PEBCs > Contraception - Med/High Priority > Flashcards

Contraception - Med/High Priority Flashcards

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1
Q

What is contraception?

A

intentional intervention of pregnancy

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2
Q

What is pregnancy?

A

implantation of fertilized egg

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3
Q

What is breakthrough bleeding?

A

bleeding during active pill days of the cycle

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4
Q

What is withdrawal bleeding?

A

bleeding caused by a drop in exogenous hormones

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5
Q

Describe the feedback mechanism between the hypothalamus and uterus.

A

hypothalamus –> GnRH –> anterior pituitary –> FSH, LH –> gonads –> estrogen, progesterone –> uterus
E and P can cause + or - feedback on hypothalamus and anterior pituitary

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6
Q

Describe the follicular phase.

A

marked by the first day of menses

FSH promotes maturation of several ovarian follicles

a dominant follicle is formed after about 7 days

as the dominant follicle continues to grow E lvls increase and the follicle develops LH receptors

rising E lvls result in proliferation of the endometrial lining and at midcycle stimulates the pituitary gland to release a surge of LH

the LH surge causes the follicle to mature and rupture, releasing the ovum into the fallopian tubes

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7
Q

Describe the luteal phase.

A

marked by the release of the ovum from the follicle

the remaining cells of the follicle become the corpus luteum, which secretes large amounts of E and P (prepares endometrium for implantation)

if ovum is fertilized –> corpus luteum continues to maintain the hormone production necessary for the early stages of pregnancy

if ovum is not fertilized –> corpus luteum degenerates and P & P drop quickly –> menses

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8
Q

What are the goals of therapy for contraception?

A

prevent pregnancy
prevent or minimize ADRs
provide pt specific conctraception

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9
Q

What are the natural methods of contraception?

A

coitus interruptus
fertility awareness-based methods

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10
Q

What are examples of non-hormonal contraception?

A

natural methods
barrier methods
spermicides
copper IUD
surgical sterilization (vasectomy, tubal ligation)

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11
Q

What are examples of barrier methods?

A

male condom
female condom
diaphragm
cervical cap
contraceptive sponge

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12
Q

In a regular cycle, when is a female most likely to be fertile?

A

days 8-19

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13
Q

What is the basal body method of contraception?

A

tracks changes in BBT that occur during menstrual cycle
-slight drop in BBT 12-24 hrs before ovulation, followed by a sharp rise in BBT after ovulation

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14
Q

What is the cervical mucous method of contraception?

A

tracks mucus changes throughout the menstrual cycle
-around the time of ovulation, the mucus takes on the appearance of uncooked egg white which provides a favorable environment for sperm

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15
Q

If using the BBT method, what is key?

A

due to difficulty determining start of fertile period, experts suggest another method of contraception from day 1 of menses until 3 days of elevated temperature

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16
Q

What is lactational amenorrhea?

A

natural contraceptive effect from exclusive breastfeeding for the first 6 months of life

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17
Q

What are the four different types of male condoms?

A

lambskin
latex
polyurethane
polyisoprene

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18
Q

Which male condoms are not effective at protecting against STIs/HIV?

A

lambskin

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19
Q

Which male condoms are effect at preventing STI/HIV transmission?

A

latex
polyurethane
polyisoprene

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20
Q

Which lubricants are compatible with lambskin condoms?

A

oil and water-based lubricants

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21
Q

What are the cons of lambskin condoms?

A

poor elasticity, may slip off
does not protect against HIV/STIs

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22
Q

Which lubricants are compatible with latex condoms?

A

only water-based lubricants
-never use with oil-based lubricants

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23
Q

What are advantages of polyurethane condoms?

A

latex-free
stronger & thinner than latex (more sensation)
effective at preventing STI/HIV transmission

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24
Q

What is a con of polyurethane condoms?

