1
Q
What % of childbearing-age women in the US become pregnant each year?
A
10%
2
Q
What % of pregnancies are unintended?
A
31%
3
Q
What is the Rhythm Method?
A
Periodic Abstinence
4
Q
What is characteristic of the Rhythm Method?
A
- Works 80-87% of the time w/ regular cycles (30-55%W/O)
2. 1 in 8 times it fails (“prego by August”)
5
Q
What does the Rhythm Method rely on?
A
- Relies on measuring basal body temp. and cervical mucus thickenss.
6
Q
What change in Temperature signals ovulation?
A
0.4-0.8 degrees F.
7
Q
What does a ovulation test kit measure?
A
It measures LH levels in Urine.
8
Q
How long is sperm viable in the uterus?
A
3-5 days
Requires abstention for 5-10 days around ovulation.
9
Q
What types of barrier contraception are there?
A
- Male Condom
- Female Condom
- Diaphragm and Cervical Cap
10
Q
What are the characteristics of the Male Condom?
A
Latex rubber prevents virus transmission
-Protects against –> STD, including HIV
Theoretical Effectiveness = 98%
Actual Effectiveness = 85%
-Mineral oil based creams decrease strength by 90%
11
Q
What are the characteristics of the Female Condom?
A
Outer ring provides additional protection against STDs.
Cumbersome, High failure rate, disliked.
Theoretical Effectiveness = 95%
Actual = 79%
12
Q
Where does the Cervical cap fit?
A
Fits over the cervix.
13
Q
Where does the Diaphragm fit?
A
Fits against the vaginal wall.
14
Q
What a important facts about the Diaphragm/Cervical Cap?
A
- Must be fitted by physician.
- Cervical cap smaller than diaphragm.
- Can be placed 6 hours before and must be left 6 hours after.
- Theoretical Effectiveness = 94%
- Actual Effectiveness = 84% or less
- Neither should be considered as means to protect against STD.
15
Q
What is a spermicide?
A
Nonionic surfactant that disrupt sperm cell membranes.
16
Q
What compound is contained in most spermicides?
A
Nonoxynol-9
17
Q
How are sperm immobilized?
A
By disrupting the acrosomal membrane (head)
18
Q
What formulations are spermicide available in?
A
Creams, Gels, Foams, Contraceptive sponge.
19
Q
What are the characteristics of the Sponge?
A
- Fits over cervix.
- Can be placed up to 6 hours before.
- Good for 24h.
- Must be left in place for 6h after not more than 30h.
20
Q
What kind of protection do spermicides provide against STDs, and HIV?
A
NONE
21
Q
What is the effectiveness of spermicides?
A
- Alone no better than 82%
- Actual 71%
Sponge:
Theoretical 91%
Actual 84%
22
Q
What are the characteristics of Combined hormonal contraceptives? (CHCs)
A
- Work by preventing ovulation.
- Also impede sperm movement.
- Exam no longer required before CHC Rx.
- Medical history and BP needed!!!!
23
Q
From what compound do hormonal contraceptives provide most of their effect and how?
A
Progestins
- Block LH surge, Inhibit Ovulation
- Thicken cervical mucus –> endometrial atrophy
24
Q
What are the 5 drug names for hormonal contraceptives?
A
- Desorgestrel
- Norethindrone
- Norgestrel
- Levonorgestrel
- Norelgestromin (patch)
25
How do progestins differ?
In estrogenic/anti-estrogenic AND androgenic effects.
estrogenic/Anti-E result from metabolism
Androgenic effects result from direct, as well as displacing testosterone from SHBG.
26
What is the main effect of Estrogens?
Suppress FSH
Prevent LH surge
-Stabalize endometrium
27
What is the most common estrogen in CHCs?
Ethinyl Estradiol (EE) (20-50ug/pill)
28
What is converted to Ethinyl Estradiol (EE) and where?
Mestranol and Liver
| 50% less potent than ones in CHC.
