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CHC Flashcards

CHC (93 cards)

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1
Q

what is the name of the Canadian guidelines for contraceptives?

A

SOGC

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2
Q

how have CHC progressed over time?

A

lower doses of estrogen and progestins
newer progestins and estrogens on the market

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3
Q

how does the menstrual cycle work?

A
  1. GnRH from hypothalamus stimulates secretion of FSH and LH from anterior pituitary gland
  2. FSH stimulates estrogen release; LH stimulates ovulation and progesterone secretion from corpus luteum
  3. estrogen controls proliferation fo endometrium
  4. progesterone controls the later secretory phase
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4
Q

how does estrogen work in CHC?

A

prevents follicular development and ovulation
- inhibits FSH release via negative feedback

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5
Q

how does progestin in CHC work?

A

inhibits ovulation (LH release)
thickens cervix to decrease sperm transport
slow tubal motility
thins the endometrium so that implantation is harder

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6
Q

when does the follicular phase happen?

A

days 1-13
(ovulation is day 14)

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7
Q

when does the luteal phase happen?

A

days 15-28

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8
Q

describe the endometrium during the follicular phase?

A

since estrogen is high during this phase, endometrium is not that thick (during period), but then later on (after period) it starts to thicken

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9
Q

describe the endometrium during the luteal phase?

A

progesterone + estrogen dominant
endometrium is thick

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10
Q

what are the types of estrogen in CHC?

A
  1. ethinyl estradiol (EE)
    - synthetic
    - longer half life + potency
    - found in majority of CHC
  2. estetrol (E4)
    - newer
    - less potent than EE
    - synthetic version of estrogen produced by human fetal liver
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11
Q

what are the types of estrogen produced by the body?

A
  1. Estrone (E1) - made in ovaries, remains after menopause
  2. estradiol (E2) - made in ovaries during repro years
  3. Estriol (E3) - produced by placenta during pregnancy
  4. estetrol (E4) - produced by fetus during pregnancy
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12
Q

what are the first gen progestins and where are they derived from?

A

derived from: testosterone > 19-nortestosterone > estranes

names: norethindrone, ethynodiol

have progesterone, estrogen, and androgen properties

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13
Q

what are the second gen progestins and where are they derived from?
*most common

A

derived from: testosterone > 19-nortestosterone > gonanes

names: norgestrel, levonorgestrel

more progesterone and androgen activity - less estrogen

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14
Q

what are the third gen progestins and where are they derived from?

A

derived from: testosterone > 19-nortestosterone > gonanes

names: desogestrel, norgestimate, norelgestromin, etonorgestrel

more progesterone activity - less androgen than 2nd gen

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15
Q

what is the fourth gen progestin and where is it derived from?

A

derived from: spironolactone

name: drospirenone

antimineralocorticoid, antiandrogen effects (for acne purposes, you’d want less androgens aka testosterone)

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16
Q

how do contraceptives improve cycle control?

A

less painful periods (dysmenorrhea) - endometrial lining stays thin, helping to alleviate pain and heaviness of periods

less blood loss when they do get a period

lower ectopic pregnancy and ovarian cysts risk - follicle development gets inhibited while taking birth control

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17
Q

what cancers do contraceptives lower the risk of?

A

colorectal
ovarian
endometrial
- these benefits can last up to 20 years after stopping birth control

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18
Q

how do contraceptives control sx in perimenopause?

A

hormones are fluctuating during that time, if you give estrogen/progesterone that is stable, then the hormones in the body will reach a stability

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19
Q

what are some other non-contraceptive benefits of birth control

A

improved acne
positive effects on bone mineral density

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20
Q

what are the medical risks of CHC?

A

VTE - estrogen has a clotting effect at high doses (at “low” doses it is more fibrinolytic aka breaks down clots that have been formed)

MI and stroke - assoc with higher doses of EE (50mcg); related to:
- smoking + over 35y.o
- hypertension

breast cancer - research is still unclear

hypertension, diabetes, increased TG, sx gallbladder disease, migraines (either from estrogen/progesterone sensitivity)

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21
Q

at what dose of EE is there is a risk of VTE

A

less than or equal to 35 mcg EE

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22
Q

what is the baseline risk of women getting a VTE vs when they are on CHC?

A

baseline: 3-5/10,000 women
on CHC: 8-9/10,000 women

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23
Q

when is the risk of VTE the highest for women on CHC?

