can pay for multiple doses.
- prevents or delays ovulation and thickens cervical mucus
- Nausea/ Vomiting
- so an anti-emetic one hour before use and caution if driving due to sedation.
-
-** If woman vomits with 2 hours of taking the medication, she should consider repeating the dose**
100
Emergency Contraception (EC):
(Ella) ulipristal acetate:
MOA:
Primary side effects:
- a single 30mg oral tablet dose is taken, up to 5 days after unprotected intercourse.
- requires a prescription
- ulipristal is used to delay ovulation.
-
- chemical cousin to mifepristone (Mifeprex) also known as "abortion pill" or RU-486
- they are not the same drug
- - - - used to terminate pregnancy
- ulipristal acetate is lower potency.
101
medroxyprogesterone
102
103
Infertility:
- inability to get pregnant after greater than > 1 year of unprotected intercourse.
The treatment of choice for females depends on the cause of the infertility.
**Infertility drug act like endogenous hormones to trigger ovulation (the release of the egg).**
- - - They can trigger the release of multiple eggs and have increased risk of multiple births.
**Remember: increase LH and FSH surge triggers ovulation**
1) clomiphene:
- 1st-line
- a selective estrogen receptor modulator (SERM), an oral tablet used to induce ovulation.
- drug acts like estrogen to increase LH and FSH levels, which triggers ovulation.
2) letrozole:
- an aromatase inhibitor, an oral tablet used to induce ovulation
- drug suppresses estrogen to increase FSH levels causing it to surge and trigger ovulation.
3) gonadotropins:
- 2nd-line
- these are used after a poor response to clomiphene
- *are not taken orally but are administered SC or IM injection*.
- drugs act as LH, FSH, or hCG (similar to LH) and trigger ovulation.
- trigger ovulation by acting similar to the endogenous (naturally produced) gonadotropins FSH or LH.
104
Menopur
105
Follistim AQ
105
Gonal-f
106
Pregnyl
107
Novarel
108
Ovidrel
