1
Q
Indications of emergency contraception?
A
Unprotected sex
- when no contraception has been used
- when a contraceptive method may have failed
- in cases of sexual assault
2
Q
What does emergency contraception contain?
A
Levonorgestrel (progesterone)
3
Q
MOA of Levonorgestrel
A
- Interferes with ovulation (prevents or delays ovulation if taken before ovulation)
- Affects muscle contractility of Fallopian tubes, impairing oocyte transport and concentration of glycodelin A (an inhibitor of sperm binding)
- Does not affect endometrium or implantation
- Does not interfere with an established pregnancy
- Ineffective if taken on day of ovulation or after ovulation
4
Q
CI of Levonorgestrel?
A
- Pregnancy (wouldn’t work but wouldn’t harm fetus either)
- Hypersensitivity to product (DUH DRENA)
- Undiagnosed vaginal bleeding (could be ectopic pregnancy) - requires referral
5
Q
Levonorgestrel: Effectiveness?
A
Dependent on time taken after intercourse:
<24 hours = 95%
25-48 hours = 85%
49-72 hours = 58%
6
Q
Levonorgestrel: Ineffective in??
A
women who weigh over 176 pounds
*may be less effective in women weighting 165-175 pounds
7
Q
Levonorgestrel: Dosing?
A
- 2 tablets (0.75mg) must be taken together for a single dose of 1.5mg as soon as possible after unprotected sex
- approved for use up to 72 hours after (some have efficacy for up to 5 days)
8
Q
Levonorgestrel: adverse effects?
A
nausea
*may take dimenhydrinate 30 mins prior to use
vomiting
cramps
9
Q
Levonorgestrel: monitoring?
A
see physician if no period within 21 days and take a pregnancy test
10
Q
Levonorgestrel: what if the patient vomits after ingestion?
A
Take another dose
11
Q
List some Rx Emergency Contraception Options
A
- Copper IUD
- Ulipristal Acetate
- Yuzpe method
12
Q
Describe the Copper IUD
A
- Most effective form of emergency contraception
- May be inserted up to 7 days after
- Requires Rx
- Can remain inserted for up to 30 months for ongoing protection
13
Q
MOA of Copper IUD
A
- inflammaotry reaction in uterus, as well as the copper ions are toxic to sperm and oocyte
- inhibits implantation
14
Q
MOA of Ulipristal Acetate
A
- Inhibits or delays follicular rupture when given prior to LH surge
- Ineffective if given on day of LH surge (ovulation)
- Endometrium not affected (if sperm has met egg - it will not disrupt implantation)
15
Q
Describe Ulipristal Acetate
A
- Requires Rx
- Single dose of 30 mg to be taken as soon as possible within 5 days after unprotected intercourse
- more effective than levonorgestrel especially at day 4 or 5
- may have less efficacy in women with a BMI > 35
16
Q
Describe the Yuzpe Method
A
- Two doses of: 100 mcg ethanol estradiol and 0.5 mg levonorgestrel given 12 hours apart
- Less effective and more side effects versus Levonorgestrel or Ulipristal acetate
- Rx
- 50% have nausea
- 20% vomit
17
Q
Mifegymiso is a type of ??
A
medical abortion
18
Q
Describe Mifegymiso
A
It contains:
- 200mg of mifepristone (oral)
- 800 microg of misoprotol (buccal) which is taken 24-48 hours after mifepristone
- Indicated for pregnancy termination for up to 49 days although company is requesting Health Canada to approve use up to 9 weeks
- Only given out at clinics from physicians - will not see in community pharmacy
19
Q
List some barrier methods
A
- male condoms
- female condoms
- contraceptive sponge
- diaphragm
- cervical barriers
20
Q
Advantages of barrier methods?
A
- Acts as a mechanical barrier (FUCKING DUH DRENA)
- Prevents against STI’s
- Most effective method next to abstinence in protection against STIs and HIV
- Prevention of pregnancy
- Convenient
- Widely available
- Easy to use
- Used only when needed
- No systemic effects
- Inexpensive
- Variety of choices
- Discreet
21
Q
Disadvantages of barrier methods?
A
- Requries motivation to use and practise for proper use
- May reduce sensitivity
- May interfere with erection
- May deteriorate in storage or when oil based lubricants used
- Allergies or sensitive to latex in some women
- Typical failure rate is 18%
22
Q
Nonoxynol-9 is what?
A
spermicide
23
Q
Is Nonoxynol-9 (spermicide) effective?
A
No evidence that it’s more effective than just condoms so it’s not recommended due to potential side effects
24
Q
Describe polyurethane or polyisoprene
A
- Both are recommended for those with latex allergies
- Polyurethane is stronger than latex, but do not have as much stretch, so breakage and slippage rates increased
- Polyisoprene is a synthetic version of latex, is softer with stretchiness and more resistant to breakage
- More expensive than latex
- Can be used with water based lubricants
Products: SKYN, AVNATI BARE, BARESKIN
25
FC2 is the only ____ _____ in Canada
female condom
26
Describe FC2 (the only female condom in Canada)
- Nitrile sheath with 2 flexible rings
- Not intended for use with male condom !!!!
- Requires a new female condom for each act of intercourse
- Remove and throw away immediately after
- Squeeze and twist outer ring before standing up to keep semen inside of condom
27
Advantages to a female condom?
- Can be inserted 8 hours prior to intercourse
- Safe to use with latex sensitivity
- No deterioration when exposed to oil based lubricants
- Longer shelf life than male condoms
28
Disadvantages to a female condom?
