Contraceptives

Question 1

The first type of Hormonal Contraceptives are Oral. what are the advantages and disadvantages of oral contraceptives?

Answer 1

Ease of use and efficacy

Disadvantage: inconsistent use may increase failure rate

Question 2

Combined oral contraceptives contain estrogen and progestin. What are the estrogens and progestins?

Answer 2

Estrogens: Ethinyl Estradiol which is active or Mestranol which is converted in the liver to Ethinyl Estradiol
Progestins: Norethindrone, Norgestrel, Levonorgestrel, Desogesttrel, Norgestimate and Drospirenone

Question 3

Almost all currently available progestins have some androgen activity. Some adverse effects of oral contraceptives are due to the androgenic activity of the progestin. Progestins vary in their androgenic activity..

Answer 3

Levonorgestrel and Norgestrel: highest androgenic activity
Norethindrone: has lower androgenic activity
Desogestrel and Norgestimate: even lower androgen activity
Drospirenone: has antiandrogenic activity

Question 4

Combined oral contraceptives are available in monophasic, biphasic and triphasic preparations. What does this mean?

Answer 4

Monophasic: fixed doses of estrogen and progestin in each active pill
Biphasic (Not used often) and Triphasic: Contain varying proportions of one or both hormones during the pill cycle

Question 5

Why were biphasic and triphasic preparations introduced?

Answer 5

Reduce the amount and total monthly dose of progestins as well as mimic more closely the hormonal changes of the menstrual cycle
–no evidence that bi or tri are superior to mono in prevention of pregnancy

Question 6

The combined oral contraceptives most commonly used today are what?

Answer 6

Low Dose
—contain 35ug of ethinyl estradiol or less
This reduced dose of estrogen and progestin has decreased adverse effects and risks associated with oral contraceptive used. However, they are more likely to result in contraceptive failure if doses are missed

Question 7

Continuous combination regimens provide hormone containing pills for 21 days, then?

Answer 7

very low dose estrogen and progestin for an additional 4-7 days

Question 8

Combination oral contraceptives work primarily before fertilization to prevent conception, by preventing ovulation. How does this occur?

Answer 8

They suppress LH and FSH release and ovulation does not occur
–additionally progestin thickens cervical mucus thus preventing sperm penetration, and induces changes in the endometrium that make implantation of the embryo unlikely.

Question 9

If the patient starts the combined oral contraceptive on day one of her menstrual cycle what happens?

Answer 9

She will be protected from pregnancy immediately

Question 10

If she starts the combined oral contraceptive on the fifth day of her period or before, what happens?

Answer 10

She will be protected from pregnancy immediately, unless she has a short menstrual cycle (23 days or less) in which case she will need backup contraception until she has taken the pill for seven days

Question 11

If the patient starts combined oral contraceptive on any other day of her cycle what will happen?

Answer 11

she will not be protected from pregnancy immediately, and will need backup contraception until she has taken the pill for seven days

Question 12

In addition to preventing pregnancy, there are several non contraceptive benefits associated with the use of combined oral contraceptive pills, those are?

Answer 12

Reduction in the risk of endometrial cancer
Reduction in the risk of ovarian cancer
Improved regulation of menstruation
Relief of benign breast disease
Prevention of ovarian cysts
Reduction in the risk of symptomatic pelvic inflammatory disease
Improvement of acne control

Question 13

Next lets go through some adverse effects of oral contraceptives.

Answer 13

1. Breakthrough bleeding: most common and is more of a problem with lower doses of estrogen
2. Headache: mild and transient ; have been reports of increased frequency of cerebrovascular accidents
3. Insulin Resistance: progestins compete with insulin for binding to its receptor, use of current oral contraceptives, which have a low dose progestin dose rarely cause hyperglycemia
4. Hirsutism: acne, oily skin are androgenic properties
5. Melasma: secondary to estrogen stimulation of melanocyte production
6. Amenorrhea
7. Dyslipidemia: no effect
8. Depression
9. Carcinogenicity: decrease endometrial and ovarian cancer

Question 14

CVS adverse effects are the major adverse effects of birth control, they are rare but serious, what are these effects?

