Contraceptives Flashcards
(99 cards)
1
Q
what are 3 different options of contraceptives?
A
pill, patch, vaginal ring
2
Q
what is combined oral contraceptives (COCs)?
A
combo of estrogen and progesterone - closely mimic the menstrual cycle and provide predictable monthly bleeding
3
Q
what are other advantage of COCs?
A
treat acne, hirsutism (abnormal hair growth), dysmenorrhea (painful menstruation), menorrhagia (heavy menstrual bleeding), endometriosis
4
Q
what is the effectivenss of COC?
A
prevent 99%; all agents in this class equally efficacious
5
Q
what is endometriosis?
A
endometrial tissue (the tissue that lines the uterus) grows on the outside of the uterus in other areas of the body such as the abdomen, the outer surface of the uterus, etc.
can lead to severe pelvin pain and COCs can help treat this condition by slowing the growth of the endometrial issue
6
Q
what are the most commonly used estrogen component in COCs?
dose?
A
ethinyl estradiol;
10-50 mcg daily, but most patients take low-dose formulations (<35 mcg/day)
7
Q
what is another type of estrogen found in COC than ethinyl estradiol?
A
- estradiol valerate; this is converted to the naturally occurring estrogen, estradiol - hoping to reduce the incidence of adverse effects but no evidence that this is the case
- estetrol - available in combo with drospirenone - plant-derived estrogen that could have less impact on certain tissues (e.g. breast) or metabolic changes (e.g. lipids) but no evidence that estetrol reduces the risks seen with estrogens (e.g. breast cancer, blood clots, etc.)
8
Q
what are the progestins in COCs - first generation?
A
Norethindrone
Norethindrone acetate
Ethynodiol diacetate
9
Q
what are the progestins in COCs - second generation?
A
Norgestrel
Levonorgestrel
10
Q
what are the progestins in COCs - third generation?
A
Norgestimate
Desogestrel
11
Q
what are the progestins in COCs - Other generation?
A
drospirenon
dienogest
segesterone
12
Q
The different progestins all have a high affinity for the progesterone receptors, but differ in ?
A
their affinity for other receptors such as androgen and glucocorticoid receptors;
The contraceptive effects of the various synthetic progestins are mediated by the progestin’s activity on progesterone
receptors in the reproductive tissue, while the side effects are often due to the progestin’s activity on other receptors.
13
Q
what are the first generation progestins have affinity for in addition to progesterone receptors?
A
androgen receptors;
14
Q
what is the difference between 1st and 2nd gen progestins?
A
1st gen bind with lower affinity to progesterone and androgen receptors when compared to second-generation progestins.
2nd gen cause less breakthrough bleeding and spotting because they have a higher affinity for progesterone receptors;
2nd gen progestins bind with higher affinity to androgen receptors than other progestins, they have more androgenic effects which can cause acne, abnormal hair growth (hirsutism), dyslipidemia, and weight gain.
15
Q
what is the difference of 3rd gen and other gen?
A
Third-generation progestins don’t have much
activity on the androgen receptors and may be associated with fewer androgenic side effects.
16
Q
what is the difference of other newer progestins , such as drospirenone and dienogest?
A
Other newer progestins, such as drospirenone and dienogest, have been designed to bind primarily to progesterone receptors with little to no affinity for other steroid receptors. They have antimineralocorticoid and antiandrogenic effects.
17
Q
what is the major but rare adverse effect associated with COCs?
A
venous thromboembolism (VTE)
18
Q
what is the risk of clotting thought to be caused by?
A
the effect of estrogen on the coagulation cascade
19
Q
who is at higher risk for VTE with COC use?
A
smoker, older age, obese
20
Q
how to reduce the risk of VTE?
A
use lowest effective and tolerated dose of estrogen - Generally, a patient shouldn’t need a product with more than 30 mcg of ethinyl estradiol.
21
Q
which progestins have also been associated with a possible increased risk of VTE?