A

within the first year of starting it
if they have genetic factors for thrombophilia
if they are of older age, smokers, obese, had recent surgery

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24
Q

which progestins (in CHCs) are thought to be associated with a 1.5-2x higher risk of VTE

A

third and fourth gens
- bc they are anti-andronergic
androgens actually stop clotting

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25
should you limit prescribing of CHC to just 1st and 2nd gen progestins to reduce risk of VTE?
NO! because the guidelines don't recommend "preferential prescribing" since the role of progestins on VTE risk is unknown bottom line: prescribe wtvr you want
26
what are the WHO absolute c/I for CHC?
1. active or hx of VTE 2. known genetic thrombophilia 3. major surgery with prolonged immobilization 4. age of 35+ and heavy smoker >15+ cigs/day 5. stroke 6. ischemic heart disease 7. severe HTN (>160/100) 8. diabetes with complications 9. liver disease 10. breastfeeding <6 weeks postpartum 11. breast cancer 12. migraines with aura
27
what is the most common a/e of CHC?
breakthrough bleeding - happens during 21 (or 24) days on the pill - most common in first 3 months of starting CHC
28
what are estrogen related a/e of CHC?
nausea chloasma (changes in skin pigmentation and sensitivity to sun ) poor contact lens fit
29
what are progestin related a/e of CHC?
mood: depression, PMS, fatigue bloating increased appetite
30
what are both estrogen and progestin related a/e of CHC?
breast tenderness fluid retention headaches/migraines
31
how do CHC decrease acne?
estrogen can increase sex hormone binding globulin (SHBG) this decreases free testosterone levels therefore decreasing androgens and causing less acne to come out
32
what a/e of CHC are associated with estrogen DEFICIENCY? *meaning the estrogen dose would need to be increased)
- early or mid cycle spotting/BTB - no bleeding - mood: irritability, depression - menopause sx (hot flashes, dryness)
33
what a/e of CHC are associated with progestin DEFICIENCY? *meaning the progestin dose would need to be increased)
late BTB/spotting heavy flows delayed period
34
what drug interactions are found with CHCs?
CYP3A4 inducers eg. anticonvulsants, HIV meds, rifampin, NHPs lamotrigine - gets cleared way faster (needs dose adjustment)
35
what effect do CYP3A4 inducers have on CHCs?
decrease the concentration of CHCs
36
does estrogen or progestin undergo enterohepatic recirculation?
EE
37
what should you advise a pt who is taking CHC and gets prescribed a antibiotic?
use barrier methods for the time that you are taking the antibiotic Abx might alter GI flora and interfere with estrogen recirculation
38
what are the steps when prescribing CHC for the first time?
step 1: is CHC indicated and safe? step 2: which CHC is the best option? step 3: educate pt on CHC, missed doses, s/e, efficacy step 4: follow up and monitoring parameters
39
go into more depth about step 1 when prescribing CHC
- pt demographics: age, weight, height - do they want a contraceptive benefit or something else (ie. acne) - any c/I - any d/I - assess flow and cycle regularity - when was last period? are they regular? any spotting? - any unprotected intercourse since your last period? - BP test (refer if over 140/90)
40
what is the lowest dose of EE available?
10 mcg (product name: Lolo)
41
what is considered low dose estrogen?
below 35 mcg
42
what dose of EE is recommended for youth?
30 or 35 mcg *can then taper down if they are experiencing a/e
43
what dose of EE is recommended for women >35yo
20 mcg or less
44
in CHC, which component is the cause of lots of variation
progestin
45
which progestin is the most estrogenic?
1st gen
46
which progestin is the most progestogenic and androgenic?
2nd gen
47
which progestins are the most anti-androgenic?
4th gen and cyproterone
48
which progestin is considered for fluid retention or PMS
drosperinone (4th gen)
49
which progestins are considered for antiandronergic effects like treating severe acne?
drospirenone and cyproterone *less free testosterone
50
what are the 2 types of phases with CHC products?
fixed (monophasic) - fixed doses of estrogen and progestin throughout the cycle multiphasic (triphasic or biphasic) - fixed estrogen dose, but progestin dose increases in 3 or 2 phases *first week is low, third week is highest dose
51
is fixed/multiphasic preferred over the other?
no there is no advantage of either one over the other
52
what are the different regimens for CHC products?
21/7 - 21 days of hormones and 7 day withdrawal interval 24/4 continuous - no period *for women who experience bad sx during their withdrawal phase 7 day HFI every 3 months
53
is a physiologic period necessary?
no - some women choose to not have one while taking CHC
54
why do some women prefer a shortened HFI?