A

less stretchy (more breakage/slippage)

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25
Which lubricants are compatible with polyurethane condoms?
oil or water-based lubricants
26
Which lubricants are compatible with polyisoprene condoms?
only water-based lubricants -never use with oil-based lubricants
27
What is a pro of polyisoprene condoms?
softer and more resistant to breakage compared to polyurethane
28
What is a female condom?
single-use lubricated (silicone-based) nitrile polymer sheath that has rings at each end to hold it in place (closed end is inserted into vagina and covers cervix, open end stays outside the vagina)
29
When can female condoms be inserted?
up to 8 hours before intercourse
30
When should female condoms not be used?
with male condoms
31
What are the pros and cons of female condoms?
pros: -may be inserted several hours in advance -may be used with any type of lubricant (not latex-based) -hypoallergenic -provides protection against STIs cons: -difficult to use -may make noise during intercourse -inner ring may cause discomfort -highest failure rate
32
What is a diaphragm?
latex or silicone dome covering the cervix (requires proper fitting against vaginal wall) that may be filled with spermicidal gel
33
When can diaphragms be inserted?
up to 2 hours before intercourse and must remain in place for at least 6 hours after intercourse (24 hrs max)
34
What are the pros and cons of diaphragm?
pros: -may be inserted in advance -reusable up to 2 yrs cons: -difficult to insert -may become dislodged during intercourse -requires refitting after childbirth -does not protect against STIs -increased risk of UTIs and toxic shock syndrome -cant be used with oil-based lubricants or topical medications
35
What is a cervical cap?
silicone dome covering the cervix (requires proper fitting) that may be filled with spermicidal gel
36
When is the cervical cap inserted?
up to 2 hours before intercourse however must remain in place for at least 6 hours after intercourse (max 48 hrs)
37
What are the pros and cons of cervical cap?
pros: -may be inserted in advance cons: -difficult to insert -may become dislodged during intercourse -no STI protection -risk of toxic shock syndrome -cant be used with oil-based lubricants or topical medications
38
What is a contraceptive sponge?
small, disposable polyurethane foam device containing nonoxynol-9 (spermicidal)
39
When is a contraceptive sponge inserted?
can be inserted up to 24 hrs before intercourse, must remain in place for at least 6 hrs after intercourse (30 hrs max)
40
What are the pros and cons of contraceptive sponges?
pros: -no fitting required -no latex -24 hr protection cons: -least effective -cannot be reused -increased risk of HIV -no STI protection -risk of toxic shock syndrome -less effective in women who have given birth
41
Which agent is a spermicide?
nonoxynol-9
42
What is a significant con of spermicides?
increases risk of HIV/STI transmission
43
How are spermicides used?
with or without barrier methods
44
How long does the copper IUD last for?
5-10 yrs
45
What is the role for the copper IUD in contraception?
1st line option for everyone
46
What are the advantages of the copper IUD?
hormone-free can be used as EC up to 7 days after intercourse can be inserted immediately post-partum long term reversible protection immediate return to fertility for most
47
What are the disadvantages of the copper IUD?
increased risk of painful menstrual cramps and menstrual flow increased risk of ectopic pregnancy during use requires physician for insertion and removal risk of uterine perforation and expulsion within 1st year risk of infection during first 21 days after insertion
48
What are the available formulations for CHC?
oral transdermal patch vaginal ring
49
Which progestins are 1st gen?
norethindrone MPA
50
What is considered to be ultra low dose estrogen?
10 mcg EE
51
What are the available formulations for progestin-only contraception?
oral IM injection IUS SD implant
52
Which progestins are 3rd gen?
desogestrel norgestimate norelgestromin etonorgestrel
52
What is considered to be low dose estrogen?
20-25 mcg EE
53
Which progestins are 2nd gen?
levonorgestrel
54
Which progestins are 4th gen?
drosperinone cyproterone acetate
55
What is the indication for cyproterone acetate?
acne only
56
Which progestin is most androgenic?
levonorgestrel
57
Which progestins are least androgenic?
desogestrel norgestimate
58
Which progestins are anti-androgenic?
drosperinone cyproterone acetate
59
What occurs as you move up a generation of a progestin?
less androgenic activity
60