A
The newer progestins (desogestrel, norgestimate), compared to the older progestins (levonorgestrel);
BUT, This risk is only an association. A meta-analysis of eight observational studies of various progestin-only contraception showed that it was
not associated with an increased risk of VTE. The use of progestins is considered medically acceptable in patients at risk of thrombosis.
22
Q
in a patient complaining of excessive breast tenderness, what COCs do you switch to?
A
a COC with less estrogen can be considered
23
Q
if you have too much estrogen, what are the symptoms?
A
nausea, breast tenderness, headache, bloating, increased blood pressure, melasma (grey-brown patchees on the face)
24
Q
if you have too little estrogen, what are the symptoms?
A
spotting, breakthrough bleeding early/mid-cycle
25
if you have too much progestin, what are the symptoms?
Breast tenderness, headache,
fatigue, mood changes
26
if you have too little progestin, what are the symptoms?
Breakthrough bleeding late cycle
27
if you have too much androgen, what are the symptoms?
Weight gain, acne, hirsutism, ↑ low
density lipoprotein (LDL), ↓ high
density lipoprotein (HDL)
28
within the COC category, there are 6 formulations, what are they?
monophasic, biphasic, triphasic, and quadriphasic formulations,
as well as extended- and continuous-cycle formulations
29
what is monophasic (one phase) COC?
the most common and contain
the same amounts of estrogen and progestin for 21 days, typically followed by a seven-day hormone-free interval
(unless it’s an extended-cycle regimen)
30
why were Multiphasic pills developed?
what are disadvantages?
in an attempt to better mimic the levels of estrogen and progesterone during the menstrual cycle.
However, these pills don’t necessarily decrease side effects. They also may be more confusing to use when handling a missed dose compared to
monophasic products
31
what does Extended-cycle regimens provide?
more days of hormones, with some products providing up to 84 days of hormone
containing pills followed by a seven-day hormone-free interval.
32
Continuous-cycle regimens?
taking hormone
containing pills daily throughout the year, with no hormone-free interval.
33
Both extended- and continuous-cycle COCs
are useful for patients with ?
menstrual-related symptoms or those who prefer not to have monthly bleeding;
These regimens can reduce symptoms of hormone withdrawal, dysmenorrhea, heavy bleeding, and help with severe
premenstrual symptoms.
Continuous-cycle contraception can be safe and effective. It does not have a significantly different risk of venous
thromboembolism compared to traditional cyclic use.
Keep in mind that to avoid monthly bleeding, patients can also use traditional monophasic
COCs by continuing to take active pills throughout the hormone-free interval. This may be a more cost-effective
approach.
34
when do you select ethniyl estradoil 20mcg + [levonorgestrel 0.1mg (Alesse) / norethindrone acetate 1mg / drospirenon 3mg (Yaz)?
Ethinyl estradiol 20 mcg monophasic
regimens are a good starting dose for
patients who want to use a COC.
May cause more breakthrough bleeding
than higher doses of ethinyl estradiol in
some patients.
35
when do you select ethniyl estradoil 30mcg + [levonorgestrel 0.15mg (Min-Ovral) / norethindrone acetate 1.5mg / norgestrel 0.3mg / desogestrel 0.15mg (Marvelon)/ drospirenone 3mg (Yasmin)]?
Consider higher doses of estrogen (30 mcg
of ethinyl estradiol or more) for patients
taking CYP3A4 enzyme inducers.
May be useful for patients who experience
bothersome breakthrough bleeding on
lower doses of ethinyl estradiol.
Consider avoiding levonorgestrel and
norgestrel products for patients concerned
with gaining weight.
Some products, such as Safyral and
Tydemy, contain folate in addition to
ethinyl estradiol and drospirenone; it may
be cheaper for patients to take a different
COC and add folate supplementation.
36
when do you select ethniyl estradoil 35mcg + [ethynodiol diacetate 1mg / norgestimate 0.25mg / norethindrone 0.4mg / norethindrone 0.5mg (Brevicon 0.5/35) / norethindrone 1mg (Brevicon 1/35)]?