29
What are the Non-Contraceptive benefits of CHCs?
1. Decreased menstrual problems
| 2. Decreased risk of ovarian and endometrial cancers, ovarian cysts, PID. --> persists after d/c of CHC.
30
What are the 4 categories of adverse effects in CHCs?
1. Estrogen Excess
2. Estrogen Deficiency
3. Progestin Excess
4. Progestin Deficiency
31
What CHC adverse effects are due to Estrogen excess?
1. Nausea, Breast Tenderness, HA, Fluid retention.
32
How do you treat adverse effects of Estrogen excess?
Decreasing dose
Progestin Only
IUD
33
What CHC adverse effects are due to Estrogen Deficiency?
Midcycle breakthrough bleeding
Hot flashes, anxiety, decreased libido.
Amenorrhea
34
How do you treat adverse effects of Estrogen deficiency?
Increase estrogen dose
35
What CHC adverse effects are due to Progestin excess?
Increased appetite, wgt gain, bloating
Acne, hirsutism
Depression, fatigue, irritability.
36
How do you treat adverse effects of progestin excess?
Decreasing Progestin dose
| Use less androgenic progestin.
37
What CHC adverse effects are due to Progestin deficiency?
Dysmenorrhea, Late cycle breakthrough bleeding.
38
How do you treat adverse effects of progestin deficiency?
Increase progestin dose
Use extended cycle or continuous regimen.
Progestin-only
IUD
39
Do CHCs protect against STDs and HIV?
NO
40
For women older than 35 years, what doses of CHCs are safe up until menopause?
CHCs containing
41
How can CHCs help premenopausal women?
help with bone mineral density and vasomotor symptoms.
42
What risks do smokers have while taking CHCs?
High dose of estrogen >50ug EE indicated increased MI risk.
43
What should women over 35 who smoke be advised against?
COCs
Progestin-Only methods PREFERRED
44
What are the risks associated with Hypertension while taking CHCs?
Even low dose of EE CHCs increase BP 6-8 mmHg.
| Use is acceptable
45
What is a major contraindication for CHCs?
Should not be used in women with end-organ vascular disease, or are smokers.
History of Thromboemboilc events.
46
What can Drospirenone-containing CHCs cause?
An increase in Serum K+
47
What is the best CHC choice for women w/ HTN and why?
Progestin Only regimens, because they do not increase BP or CV risk.
48
What are some Dyslipidemia risks of CHCs?
Progestins DECREASE HDL and Increase LDL.
Estrogens DECREASE LDL and Increase HDL.
- Usually no net effect on lipid profiles.
49
Women with what level of LDL should not use CHCs?
Uncontrolled Dyslipidemia LDL > 160mg/dl.
50
Is CVD risk from CHCs due to Thrombosis (clotting) or Atherosclerosis?
Thrombosis (clotting)
51
Should women w/ diabetes and vascular disease use CHCs?
NO, even though CHCs dont affect insulin release or A1C, and no increased risk of T2DM.
52
Can CHCs increase or decrease migraines?
Both.
53
What kind of migraine can carry a increased risk of stroke? and should CHCs be used?
Migraine with Prodromal Aura.
| Should not Use CHCs.
54
What should women who develop migraines with or without aura on CHCs do?
Discontinue use immediately.
55
Which CHCs are recommended for women with migraines?
Progestin only methods.
56
Estrogens increase the production of...... Which increases the risk of.......... and........?
Clotting Factors
Deep Vein Thrombosis (DVT)
Pulmonary Embolism.
57
Risk of VTE increases 4-fold in women using what?
Low-dose OCs.
58
Obese women are at a higher risk of what while on CHCs?
Contraceptive Failure
| Increased VTE risk
59
Which CHCs are preferred in the obese population?
Depot MPA
| Levonorgestrel IUD
60
What are patients with Systemic Lupus Erythematosus (SLE) at risk for?
Risks of pregnancy high (miscarriage)
61
Which CHCs should be used in women w/ SLE + anti-phospholipid antibodies or vascular complications?