When is low dose EE best?
for young people, with decreased side effects and lighter cycles
61
What are common AE of COC?
BTB amenorrhea NV bloating chloasma breast tenderness mood changes
62
What are the serious AE of COC?
thrombosis stroke MI HTN
63
What does extended/continuous COC increase the risk of?
irregular bleeding (when coming off product)
64
What is the risk with antiandrogenic COCs?
hyperkalemia risk increased VTE risk
65
Which COCs are best for acne?
antiandrogenic
66
What are the pros of extended/continuous COCs?
very few cycle days and lower side effects used for endometriosis + POS
67
What are contraindications to COC?
history of MI/heart disease VTE thrombogenic mutations severe cirrhosis liver tumour breast cancer diabetes with microvascular complications migraines with aura < 6 weeks post-partum if breastfeeding smoker > 35 yrs (>= 15 cigs/day) HTN (> 160/110) known coagulation factor deficiency
68
When should COC not be initiated?
smoking 15 cigs/day or more after age of 35 experiencing migraines with aura at any age undiagnosed vaginal bleeding pregnant or < 6 wks postpartum if breastfeeding hormone-sensitive cancers high BP that is uncontrolled CVD: MI, vascular disease, ischemic heart disease
69
How is missed COC managed if the pt missed 1 pill and < 24 h since last pill?
take pill immediately continue taking pack normally
70
How is missed COC managed if the pt missed >= 1 pill and > 24 h since last pill?
week 1: -take pill immediately -continue taking pack normally -use back-up contraception x 7 days -consider EC week 2/3: -take pill immediately -continue taking pack until HFI -then skip HFI and start new pack
71
How is missed COC managed if missed >= 3 pills?
use backup contraception x 7 days and consider EC
72
What are the questions that should be asked when a pt misses contraception doses?
doses missed? time of last dose? unprotected sex? where at currently in cycle?
73
What are the hormones contained in the CHC patch?
35 mcg EE and 200 mcg norelgestromin
74
How is the Evra patch used?
applied once a week for 3 weeks followed by a 1-week patch free period (HFI)
75
What are the advantages of the Evra patch?
improved adherence extra built-in protection: hormones elevated for extra 2 days
76
What are the disadvantages of the Evra patch?
decreased efficacy for women weighing > 90 kg possible skin irritation increased VTE risk (conflicting results) higher rates of breast tenderness (only 1st 2 cycles)
77
How is missed doses of Evra managed if detachment < 24 h?
put old patch back on OR put new patch on immediately complete 3-week cycle
78
How is missed doses of Evra managed if detachment >= 24 h?
week 1: -put new patch on immediately -complete 3-week cycle -backup contraception x 7 days -consider EC week 2/3: -put new patch on immediately -then skip next HFI and start new cycle
79
How is missed doses of Evra managed if detachment >= 72 hrs?
backup contraception x 7 days consider EC
80
What occurs to the patch change day if someone misses a dose?
patch change day remains the same when doses are missed during any week
81
What are the hormones in the CHC vaginal ring?
15 mcg EE and 120 mcg etonorgestrel
82
How is the NuvaRing administered?
inserted into the vagina where it remains in place for 3 weeks followed by a 1-week HFI ring should be inserted on the same day
83
What are the advantages of NuvaRing?
improved adherence no special fitting required extra built-in protection: hormones elevated up to 1 extra wk can remove ring temporarily for up to 3h causes less irregular bleeding than COC
84
What are the disadvantages of NuvaRing?
increased vaginal secretions can cause vaginitis and leukorrhea vaginal discharge and irritation is primary reason for d/c
85
Where is NuvaRing stored?
fridge
86
How are missed doses of NuvaRing managed if removal <= 3 h?
reinsert immediately continue cycle normally
87
How are missed doses of NuvaRing managed if ring inserted >= 24 h late or removed > 3 h?
week 1: -reinsert ring immediately -continue cycle normally -use backup contraception x 7 days -consider EC week 2/3: -reinsert ring immediately and remove on the scheduled removal day -then insert new ring to start a new cycle (no HFI)
88
How are missed doses of NuvaRing managed if removal >= 72 h?
backup contraception x 7 days consider EC
89
What are the effects of CHC on acne?
may cause acne to appear, disappear, or significantly improve progestins with higher androgenic activity = more likely to increase acne higher dose EE may decrease acne estrogen-dominant COC may reduce overall incidence of acne use of newer progestin with lower androgenic or anti-androgenic activity improve acne