Consider higher doses of estrogen (30 mcg
of ethinyl estradiol or more) for patients
taking CYP3A4 enzyme inducers.
May be useful for patients who experience
bothersome breakthrough bleeding on
lower doses of ethinyl estradiol.
37
when do you select ethniyl estradoil 50mg + ethynodiol diacetate 1mg ?
Consider higher doses of estrogen (30 mcg
of ethinyl estradiol or more) for patients
taking CYP3A4 enzyme inducers.
Avoid in obese patients and smokers.
38
what are multiphasic COCs available?
ethyinyl estradiol 10 and 20mcg + desogenstrel 0.15mg
ethinyl estradiol 35mcg + norethindrone acetate 0.5-1mg (Synphasic) / norgestimate 0.18 - 0.25mg (Tri-Cyclen)
ethinyl estradiol 20-35mcg + norethindrone acetate 1mg
ethinyl estradiol 25mcg + norgestimate 0.18-0.25mg (Tri-Cyclen Lo) / desogestrel 0.1-0.15mg (Linessa)
ethinyl estradiol 30-40mcg + levonorgestrel 0.05-0.125mg (Triquilar)
estradiol valerate 1-3mg + dienogest 2-3mg
39
what is the product selection consideration for multiphasic COC regimens?
Multiphasic COCs haven’t
been found to be better at
preventing side effects than
monophasic pills.
Patients interested in COCs
should be initiated on
monophasic pills due to more
safety data and easier
instructions if a dose is missed
40
what do you consider when use LOLO? (ethinyl estradiol 10mcg x 26 days; norethindrone acetate 1mg x 24 days; 2 days med free pills)
Fewer placebo days may mean fewer
symptoms from hormone withdrawal.
Low dose of ethinyl estradiol may result in
more breakthrough bleeding.
41
when do you consider three-month cycle COCs?
Reduces symptoms of hormone withdrawal;
consider for patients with severe premenstrual
symptoms, dysmenorrhea, or heavy bleeding
Consider using in obese patients to improve
efficacy
42
which ones are three-month cycle COCs?
ethinyl estradio 20mcg x 84 days, then 10mcg x 7 days + levonorgestrel 0.1mg x 84 days (not available in Canada)
ethinyl estradio 30mcg x 84 days + levonorgestrel 0.15mg x 84 days; then 7 days blank tablet (Seasonale, Indayo)
ethinyl estradio 30mcg x 84 days, then 10mcg x 7 days + levonorgestrel 0.15mg x 84 days (Seasonique, Quaterna)
Ethinyl estradiol 20 mcg x 42 days, then 25 mcg x 21 days, then 30 mcg x 21 days, then 10 mcg x 7 days + Levonorgestrel
0.15 mg x 84 days (not available in Canada)
43
when do you consider continuous COC?
who do not want any monthly bleeding at all;
in obese patients to improve efficacy
44
what is continuous COC available?
Ethinyl estradiol 20 mcg all days, no break + Levonorgestrel 90 mcg all days, no break
45
which COC has plant derived estrogen?
Estetrol 14.2 mg x 24 days + Drospirenone 3 mg x 24 days (Nextstellis)
46
when do you use progestin only pills?
when patients cannot take estrogen - nursing patients, smokers;
47
what does progestin only pill cause in terms of bleeding/menstruation or breakthrough bleeding?
The progestin-only pill generally results in less bleeding during menstruation, but patients have more breakthrough bleeding compared to combined hormonal contraception.
48
One of the progestin-only pills is available as norethindrone 350 mcg. what do you counsel on patients?
This is much less progestin than what is
contained in COCs. Patient education with progestin-only pills is VERY important, since adherence is critical to efficacy and instructions are different from oral COCs.
there are no "free"
weeks and each pill contains active medication. In other words, a pill will be taken every day with no breaks. This is
important to keep in mind because the packaging of these products looks very similar to COCs that have a week of
inactive pills.