lessens the risk of getting pregnant bc FSH levels will remain lower for longer (bc you're giving estrogen for longer periods) women experience sx on HFI and would like to shorten that (pain, endometriosis, headaches, PMS, menopause)
55
on a 24/4 regimen what are the chances of follicular development during the HFI?
2%
56
on a 21/7 regimen, what are the chances of follicular development during the HFI?
22%
57
what happens if you're on a 21/7 regimen but forget to restart you're pills after day 7 and extend the HFI to 10 days?
chances of follicular development increase to 56%
58
how long does it take CHC to start working?
7 consecutive days
59
which regimen of CHC is assoc with most breakthrough bleeding/spotting/
continuous regimen
60
how does the transdermal patch, Evra, work?
apply a new patch every 7 days for 3 weeks, then 1 week off
61
can the patch be used continuously instead of 21/7?
yes
62
what happens if a women forgets to change her patch after day 7?
the patches are actually good for 9 days to allow some leeway in case a women forgets to change after day 7
63
what is one c/I of the patch?
women over 90kg
64
how does the ring, NuvaRing, work?
inserted once every 3 weeks, then removed for 1 week new ring inserted after
65
what are c/I of the ring?
uterovaginal prolapse vaginal stenosis
66
can the ring be used continuously?
yes one ring also lasts up to 4 weeks to allow leeway
67
what are some pt education pts about the ring?
does not need to be removed for intercourse if removed and left out for >3 hours, then use condoms for 7 days dont use with a diaphragm or oil based products might be related to higher VTE rates
68
what is the newest CHC on the market?
Nextstellis (estetrol/drospirenone) E4 is a synthetic version of estrogen produced in fetal liver longer half life compared to estradiol (from ovaries) only estrogen that has selective binding properties to nucleus estrogen receptor
69
what is the Nextstellis regimen?
24/4
70
what are some advantages of Nextstellis?
less effects on hemostasis - lower VTE risk? weaker effects on mammary glands not metabolized by CYP, but progestin is, so keep that in mind
71
what does our prof like to do when prescribing?
for younger pts, do 30-35 mcg EE start with 20, then monitor in 3 months and increase dose
72
what is a Sunday start?
start taking CHC on the first Sunday after your period starts - if period starts on a Friday, then 2 days later (Sunday) you would start the CHC
73
what is a first day start?
start CHC on the first day of your period
74
what is a quick start method?
start CHC the same day you get it filled *most common *regardless of what day you are on your period
75
which start method requires back up contraception in the first 7 days after starting CHC?
Sunday start quick start
76
when will most a/e disappear?
after 3 months of starting CHC
77
what are the red flags after starting CHC?
ACHES A - abdominal pain C - chest pain H - headaches E - eye problems S - severe leg pain
78
how do you know a headache is a warning sign?
if it is sudden, persistent, severe not getting any better happened after starting CHC
79
when is the worst time to miss a CHC dose?
during weeks 1 and 3 - bc either of these weeks can extend the HFI (forgetting to take a pill after your HFI ends, or forgetting to take a pill near the end of week 3)
80
what to do if you missed a pill in week 1 or 2?
take a new pill as soon as you remember (even if it means you took 2 pills that day)
81
what to do if it's been longer than 2 days and you just remembered you forgot to take your pill?
take pill right away but add on 7 days of condoms as backup
82
what to do if you missed a pill in the last days of week 3?
take a new pill as soon as you remember, SKIP THE HFI and just start a new pack of birth control
83
do CHC prevent STIs?
no
84
do CHC cause weight gain?
no, they do cause bloating, water retention tho during first few weeks of starting
85
do CHC prolong return of fertility after d/c?
no
86
what to do with ongoing BTB?
change to a different CHC (either change EE dose or switch to a diff progestin) shorten HFI (21/7 --> 24/4) Rx: ibuprofen or estrogen pills for 7 days
87
what are the most common a/e of CHC?
nausea water retention headache mood changes acne weight gain
88
how to combat nausea a.e?
take at bedtime with food lower EE dose
89
how to combat water retention a.e?
watch salt intake Lower EE dose switch progestin switch to drospirenone
90
how to combat headache a.e?
switch to continuous, if headache happens during HFI lower EE dose, if headache happens while on CHC
91
how to combat mood changes a.e?
switch to different progestin
92
how to combat acne a.e?
it will usually get better with time but if it doesn't, switch to anti-androgenic CHC
93
how to combat weight gain a.e?
assess if weight gain is caused from fluid retention or not - studies show CHC do not cause weight gain if it is persistent, refer
Pharm 443
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