90
What is the effect of drosperinone-containing COC on benign breast disease?
50-75% reduction in the risk of fibroadenomas, chronic cystic breast disease, and breast biopsies
91
What is the effect of CHC on dysmenorrhea?
menstrual pain may be decreased by 60% after starting COC esp with a formulation with decreased estrogenic and increased progestational activity
92
What is the effect of CHC on endometrial cancer?
cyclic COC contain sufficient progestin to prevent endometrial hyperplasia and to reduce the risk of endometrial cancer by 50-70%
93
What is the effect of CHC on menorrhagia?
total amount of menstrual flow in established COC users decreases up to 40% -this may be caused by progressive thinning of the endometrium induced by use or a lack of irregular bleeding
94
What is the effect of CHC on ovarian cancer and ovarian cysts?
decreased risk of developing functional ovarian cysts and pre-existing cysts are more rapidly resolved; surgery rates for ovarian masses are reduced with women taking COC
95
What is the effect of CHC on PID?
COC users were half as likely to develop PID than nonusers due to the thickening of the cervical mucus
96
What are the most frequent reasons for d/c of CHC?
BTB and spotting
97
What is the most common cause of BTB from CHC?
missed pills or irregular pill taking
98
What is early-cycle (days 1-9) bleeding due to?
insufficient estrogen
99
What is late-cycle bleeding (days 10-21) due to?
insufficient progestin
100
Who is progestin-only contraception best suited for?
suffer from migraines are breastfeeding have sickle cell disease have dysmenorrhea, menorrhagia, or anemia have CI to CHC women with endometriosis
101
What are the absolute CI to progestin-only contraception?
current breast cancer
102
What are the AE of progestin-only contraception?
HA breast tenderness NV
103
How is norethindrone taken?
continuously (no HFI)
104
How does the efficacy of norethindrone compare to CHC?
less effective for preventing pregnancy than CHC
105
What are the advantages of norethindrone?
non-contraceptive benefits: -decreased dysmenorrhea -decreased risk of endometrial cancer -protection against PID lower doses of progestin than CHC best for pts with a CI to CHC
106
What are the disadvantages of norethindrone?
must be taken on a tight regular schedule higher incidence of ectopic pregnancy irregular bleeding
107
What is a considered a missed dose of norethindrone?
> 3 hours late
108
How are missed doses of norethindrone managed?
had unprotected intercourse within 5 past days? yes: -take pill next day -continue cycle normally -backup contraception x 48 hrs -EC advised no: -take pill immediately -continue cycle normally -use backup contraception x 48 hrs
109
Which drug is available as IM injection for contraception?
depot medroxyprogesterone acetate
110
How frequently is Depo-Provera given?
IM injection q 12 weeks
111
What timeframe should the injection interval of Depo-Provera not exceed?
should not exceed 13 weeks
112
What are the advantages of Depo-Provera?
recommended for epileptic pts very effective for dysmenorrhea and menorrhagia may lead to amenorrhea decreased incidence of seizures, sickle cell, myomas
113
What are the disadvantages of Depo-Provera?
delayed onset of fertility after stopping drug (up to 1yr) weight gain: 2.5 kg in 1st yr, 3.7 kg 2nd yr, 6.3 kg 4th yr decreased BMD: esp within first 2 yrs acne hirsutism headaches
114
How are missed doses of Depo-Provera managed if last injection was 13 to < 14 weeks ago?
take pregnancy test if negative, give next injection ASAP and backup x 7 days
115
How are missed doses of Depo-Provera managed if last injection was >= 14 weeks ago?
had unprotected intercourse within past 14 days? yes: -if bHCG -ve: give next injection ASAP -use backup contraception x 7 days -rpt bHCG 3 weeks after injection -if unprotected intercourse within last 5 days, use EC no: -if bHCG -ve: give next injection ASAP -use backup contraception x 7 days
116
Which drug is contained in the progestin IUS?
levonorgesrel
117
How long does the progestin IUS last for?
Mirena - 8 yrs Kyleena - 5 yrs
118
What are the advantages of progestin IUS?
significant decrease in endometrial cancer risk very effective for amenorrhea and menorrhagia may lead to amenorrhea can be inserted immediately post-partum long term reversible protection
119
What are the disadvantages of progestin IUS?
requires physician for insertion and removal risk of uterine perforation expulsion risk within 1st year risk of infection during first 21 days after insertion
120