Counsel patients starting the progestin-only pill to always take ALL the pills in their pack and start a new pack right after finishing the previous pack. Since the progestin-only pill has such a short half-life, it's also important to let patients know to take the pill at the same time each day. Tell your patients that taking it more than three hours late can increase the risk of pregnancy.
If the progestin-only pill is taken more than three hours late, patients should use backup contraception for 48 hours. Because there is less room for error with the progestin-only pill, efficacy with typical use may be problematic. Irregular and unpredictable menstrual bleeding is the most common adverse effect.
Educate patients in advance that this can occur, as this is the most common reason that patients stop using progestin only products.
49
Drospirenone (used in several COCs) 4mg is also now available as a progestin-only pill (U.S.). What is the difference between this and norethindrone 350mcg pill?
Drospirenone (Slynd) 4 mg is
taken for 24 days, followed by four days of placebo. It may provide a little bit more flexibility with dosing, compared to
norethindrone progestin-only pills. If two or more pills are missed, one pill should be taken as soon as the patient
remembers and then the regular daily schedule should be resumed. Backup contraception is recommended for seven
days after missing a pill. However, the evidence to support efficacy with these late doses is limited and contraceptive
failure rates and adverse effects often go up with “real world" use.
50
what are some transdermal patches available?
Ethinyl estradiol 30 mcg plus levonorgestrel 120 mcg/day (U.S.) (Twirla)
Ethinyl estradiol 35 mcg plus norelgestromin 150 mcg/day (U.S.) (Xulane,Zafemy)
Ethinyl estradiol 35 mcg plus norelgestromin 200 mcg/day (Canada) (Evra)
51
how are patches applied?
Patches are applied weekly for three weeks followed by a patch-free week.
52
what are the advantages and disadvantages of patches ?
Some patients like the patch because they only need to remember to change it weekly as
opposed to taking a daily pill, leading to improved adherence.44 While around one in 10 females use the patch, almost
half stop using it, primarily because they are not satisfied with it or due to adverse effects.45 This may be because it has
a higher exposure to estrogen over time compared to some of the other combined hormonal agents.
53
how to counsel patients on patches?
Make sure patients know of potential side effects before
starting. Counsel patients to place the patch on their upper arm, stomach, back, or buttock where it won't be rubbed by
tight clothing.
They should consider rotating the application site with each new patch to reduce the risk of skin
irritation. Recommend patients use a calendar “appointment” and reminder to help them remember when to change their
patch and when to restart the four-week cycle. Let them know that their patch-free week is when they can expect to
experience withdrawal bleeding. Keep in mind that the patch may be less effective in patients who are obese
54
what is the concern of Evra patches for obese patient?
Xulane, Zafemy, and Evra: reduced efficacy with body weight of 198 pounds (90 kg) or more
55
NuvaRing - what is the dose? how to use? concern?
They release 15 mcg of ethinyl estradiol and 120 mcg of etonogestrel a day
This ring is inserted for three weeks and then disposed of. A new ring is inserted one week later.
Store in refrigerator prior to dispensing.
The safety and efficacy of this vaginal
ring in patients with a BMI of more than 29 kg/m2 has not been established
56
how to counsel the ring?
Let patients know that the vaginal ring has low estrogen exposure compared to the other available CHCs, so they may
experience fewer estrogen-related side effects. However, the ring does lead to more localized issues. Counsel patients
who are switching from the pill that the ring can cause more vaginal irritation and discharge.50 Some patients may be
concerned that the ring may be uncomfortable or may fall out. Reassure patients that it is uncommon for the ring to fall
out, but may be accidently expelled during sexual intercourse, bowel movements, or with use of tampons.
57
Another type of hormonal contraceptive is the depot injection - which is the ingredient?
medroxyprogesterone acetate 150mg - progestin-only hormonal contraceptive is intramuscular (IM) (Depo Provera, generics) injection that is administered every three months.
58
how to counsel patient on depo-provera?