Answer 14

Thromboembolism, Thrombophlebitis, Hypertension, increased incidence of MI and cerebral and coronary thrombosis

• -most common among women who smoke and who are older than 35
• -estrogen increase hepatic production of factor VII, factor X and fibrinogen

Question 15

Moving on to drug interactions. Explain the effect of Rifampin use on oral contraceptives?

Answer 15

Reduces efficacy by inducing hepatic P450 enzymes and thus increasing the metabolism of estrogen
–use of a backup nonhormonal contraceptive method during the course of rifampin is recommended

Question 16

What are the other P450 inducers known to cause increased metabolism of combined oral contraceptives?

Answer 16

Carbamazepine, oxcarbazepine, phenytoin, phenobarbital, primidone, topiramate, vigabatrin and St. John’s Wart

Question 17

What are the absolute contraindications of oral contraceptives?

Answer 17

Pregnancy 
Thrombophlebitis or thromboembolic disorders 
Stroke or coronary artery disease 
Cancer of the breast 
Abnormal vaginal bleeding 
Estrogen dependent cancer 
Benign or malignant tumor of the liver 
Uncontrolled HTN
Diabetes mellitus with vascular disease 
Age over 35 and smoking greater than 15 cigarettes a day
Thrombophilia
Migraine with aura
Active hepatitis 
Surgery or orthopedic injury requiring prolonged immobilization

Question 18

What are the relative contraindications of oral contraceptives ?

Answer 18

Migraine without Aura 
Hypertension 
Heart or kidney disease 
Diabetes Mellitus
Gallbladder Disease 
Cholestasis during pregnancy 
Sickle cell disease 
Lactation

Question 19

Now or women unable to take estrogen containing oral contraceptives, there is an alternative – progestin only contraceptives. What are some features of this type of contraceptives?

Answer 19

Progestin Only (Minipills)

• –contain norethindrone or norgestrel
• -less effectives than combined oral contraceptives
• -have no shown the risk of thromboembolic events as products containing estrogen have.
• -decreased dysmenorrhea, decreased menstrual blood loss and decreased premenstrual syndrome symptoms

Question 20

Progestin only pills are highly efficacious but block ovulation in only 60 to 80% of cycles, so what contributes to their effectiveness?

Answer 20

Thickening of cervical mucus, which decreases sperm production, and to endometrial alterations that impair implantation

Question 21

What are some non oral hormonal contraceptives?

Answer 21

Transdermal – patch —- contains ethinyl estradiol and progestin
Transvaginal — ring — ethinyl estradiol and a progestin
Injectable Preparations — depo provera – progestin only that contains depot medroxyprogesterone acetate – given once every 3 months

Question 22

What are some of the Side Effects of the Depo - Provera injection?

Answer 22

Cons:
menstrual irregularities and weight gain
significant loss of bone mineral density — a black box warning cautions against the risk of potentially irreversible bone mineral density loss associated with long term use.
on discontinuation, the return of fertility can be delayed by approx 10 to 12 months

Question 23

What are the subdermal progestin implants and IUS?

Answer 23

Subdermal:
–contains progestin and is effective for 3 years and is placed under the skin
IUS:
Levonorgestrel reservoir and is effective for 5 years

Question 24

What are some non hormonal contraceptive methods?

Answer 24

Barrier Contraceptives
—Condoms
—Diaphragms and Cervical Caps: used along with spermicides to prevent pregnancy
Spermicides: nonoxynol-8, destroys the cell membranes of sperm
Intrauterine Devices (IUDs): does not prevent ovulation
Sterilization: interruption of the fallopian tubes in women or the vas deferens in men

Question 25

What methods of contraceptive are the most effective?

Answer 25

Oral Combined Contraceptive Pill: 99.9% ; 97%
Mirena: 99.9% ; 99.8%
Implanon: 99.95% ; 99.95%
Progestin Only: 99.5% ; 97%

Question 26

What are the hormonal methods for emergency postcoital contraception?

Answer 26

Plan B and Next Choice
–levonorgestrel (first tablet within 73 hours of sex and the second 12 hours later)
Ella
–ulipristal acetate: selective progesterone receptor modulator that acts mainly as a progesterone antagonist to inhibit or delay ovulation

Question 27

What is the non hormonal method for emergency postcoital contraception?

Answer 27

Copper IUD – within 5 days of sex