Which drug is available as a subdermal implant for contraception?
Nexplanon (etonorgestrel)
121
Where is Nexplanon inserted?
under the skin on the underside of the non-dominant arm for up to 3 yrs
122
What is required post-insertion of Nexplanon?
backup contraception for 7 days -unless inserted within first 5 days of the menstrual cycle or immediately postpartum
123
What are the advantages of Nexplanon?
long term reversible protection
124
What are the disadvantages of Nexplanon?
unpredictable bleeding patterns acne weight gain ovarian cysts pain, numbness, scarring at insertion/removal
125
What are the different ways to initiate contraception?
day 1 start Sunday start quick start
126
Describe the day 1 start method to initiate contraception.
initiate on first day of menses advantage: more rapid contraceptive effects no backup contraception required
127
Describe the Sunday start method to initiate contraception.
initiated on the first Sunday after beginning menstruation if menses begins on Sunday, start on the day backup contraception needed if menses is beyond day 5 of start day bleeding usually does not occur on weekends
128
Describe the quick start method to initiate contraception.
initiated at any point in the cycle advantage: minimizes confusion about when to start 1st pack use backup contraception x 7 days
129
What are the key drug interactions with oral contraceptives?
3A4 inducers antibiotics (rifampin)
130
What is the effect of CYP 3A4 inducers on oral contraceptives?
decreased efficacy of estrogen by increasing metabolism
131
What are examples of CYP 3A4 inducers?
phenytoin phenobarbital CBZ rifampin St Johns Wort griseofulvin
132
What are the solutions to the CYP 3A4 inducer-COC interaction?
use barrier methods, DMPA, or IUD/IUS switch anticonvulsant to one that doesnt affect E levels
133
What is the effect of rifampin on contraceptives?
decreases E and P levels in PO contraceptives
134
What are the solutions to the rifampin-COC interaction?
use backup methods during rifampin therapy use nonhormonal options such as IUD
135
What are the available options for EC?
levonorgestrel ulipristal acetate Yuzpe
136
How is Plan B taken?
1 tablet within 72 hrs of unprotected sex
137
How can the AE of Plan B be minimized?
take with food or give with Gravol 1/2 hour before to prevent GI effects
138
What is the MOA of Plan B?
stops egg release from the ovary, prevents fertilization and implantation
139
What are the AE of Plan B?
NV cramps dizziness irregular bleeding spotting
140
How can UPA be taken?
up to 120 hrs (5 days) after unprotected sex or contraceptive failure
141
What should be excluded before UPA is taken?
pregnancy
142
What is the MOA of UPA?
inhibits or delays ovulation by preventing progesterone binding to progesterone receptor which prevents the LH peak that triggers ovulation and eventual follicular rupture
143
What are the AE of UPA?
nausea headache dysmenorrhea abdominal pain fatigue dizziness
144
When is Yuzpe Method used for EC?
when other methods are not available
145
Up to how long can the copper IUD be used for EC?
up to 7 days after unprotected sex
146
What must occur before insertion of copper IUD?
pregnancy exclusion
147
What is the added benefit of the copper IUD for EC?
ongoing contraception
148
What is the most effective EC?
copper IUD
149
When is contraception be restarted after Plan B?
on day that Plan B used
150
When can contraception be restarted after UPA?
5 days after UPA
151
How do EC recommendations vary based on weight?
UPA: BMI >= 25 Plan B: reduced efficacy if BMI >= 25
152
When are Plan B or UPA ineffective?
taken on the day of or after ovulation
153
How long is COC avoided for postpartum?
until breastfeeding established (usually 6 weeks) -can restart 3-4 weeks if not breastfeeding
154
What is key with UPA use if breastfeeding?
breastfeeding not recommended for the first week
155
Which contraceptives can be used immediately post-partum?
IUD/IUS progestin-only methods
156
What does continuous/extended use of CHC provide relief from?
severe dysmenorrhea heavy flow socially undesirable flow
157
How long should a HFI max out at with continuous/extended CHC?
should not exceed 7 days
158
What are the advantages of continous/extended CHC?
decreased likelihood of AE improved sx of endometriosis and PCOS
159
What are the disadvantages of continous/extended CHC?
irregular, unscheduled bleeding
160
What is avoided with the vaginal ring?
hepatic 1st pass and GI metabolism
161
When does menstruation restart when an IUS is removed?
within 1-3 months
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