Unfortunately almost half stop using it, mainly due to side effects and changes in menstrual cycle. Like other progestin-only products, patients can experience spotting and breakthrough bleeding initially, but after one year many patients stop having periods. While this can be a concern for some patients, others may see it as a benefit.
Patients may worry about weight gain with medroxyprogesterone. Let them know that after five years, they can expect about an average weight gain of five pounds.
Warn patients ahead of time that it may take longer to get pregnant after stopping the medroxyprogesterone injection because of prolonged amenorrhea and anovulation after the last injection.
Injectable medroxyprogesterone can also decrease bone mineral density, so it may not be the best choice in patients at risk for steoporosis or possibly adolescents. Most of the bone loss occurs during the first two years of therapy. Make sure all patients get enough calcium and vitamin D
59
Patients may be concerned with the return to fertility after using contraceptives. what do you counsel?
contraceptives do not have a negative effect on the ability of women to conceive after they are discontinued
60
if patient had bariatric surgery, what is the concern of using COCs and the progestin-only pills?
a hx of bariatric surgery can lead to a decreased absorption of COCs and the progestin-only pill if the procedure is considered to be malabsorptive - These surgeries include biliopancreatic diversion and Roux-en-Y
For malabsorptive procedures, oral
contraceptives should be avoided and instead the patch, ring, or injection can be recommended or prescribed.
61
if patient has breast cancer or had a past history of breast cancer, can she have COCs?
no - Patients who currently have breast cancer or who had a past history of breast cancer and no evidence of current disease for five years should avoid hormonal contraceptives.
Consider suggesting a copper intrauterine device (IUD) for these patients.
62
For patients who have a
family history of breast cancer, a history of a benign breast disease, or a BRCA gene mutation, can she has COCs?
Yes - For patients who have a
family history of breast cancer, a history of a benign breast disease, or a BRCA gene mutation, there are no restrictions
(Category 1) for using hormonal contraceptives. Most evidence suggests that breast cancer risk in these patients will not
increase further with hormonal contraceptives.
63
There are certain patient characteristics that increase the risk of VTE when CHCs are used. These include ...
smoking,
obesity, age 35 or older, and recent major surgery
64
For patients who smoke, if they are under the age of 35, what contraceptions they can use?
they can use CHCs (Category 2), the progestin-only pill
(Category 1), or the injection (Category 1);
However, ethinyl estradiol should be at a dose of less than 50 mcg.
65
If a patient is 35 or older and smokes?
they should NOT use CHCs (Category 3 or 4, depending on how many cigarettes per
day), but can use the progestin-only pill (Category 1) or the injection (Category 1).
66
For patients who are obese (BMI 30 kg/m2 or more), can they use contraceptives?
they can use CHCs (Category 2), the progestin-only pill (Category
1), and the injection (Category 1 or 2, depending on the patient’s age);
However, ethinyl estradiol should also be at a
dose of less than 50 mcg.
67
what are weight limitations of some products?
The effectiveness of the etonogestrel implant (Nexplanon) in very overweight females (e.g., >130% of ideal body
weight, BMI >35 kg/m2) is unknown.
The use of the CHC patches Xulane and Zafemy in patients who weigh over 198 pounds (90 kg) should be
avoided because the efficacy might be reduced.40
The effectiveness of the contraceptive patch Twirla is reduced in females with a BMI ≥25 kg/m2. Twirla is
contraindicated in females with a BMI ≥30 kg/m2, due to risk of venous thromboembolism.
There is limited data available for the
Annoveravaginal ring for females with a BMI >29 kg/m2. Females with
BMI >29 kg/m2 were excluded from trials after reports of venous thromboembolism in this population.
The COC, Nextstellis may be less effective in females with a BMI ≥30 kg/m2, and reduced efficacy may be
associated with increasing BMI.
68
for CHC use in age 40 and over, what is the concern?
When looking at the U.S. MEC recommendations for age, be aware that CHCs are a Category 1 recommendation for patients under 40 years of age, but change to Category 2 for patients 40 and older.
