Contraception, Infertility, Pregnancy, & Lactaction Flashcards
(37 cards)
What are the 3 phases of the menstrual cycle?
Follicular - FSH spurs follicle development and causes estrogen to surge. Estrogen peaks by the end of this phase, which causes luteinizing hormone (LH) and FSH to increase.
Ovulatory - the LH surge triggers ovulation 24-36 hours later. Ovulation is the release of the egg (ova) from the ovary.
Luteal - The start of ovulation begins the luteal phase. Progesterone is dominant in this phase.
What do ovulation kits do/test for?
Ovulation kits predict the best time to have intercourse.
These kits test for LH in the urine and are positive if LH is present (LH surge results in the release of the oocyte (egg) from the ovary into the fallopian tube. The egg lives for 24 hours once released).
A person wishing to conceive should have intercourse when the LH surge is detected and for the following 2 days.
What hormone is released when the fertilized egg attaches to the lining of the uterus?
human chorionic gonadotropin (hCG) is released.
hCG can be detected in the urine or blood, which indicates pregnancy. Testing urine first thing in the morning is when the hCG will be the strongest.
What 5 things should all women do if they are planning to conceive?
- Increase their folic acid (ex. dried beans, leafy green vegetables, oranges, supplements). Adults are recommended to take 400mcg of dietary folate per day, but during pregnancy it’s recommended to have 600mcg dietary folate equivalents per day.
- Stop smoking, using illicit drugs, and drinking excessive amounts of alcohol
- Keep vaccinations current
- Avoid toxic chemicals (including hazardous drugs)
- Consult with a healthcare provider to evaluate the teratogenic potential of all current medications
What is the only reversible contraceptive method that has a delay in return to fertility? What is a unique adverse effect that this can cause as well?
medroxyprogesterone injection
this can also cause a loss in bone mineral density (pt should take adequate calcium and vitamin D)
What are the 2 most effective reversible methods of contraception?
Implant (0.05%)
IUD (LNG 0.2%, copper 0.8%)
What is required to be dispensed with oral contraceptives?
the FDA requires that the Patient Package Insert (PPI) be dispensed with oral contraceptives
What makes drospirenone unique? When should it not be used?
It is used with some COC to reduce adverse effects commonly seen with oral contraceptives.
It is a mile potassium-sparing diuretic due to antimineralocorticoid activity, which decreases bloating, premenstrual syndrome symptoms and weight gain. Drospirenone products are also associated with less acne due to anti-androgenic activity.
(norgestimate is another progestin with low androgenic activity)
Do not use drospirenone in women with clotting risk. It can increase potassium levels, so do not use with kidney, liver, or adrenal glad disease.
Do patches or oral pills cause a higher systemic estrogen exposure? When should the patches be avoided?
Patches cause a higher systemic estrogen exposure, which leads to a higher risk of clot.
Avoid these with any pt w/ high clotting risk (pts > 35 who smoke, pts with cerebrovascular disease, past blood clots, or postpartum patients). Also avoid in women with a BMI ≥ 30.
Some patches (Xulane, Zafemy) may be less effective in women who weight > 198 lbs (90kg)
When does spotting with continuous contraception typically resolve?
typically resolves after 3-6 months
What do these names mean in birth control: Lo, Fe, 24, Pro?
Lo - indicates ≤ 35 mcg of estrogen (less estrogen causes less estrogenic side effects)
Fe - indicates an iron supplement is included
24 - indicates a shorter placebo time (24 active + 4 placebo)
Pro - indicates a progestin is in the product
What type of COC are these formulations: Junel Fe 1/20, Microgestin Fe 1/20, Sprintec 28, Loestrin 1/20, Yasmin 28, Yaz, Lo Loestrin Fe
These are all monophasic formulations
(1/20 = 1mg norethindrone and 20mcg EE)
What type of COC are these formulations: Tri-Sprintec, Seasonique, Yasmin 28, Yaz
Tri-Sprintec: triphasic
Seasonique: Extended cylcle (period occurs every 3 months)
Yasmin 28, Yaz: drospirenone containing formulations
What type of contraception are these: Errin, Camila, Nora-BE
These are all progestin-only pills
They all contain a fixed dose of norethindrone
What are the severe & rare adverse effects of estrogen (ACHES)?