Progestin only contraceptives.
62
When were Oral Contraceptives first introduced and by who? What were the characteristics of the formulation?
1960 and by Searle.
| High-dose formulations containing a progestin (norethylnodrel, 5mg) and 75ug mestranol.
63
When did contraceptives become legal in all states?
1965.
64
What are advantages to "The Pill"?
Requires no preparation, no planning.
Highly effective in preventing pregnancy.
Unleashed the sexual revolution.
Allowed women to attend college, embark on careers.
65
Who wrote the song "The Pill"?
Lorene Allen, Don McHan, T.D. Bayless.
66
What is the efficacy of oral contraceptives?
Theoretical >99%
| Actual 92%
67
What are the characteristics of monophasic OCs?
Fixed amount of estrogen and progestin for 21 days, followed by 7 placebo pills.
68
What are the characteristics of Biphasic/Triphasic/Multiphasic OCs?
Vary estrogen and progestin contents to manage breakthrough bleeding and adverse effects.
69
What are the characteristics of extended cycle OCs?
Increase the time between periods to 3 mo. 84 active pills, 7 placebos --> 4 periods/year.
70
What are characteristics of Lybrel?
Elminates hormonal cycle
365 pills w/ no placebo.
20ug of EE w/ 90ug of levonorgestrel.
71
Why is placebo included in most OC packages?
Reassures women that they are not pregnant.
| 60% of women would prefer no period every month, 33% would chose never to have one.
72
What are characteristics of 3rd/4th generation OCs?
Contain newer progestins w/ less androgenic activity.
73
What are the 3rd/4th generation OCs?
Desogestrel
Norgestimate
Drospirenone
74
What is special about Drospirenone?
Has anti-aldosterone effects. (mineralcorticoid receptor antagonist)
-less bloating and wgt gain
Higher risk of VTE vs. Levonorgestrel.
FDA warning on products.
75
What are characteristics of Progestin only pills?
Less effective, associated w/ irregular bleeding.
Must be taken everyday at same time.
40% still ovulate --> ectopic pregnancy risk
76
Are all COCs equally effective?
YES
77
What formulations of OCs are first choice?
Low dose --> 35 ug or less EE and
78
In which populations do very low dose formulations of OCs (20-25ug EE) have lower adverse effects in?
1. adolescents
2. Underweight (35 yo
4. Perimenopausal
79
For women >160 lb what formulations of OCs should be used and why?
35-50 ug formulations, do not exceed 50 due to VTE risk.
because pregnancy risk is higher with low dose and heavy weight.
80
Which type of formulation of OCs is easiest to manage?
Monophasic formulations.
81
What formulations of OCs can lessen spotting and progestin adverse effects?
Bi/Triphasics
82
What formulations of OCs lessen menstrual issues?
Extended formulations.
83
What population of women are progestin only candidates?
1. Migraines w/ aura
2. Thromboembolic diseases
3. Cerebrovascular disease
4. SLE
5. Women >35 w
- Smoker
- Obesity
- HTN
84
What are characteristics of the Transdermal patch (ortho evra) hormonal contraceptive?
1. EE + norelgestromin (active metabolite of norgestimate)
2. As effective as COCs (fails >198lb)
3. Estradiol exposure 60% higher b/c avoids first pass.
4. Apply abdomen, buttock, upper arm weekly for 3 weeks.
85
What are characteristics of Vaginal Rings as a form of Contraceptives? (Nuvaring)
1. EE + Etonogestrel
2. As effective as COCs.
3. Inserted and worn for 3 wks.
4. Does not interfere w/ intercourse, low discomfort.
5. Provides lower systemic dose of estrogen.
86
What are characteristics of the Depo-Provera form of Contraceptive?
1. Injectable Progestin
2. 150 mg medroxyprogesterone acetate (DMPA)
3. IM (butt or arm) SubQ (abdomen or Thigh)
4. Inhibits ovulation for 3 months
5. 97% actual efficacy.