69
Patients who have had recent major surgery (or have one scheduled in the future) resulting in prolonged immobility
should definitely NOT use CHCs (Category 4) but can use the ..?
progestin-only pill and the depot injection (Category 2 for both)
70
Patients who have had a recent major surgery (or have one scheduled in the future) that did NOT result in prolonged immobility?
can use CHCs (Category 2)
71
Some experts suggest using a high-dose estrogen COC for patients who are obese because of questions of efficacy. However, what others suggest?
others suggest that it’s not prudent to routinely prescribe high-dose COCs to heavier patients, especially
because they are at higher risk of VTE.
72
Some drugs can induce the CYP450 hepatic enzymes that metabolize hormonal contraceptives and cause them to be less
effective. what are some anticonvulsants that cause this?
phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine - Category 3 for CHCs and the progestin-only pill - should be avoided if possible
73
for lamotrigine, which CHC can be used?
CHCs are category 3 because estrogen decreases lamotrigine levels by about 50%, not because the efficacy of the contraceptive is affected.
the progestin-only pill is Category 1 and can be used.
74
what is the antiretroviral protease inhibitors that interacts with CHCs? (Category 3)
fosamprenavir;
The progestin-only pill or the depot injection can be used in patients on this drug (Category 2)
75
what is the concern about depression?
Depression may be adversely affected by progestins. Although the U.S. MEC indicates Category 1 for all hormonal
contraceptive products, be aware that progestins can exacerbate depression. Consider avoiding injectable progestin since
this is long-acting and can be more difficult to discontinue if depression is exacerbated.65
76
what is the concern about diabetes?
Hormonal contraceptives may impair glucose control and carbohydrate metabolism. They are Category 2 for most
patients with type 1 or type 2 diabetes.
77
patients with diabetes with complications such as nephropathy, retinopathy, neuropathy, or some other vascular disease or those who have had diabetes for over 20 years, what is the category of CHC and depot injection?
CHCs (Category 3/4) and the depot injection (Category 3) are NOT
recommended
78
Ischemic heart disease, either current or a history of, and a history of stroke requires cautious use of hormonal
contraceptives due to the increased risk of ?
blood clotting which can result in a cardiac event or stroke;
CHCs are not
recommended at all (Category 4), and neither is the depot injection (Category 3). The progestin-only pill can be initiated
(Category 2) but shouldn’t be continued (Category 3) if ischemic heart disease symptoms worsen.
79
Patients who don’t have ischemic heart disease, but have multiple risk factors for it (i.e., older age, smoking, diabetes, dyslipidemia, hypertension)?
require close evaluation. CHCs should be avoided in these patients (Category 3/4) and
so should the depot injection (Category 3). The progestin-only pill can be used (Category 2).
80
High Blood Pressure controlled?
The CDC recommends measuring blood pressure prior to initiating a hormonal contraceptive.
Patients who have hypertension that is controlled should not take CHCs (Category 3) but. can take the progestin-only pill (Category 1) or receive the depot injection (Category 2).
81
High Blood Pressure uncontrolled?
CHCs move to Category 4, the progestin-only pill to
Category 2, and the depot injection moves to being not recommended at Category 3.
82
Estrogen can increase triglyceride levels and progestins can increase LDL. This can be more problematic in a patient who has hyperlipidemia. can you use CHC?
yes - generally a patient with hyperlipidemia can use a CHC if the patient doesn’t have any other known cardiovascular risk factors or a severe genetic lipid disorder (i.e., homozygous or heterozygous familial hypercholesterolemia) that significantly increases the lifetime risk of cardiovascular disease.
83
can you use CHC for patients with hx of VTE?
Generally, CHCs should not be used in patients with a history of VTE, even if it was an acute episode. All other
hormonal contraceptives are Category 2. Those with a family history of VTE can use CHCs (Category 2) or any of the
other hormonal contraceptives.