- Typical failure rate is 21%
- No data for nitrile polymer regarding efficacy and STI prevention
- Higher cost than male condoms ($3/condom)
- Fit is affected by vaginal anatomy
- Difficult to insert
29
Describe Spermicidal Products
- Most contain Nonoxynol-9 that destroys sperm
- May be used alone or with a second method (condoms, cervical caps, diaphragms)
- Frequent use may lead to irritation and lesions on genital mucosa (which may increase risk of transmission of infections)
- Will not prevent transmission of STIs and STDs (obvs)
- Avoid use if multiple acts of daily intercourse
30
Spermicidal products include ??
- Gels - used with a diaphragm or cervical cap
- Foams - VCF Foam (Nonoxynol-9 12.5%). Insert 1 applicatorful no more than 1 hour prior to each act of intercourse
- Film - VCF (Nonoxynol 9 28% films). Inserted 15 mins (up to 3 hours) before intercourse. One film used per act of intercourse.
31
Describe the Contraceptive Sponge
- Small, disposable (single use), polyurethane foam intravaginal device, contains nonoxynol-9
- Concave side should sit over cervix, loop on other side helps with removal
- Inserted up to 24 hours before intercourse and must be left in the vagina for at least 6 hours after last act of intercourse but should not remain in vagina for more than 30 hours (risk of toxic shock syndrome)
32
MOA of the Contraceptive Sponge
- Provides a physical barrier to sperm
- Absorbs sperm
- Contains a spermicide
33
Advantages to the Contraceptive Sponge
- 12% failure rate in nulliparous women
- 24% failure rate in porous women
- One size fits all
- 24 hours of protection
- Protection begins right away
- No need to change with repeated acts of intercourse
- Can be used with male condoms (increases effectiveness)
34
Disadvantages to the Contraceptive Sponge
- CI in those with allergic to spermicidal
- Difficulty in removing - must remain in vagina for at least 6 hours after intercourse and must not be left in vagina for more than 30 hours
- Avoid those with history of TSS
- Increased chances of urinary infections
- No protection from HIV (Sponge may damage vaginal tissue and increase chances of HIV transmission)
35
CI to sponge or spermicide ?
- Being at high risk for HIV (Absolute CI)
- Being HIV positive or having AIDs due to increased chance of transmission to uninfected sexual partners
- Allergy to nonoxynol-9
- History of TSS
- Inability to correctly insert
- Repeated urinary tract infections
- Full term delivery (within 6 weeks), recent abortion (spontaneous or induced), vaginal bleeding (including menstrual flow for sponge)
36
Describe a Diaphragm
- Intravaginal barrier used with a gel
- 3 types available in Canada:
- Milex wide-seal silicone, Omniflex, and Milex Arcing
- Requires sizing and Rx by HCP
- Yearly replacement
Caya SILCS
- one size available, Rx not required
- can last up to 2 years
- has an area to help hold during insertion and removal
37
How do you use a diaphragm ?
- Insert up to 2 hours prior to intercourse
- Additional acid-buffering lubricant needed to be inserted with an applicator for repeated acts of intercourse of if >2 hours since diaphragm inserted and intercourse has not yet occurred
- Must remain in place for a minimum of 6 hours after intercourse
- Must be removed before 24 hours after initial insertion (risk of TSS)
- Wash with warm water and mild soap
38
Advantages of a diaphragm ?
- 12% failure rate
- Can be inserted up to 6 hours prior to intercourse
- Easier to insert than the cervical cap
- Can be used during menstruation
- Can be re-used for subsequent acts of intercourse
- Re-useable for several years
39
Disadvantages of a diaphragm ?
- Higher risk of urinary tract infections
- Requires practise to insert prior to first time use
- Risk of TSS
- Must inspect regularly for rips/tears
40
Describe pregnancy tests
- Use human chorionic gonadotropic (HCG)
- Detected in blood or urine after 6-8 days after conception
- Highest concentration between 9am and 12 pm
- Concentration doubles every 2 days, peaks in 60 to 70 days
- Initial tests use urine, then confirmed with a blood test
41
Describe the HCG levels after conception
HCG levels after conception:
- After 1 week: 5mlU/ml
- Peak at 100 000 mlU/ml
- Urine tests can detect levels at 20-100 mlU/ml
42
What can false-positive and false-negative results be from?
- May be due to human error
- False-negative test can occur up to 17 days after insemination
- Testing too early
- Testing too late
- Expired test kit
- Tumor production of HCG
43
Describe Vaginal Dryness and what it's caused by
- Usually a postmenopausal issue
- Low levels of estrogen during perimenopause and menopause may result in vaginal dryness
Decrease in estrogen causes:
- Thinning of vaginal tissue
- Loss of collagen support
- Increased vaginal pH
- Reduced production of vaginal lubrication even with sexual arousal
44
What are vaginal lubricants used for?
- vaginal dryness
- dyspareunia (pain during sex)
- comfort with condom use
- can be used during intercourse
45
Describe vaginal moisturizers
Replens: contains bioadhesive polymers that bind to vaginal epithelium and provide water and electrolytes to cells
* Others contain equally effective ingredients (ex. pectin)
- Longer duration of action, 2-3 days versus lubricants
- Used on a routine basis - not immediately before intercourse
* Like a hand cream to prevent dry skin.. Moisture not lubrication !!
Clinical 1 (Part B)
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