6. *prolonged delay to fertility post D/C. (10-18m)
87
What are the menstrual irregularities w/ spotting/heavy bleeding while using Depo-Provera?
30% 1st year, 10% after
| 55% report amenorrhea after 1 year.
88
What is a main concern while using Depo-provera?
Decrease in bone mineral density due to estradiol production being suppressed by DMPA.
FDA recommends no longer than 2yr use.
89
What are characteristics of the Implanon Subdermal Progestin Implant?
1. Flexible matchstick size implant containing etonorgestrel.
2. Placed under skin of upper arm.
3. Lasts 3 years.
4. Suppresses ovulation in 97%
5. Irregular menstrual bleeding and spotting most common complaint.
6. Does not affect BMD, fertility returns rapidly
90
What do IUDs release and what effect does it have?
Copper ions (ParaGard)
Levonorgestrel (Mirena, Skyla, Liletta)
1. Both reduce sperm mobility or viability (Cu)
2. Both may also interfere with implantation.
91
What is the effectiveness of IUDs?
Both types 99%
- 0.8% failure rate 1st year Copper
- 0.2% failure rate 1st year Mirena
92
How long is ParaGard (copper) IUD effective for?
10 Years
- Tends to increase blood flow by 35%
- Increases incidence of dysmenorrhea
93
How long is Mirena (levonorgestrel) IUD effective for?
5 years.
- Releases 10ug progestin/d, low systemic abs.
- Reduces menstrual flow but increases spotting 1st year.
- Incidence of amenorrhea =20% 1st yr, 60% 5yr
94
Both IUDs may increase the incidence of what?
Pelvic Inflammatory Disease (PID)
1-2.5%
-Highest risk immediately after insertion.
95
When does fertility return upon removal of IUDs?
Immediately
96
What is the most important fact of IUDs?
It is the most widely used form of reversible contraception.
97
What are the types of Emergency Contraception?
Progestin-only Pills (plan B)
Yuzpe regimen
Anti-Progestins
Copper IUD
98
What are the characteristics of the Progestin-only EC?
1.Contain 1.5 mg levonorgestrel, 1 dose or 2 split, 12hr apart.
99
What does Progestin-only EC affect?
Prevents Ovulation
Prevents sperm motility
effective in early stages of LH surge to prevent follicle rupture.
100
What does Progestin-only EC NOT affect?
Implantation or Post-Implantation events.
101
How soon should Progestin-only EC be taken?
within 72hr of intercourse.
FDA estimate 85% efficacy.
May be effective up to 5 days after.
102
What are adverse effects of Progestin-only EC?
Nausea most common.
| May induce withdrawal bleeding within 7 days, or delay menstruation 2-3 days.
103
When did Progestin-Only EC become available without Rx to all age patients?
Feb 2014.
104
What is characteristic of the Yuzpe regimen?
1. It is a COC approved for EC.
2. 100 ug EE + 0.5 mg levonorgestrel repeat after 12 hours
3. 74% effective within 72hours
4. Adverse effects worse than w/ progestin only regimen.
105
What are the two Anti-Progestins used for EC?
Ulipristal (ella) and Mifepreistone (off label)
106
What do Anti-Progestins do?
1. Block ovulation, impair endometrial proliferation.
2. Effective up until day of LH peak surge.
3. Longer acting than levonorgestrel.
107
How soon should Anti-Progestins be used?
within 5 days of coitus. 60% effective. Rx only
108
What are Anti-Progestins considered as?
"embrotoxic"
109
When is Anti-Progestin contraindicated?
Severe liver disease b/c metabolized by CYP3A4
110
What is the most effective form of EC?
Copper IUD 99%
111
What is special about copper IUD as EC?
1. Can be left in place or removed after menstruation.
2. Prevents sperm motility and viability.
3. may also prevent implantation.
Endocrine
flashcards
Decks in class (9)
# Cards