84
can you use CHC if have acute cases of hepatitis, liver cancer, cirrhosis, a history of gall bladder disease, and cholestasis (a reduction or stoppage of bile flow)?
may have to avoid CHCs since they contain estrogen. The estrogen found in CHCs can cause mild inhibition of bilirubin excretion (leading
to jaundice) and cholestasis that may lead to liver injury.
CHCs have also been found to slightly increase the risk of gall bladder disease and have been linked to liver tumors.
Also, liver impairment in general can result in poor metabolism of hormones, which can decrease efficacy. If a patient does have any of these liver issues, make sure to investigate further and use the details outlined in the U.S. MEC to help decide whether or not CHCs are okay to use.
85
can you use CHC if migraine?
Estrogen-containing contraceptives can increase the risk of stroke in patients who have migraine headaches with aura (light sensitivity, numbness, sick to stomach, lose sight or have other vision problems, etc). Patients who suffer from
migraines with aura shouldn’t use CHCs (Category 4). Patients who have migraines without aura can use CHCs, but discontinuation may be necessary if migraines are exacerbated. The progestin-only pill may be preferred in these
patients.
86
after childbirth, when can you use CHC?
after 21 days postpartum - (before that, CHC is category 4)
but can use progestin-only pill or the depot injection (category 1 for non-breastfeeding patients or 2 for breastfeeding patients)
87
you had a baby 30 days ago and breastfeeding, no risk factors for VTE- can you use CHC?
yes - category 2;
all other hormonal contraceptives are category 1
88
if you are not breastfeeding, no risk factor for VTE, when can you use CHC?
after 21 days
89
if you have RA and on steroid, which contraceptive is preferred?
progestin only pill (category 1);
but can use CHC (category 2);
depot (category 2/3) - use with caution
90
if you have systemic lupus erythematosus, can you use contraceptive?
no - SLE patients with a positive or unknown antiphospholipid antibody test shouldn't use any hormonal contraceptive;
This is because the presence of antiphospholipid antibodies increases the risk of ischemic heart disease,
stroke, and VTE. Using a hormonal contraceptive can further elevate this risk
91
if you have acne after using CHCs, how to adjust therapy?
Switch to a COC with a 3rd generation progestin, drospirenone or dienogest, since they have less androgenic activity
Switch to a product with a higher estrogen dose
Move to an extended- or continuous-cycle regimen
92
if you have breakthrough bleeding after using CHCs, how to adjust therapy?
First, make sure the patient has been adherent to their therapy for at least the first three months and that there are no drug
interactions
Second, determine if the bleeding occurs early- or mid-cycle versus late-cycle -
Early- or mid-cycle: Switch to a higher estrogen dose
Late-cycle: Switch to a 2nd generation progestin since these are more potent, or increase the progestin dose
93
if you have Endometriosis-related menstrual pain, how to adjust CHC?
consider a continuous-cycle regimen
94
Menstruation-related problems (anemia,
heavy bleeding, bloating, dysmenorrhea,
endometriosis, menstrual headache) - how to adjust CHC?
Consider a continuous- or extended-cycle regimen
95
Migraines - how to adjust CHC?
Stop estrogen-containing contraceptive and switch to a progestin-only c ontraceptive
96
Too Much Androgen: Increased appetite,
weight gain, acne, oily skin, hirsutism,
dyslipidemia ?
Switch to a progestin with less androgenic activity such as 3rd
generation progestins, drospirenone, or dienogest
97
Too Much Estrogen:
Nausea, breast tenderness, melasma (grey
brown patches on the face), increased
blood pressure, headache, bloating
Switch to a lower-dose estrogen product but avoid the patch since it gives a higher estrogen exposure
Consider the vaginal ring because it has the lowest estrogen exposure
Consider a product with drospirenone if bloating is a particular problem
98
too much progestin - headache, breast tenderness, fatigue, change in mood?
switch to a progestin with less activity at progesterone receptors, such as dropirenon or a 1st gen progestin
99
