Oral Contraception Rx

Question 1

Advantages and disadvantages of OCP use

Answer 1

Advantages: 
effective contraception 
better cycle control 
dec IDA
better bone density
protects from ovarian and endometrial CA

     Disadvantages
no protection against STDs
inc risk of VTE, stroke
May inc BP
AE's, drug interactions
inconvenience of daily pill
cost

Question 2

Absolute Contraindications of OCP use

Answer 2

• Hx of thromboembolic disease
• Hx of stroke or CAD
• Hx of breast cancer
• Hx of estrogen-dependent neoplasm
• Undiagnosed abnormal uterine bleeding
• Pregnancy (known or suspected)
• Heavy smokers ( ≥ 15 cigarettes/day) over the age of 35
• Hx hepatic tumors
• Active liver disease
• Migraine HA with focal neurologic symptoms
• Postpartum (during 1st 21 days as well as days 21-42 in women with additional TE risk factors)

Question 3

Relative CI to OCP use

Answer 3

• Smoking < 15 cigarettes/day (at any age)
• Migraine HA disorder without focal neurologic symptoms
• Hypertension (SPB ≥ 160 or DBP ≥ 90 per WHO)
• Fibroid tumors of uterus
• Breast-feeding
• Diabetes
Family history of dyslipidemia
• Sickle cell disease
• Active gallbladder disease
• Age > 50 years
• Elective major surgery requiring immobilization (planned in the next 4 weeks)

Question 4

Estrogen AE’s

Excess and deficiency

Answer 4

Excess	
•	Nausea
•	Breast tenderness 
•	Increased BP 
•	Melasma 
•	Headache
Deficiency	
•	Early or mid-cycle breakthrough bleeding
•	Increased spotting
•	Hypomenorrhea

Question 5

Progesterone AEs

excess and deficiency

Answer 5

Excess	
•	Breast tenderness
•	Headache
•	Fatigue
•	Mood changes
Deficiency	
•	Late breakthrough bleeding

Question 6

Androgen excess

Answer 6

result of androgenic activity of progestins

• Increased appetite
• Weight gain
• Acne, Oily skin
• Hirsutism
• inc LDL, dec HDL

Question 7

Weight considerations

Answer 7

• Avoid low does OCs in women with a BMI > 27.3 or weight > 74.8 kg
• Concern of increased pregnancy risk in heavier patients

Question 8

OCs effect on other drugs

Answer 8

• inc or dec anticoagulant effects
• inc effects of TCAs, beta blockers, caffeine, corticosteroids, and theophyllines
• dec effects of some benzodiazepines and prolong the half-life of others

Question 9

Other drugs effect on OCs

Answer 9

• Atorvastatin inc AUC of NE & EE
• Antibiotics can dec effects of OCs (penicillins and tetracyclines)
• CYP450 inducers can dec effects of OCs (barbiturates, CBZ, felbamate, protease inhibitors, PHT) - use an alternate or additional form of birth control with concomitant use

Question 10

young, healthy patient

Answer 10

monophasic with intermediate estrogen

Ortho-Cyclen or Sprintec

Question 11

Acne

Answer 11

FDA OC approved for acne

Ortho-Tricyclen, Yaz

Question 12

Minimize estrogen exposure

Answer 12

very low estrogen

Alesse

Question 13

Breastfeeding or estrogen CI

Answer 13

avoid estrogen

Micronor, Nor-QD

Question 14

PMS, HA, anemia, endometriosis

Answer 14

consider extended cycle

Seasonale

Question 15

Patient education

Answer 15

o Adherence is essential
o Start on day 1 of period or Sunday after period starts
o Procedure for missed pills (take ASAP then use backup for 1 week)
o Most OCP will cause spotting in new users but will resolve within 2-3 cycles
o No protection against STDs
o Use backup method (condoms) if on antibiotics
o Use backup method (condoms) if have break-thru bleeding

Question 16

Warning signs

Answer 16

• Abdominal pain Gallbladder DZ, blot clot, pancreatitis
• Chest pain SOB, PE or MI
• Headaches CVA, HTN, Migraines
• Eye problems CVA, HTN
• Severe leg pain DVTs

Question 17

F/U

Answer 17

Come back in 3-6months
assess adherence
AE: many AEs in first cycle improve by 2nd or 3rd cycle
BP
Need to come back in yearly

Question 18

Emergency contraception

Answer 18

IUDs
o Not widely used, not FDA approved

Oral hormonal agents
•Take within 72 hours, possibly up to 120 hours
o Plan B (levonorgestrel 0.75 mg/tab x 2 tabs) or Plan B One Step (levonorgestrel 1.5 mg/tab x 1)

Next Choice
• Yuzpe Method
o Use of regular combined OCs to deliver high dose estrogen and progestin
• Decreased efficacy and increased AE compared to Plan B

Question 19

Emergency Contraception AE and efficacy

Answer 19

AE: nausea and vomiting - less with Plan B than Yuzpe; irregular bleeding - period comes 1 week before or after expected time

Efficacy: best if taken 12-24 hrs after intercourse, but can go out to 72hrs to 120hrs