A - abdominal pain that is severe
C - chest pain (can indicate a heart attack or PE)
H - headaches
E - eye problems
S - swelling or sudden leg pain
What are 3 boxed warnings for hormonal contraceptives? When should we NOT use estrogen?
Boxed warnings:
- all CHC products: do not use in women > 35 yo who smoke (risk of CVD)
- estrogen + progestin transdermal patch: do not use in women with BMI ≥ 30
- depo-provera: loss of bone mineral density with long term use
Do NOT use estrogen with these conditions:
- hx of DVT/PE, stroke, CAD
- hx of breast, ovarian, liver, or endometrial cancer
- hx of migraines with aura
What would be the preferred product selection for these types of patients:
- acne or hirsutism
- fluid retention/bloating
- mood changes/disorder
- overweight
- premenstrual dysphoric disorder
acne or hirsutism: use COC with a progestin that has lower androgenic activity (ex. norgestimate [Sprintec 28]) or no androgenic activity (ex. drospirenone [Yaz, Yasmin])
fluid retention/bloating: choose a product with drospirenone (Yaz, Yasmin)
mood changes/disorder: use monophasic COC - extended cycle or continuous with drospirenone is preferred
overweight: any method, but no patch if BMI > 30, DO not use DMPA if trying to avoid weight gain
Premenstrual dysphoric disorder: choose a product containing drospirenone (ex. Yaz). An SSRI antidepressant may be needed
What would be the preferred product selection for these types of patients:
- breastfeeding
- estrogen contraindication
- postpartum
- migraine
- hypertension
breastfeeding or estrogen contraindication: choose progestin-only (ex. Errin, Camila, Nore-BE) or nonhormonal method
Postpartum: do not use CHC for 3 weeks (6 weeks if additional VTE risk factors), can use progestin-only or nonhormonal method during this time
migraine: no aura, choose any method. If with aura, choose progestin-only.
hypertension: if BP uncontrolled, chose progestin-only or nonhormonal method
What would be the preferred product selection for these types of patients:
- heavy menstrual bleeding (menorrhagia)
- nausea
- spotting/”breakthrough bleeding”
- wishes to avoid monthly cycle/menses
heavy menstrual bleeding: Natazia (COC) and Mirena (IUD) are indicated for this
Nausea: take at night with food. Consider decreasing estrogen dose or switching to progestin only product
spotting/”breakthrough bleeding”: wait 3 cycles before switching. If early or mid-cycle spotting occurs, the estrogen dose may need to be increased. If later int he cycle, the progestin dose may need to be increased
avoid monthly cycle/menses: use extended (91-day) or continuous formulations
When starting COC, how long does it take for hormonal pills to achieve contraceptive efficacy? How long is a back-up method required? When can you start COC? When can you start POPs?
It takes 7 days for hormonal pills to achieve contraceptive efficacy
- back up contraception is required for 7 days, unless the COC is started within 5 days after the start of the period
- you can start as soon as TODAY. Can also start the Sunday after onset of menstruation or first day on menses.
You can start POPs at any time.
- use a back up method for 2 days after starting, unless it was started w/in 5 days of the start of menses
What is the general approach to missed doses?
The specific product recommendations will be in the package insert.
Generally for COCs:
- start as soon as remembered
- if more than one COC pill is missed, back-up contraception is required for 7 days
For POPs:
- if pill taken > 3 hours past scheduled time, back up contraception is required for 48 hours
What are the 3 options for emergency contraception? Which is the most effective? What is the necessary timing with these options?
copper IUD (Paragard) - most effective. Must be placed within 5 days
Ulipristal acetate (Ella) - take ASAP, within 5 days
Levonorgestrel 1.5mg (Plan B One-Step) - take ASAP, within 3 days
- if pt vomits w/in 2 hours, consider retaking dose
What are 3 drugs that are used in infertility to increase LH/FSH to cause ovulation?
clomiphene (SERM)- acts as estrogen to increase LH/FSH
aromatase inhibitors (letrozole)- suppress estrogen to increase FSH
gonadotropin drugs - act as LG, FSH, or hCG
- ex. Menopur, Follistim AQ, Gonal-f, Pregnyl, Novarel, Ovidrel
How much calcium and vitamin D does a pregnant woman require?
1000mg/day of calcium
600 IU/day of vitamin D
