OCPs

Question 1

what are the 2 types of OCPs

Answer 1

1. Combined OCPs
   
   • estrogen + progestin
2. Progestin-Only OCPs

Question 2

2 major approaches OCPs prevent pregnancy

Answer 2

1. Prevent ovulation
2. Impair implantation

Question 3

we can prevent ovulation by suppressing __ and __ release by preventing ___ in estrogen levels via giving patient __ __ levels

Answer 3

we can prevent ovulation by suppressing LH and FSH release by preventing fluctuations in estrogen levels via giving patient stable estrogen levels

Question 4

we can prevent implantation by maintaining elevated __ levels via giving patient ___ elevated __

Answer 4

we can prevent implantation by maintaining elevated progesterone levels via giving patient stable elevated progestin

Question 5

Combined OCP
estrogen + progestin agents

Answer 5

• Estrogen
  
  • ethinyl estradiol or mestranol (prodrug converted to ethinyl estradiol)
• Progestin
  
  • Levonorgestrel
  • Desogestrel
  • Norethindrone
  • Norgestrel
  • Norgestimate
  • Drospirenone

Question 6

Almost all progestins have some ___ activity in varying degrees - explain these

Answer 6

Almost all progestins have some androgenic activity in varying degrees - explain these

• Levonorgestrel, Norgestrel: highest
• Norethindrone: lower
• Desogestrel, Norgestimate (3rd gen): even lower
• Drospirenone: antiandrogenic

Question 7

Combined OCPs are available in ___, ____, and ___ preparations - explain these

Answer 7

Combined OCPs are available in monophasic, biphasic, and triphasic preparations

• Monophasic: ​fixed estrogen and progestin dose /pill
• Biphasic/Triphasic: ​varying proportions of hormones during pill cycle
  
  • ↓ amount and total monthly dose of progestins
  • mimics normal physiological hormonal changes more closely

Question 8

Combined OCPs most commonly used are called ‘___’ containing ___ of ____ or less

Has decreased adverse effects/risks, but more likely to result in ____ if doses are missed

Answer 8

Combined OCPs most commonly used are called ‘low-dose’ containing 35 μg of ethinyl estradiol or less

Has decreased adverse effects/risks, but more likely to result in contraceptive failure if doses are missed

Question 9

Types of OCPs

Answer 9

• 21 hormonally active pills
  
  • followed by 7 placebo pills to allow withdrawal from bleeding and facilitates consistent daily pill intake
• Extended-cycle formulations
  
  • 84 days of hormonal pills, followed by 7-day placebo phase
  • 4 periods /year
• Continuous combination regimens
  
  • ​hormone-containing pills for 21 days, then very-low-dose estrogen and progestin for an additional 4-7 days

Question 10

Combination OCPs work primarily to prevent conception by preventing ____

___ LH and FSH release and ovulation does not occur

progestin prevents sperm penetraction by ____, and induces endometrium changes that impair ___

Answer 10

Combination OCPs work primarily to prevent conception by preventing ovulation

suppress LH and FSH release and ovulation does not occur

progestin prevents sperm penetration by thickening cervical mucus and induces endometrium changes that impair implantation

Question 11

OCP benefits

Answer 11

• ↓ risk of ENDOMETRIAL and OVARIAN cancer
• Improved regulation of menstruation
• RELIEF of benign breast disease
• PREVENTS ovarian cysts
• ↓ risk of symptomatic pelvic inflammatory disease
• acne control

Question 12

about OCP AEs

Answer 12

• cardiovascular toxicity concerns initially limited long-term use
• adjusting/decreasing estrogen and progestin dose reduces AEs
• many AEs (eg nausea, bloating, breakthrough bleeding) improve spontaneously by third cycle

Question 13

____ is the most common AE of OCPs → more of a problem with __ doses of estrogen because estrogen ___ the endometrium

Answer 13

Breakthrough bleeding is the most common AE of OCPs → more of a problem with LOWER doses of estrogen because estrogen stabilizes the endometrium

Question 14

OCP AE: headache

Answer 14

• Usually mild and transient
• migraine may be associated with cerebrovascular accidents
• Women who develop migraines should stop taking the contraceptive

Question 15

OCP AE: Insulin Resistance

Answer 15

• progestin competes with insulin for insulin receptor → insulin resistance
• current OCPs have a low progestin content and rarely cause hyperglycemia

Question 16

OCP AE: Hirsutism

Answer 16

• acne, oily skin and hirsutism from androgenic progestins
• switch to a less androgenic progestin

Question 17

OCP AE: Other

Answer 17

• Melasma - estrogen stimulates melanocyte production
• Amenorrhea - some patients
• Dyslipidemia - most low-dose OCPs have no impact on HDL, LDL, triglycerides or total cholesterol (MYTH)
• Depression (6%) - stop therapy if this occurs

Question 18

Do NOT give OCPs to women older > 35 AND who smoke

why?

Answer 18

• most at risk for cardiovascular disorders
• rare, but very serious
• thromboembolism
  
  • ​estrogen produces ↑ factor VII, factor X, fibrinogen
• thrombophlebitis, hypertension, MI, cerebral and coronary thrombosis
• ↑ risk with obesity, smoking, HTN, diabetes

Question 19

OCPs ___ incidence of endometrial and ovarian cancer

Answer 19

OCPs decrease incidence of endometrial and ovarian cancer

Question 20

___ induces CYP450 and increases metabolism of estrogen

Answer 20

Rifampin induces CYP450 and increases metabolism of estrogen

(use a backup nonhormonal contraceptive during course of rifampin therapy)

Question 21

Drugs that increase metabolism of OCPs

Answer 21

P450 inducers

• Carbamazepine
• Oxcarbazepine
• Phenytoin
• Phenobarbital
• Primidone
• Topiramate
• Vigabatrin
• St John’s Wort

Question 22

Broad-spectrum antibiotics reduce intestinal bacteria and can ____

(Ethinyl estradiol is hydrolyzed by intestinal bacteria and reabsorbed as active drug)

Answer 22

Broad-spectrum antibiotics reduce intestinal bacteria and can decrease estrogen levels

(Ethinyl estradiol is hydrolyzed by intestinal bacteria and reabsorbed as active drug)

Question 23

ABSOLUTE contraindications for OCPs

Answer 23

• Pregnancy
• Thrombophlebitis or thromboembolic disorders
• Stroke or coronary artery disease
• Breast cancer
• Undiagnosed abnormal vaginal bleeding
• Estrogen-dependent cancer
• Liver Tumor
• Uncontrolled HTN
• DM w/ vascular disease
• Age >35 and smoking >15 cigarettes daily
• Thrombophilia
• Migraine with aura
• Active hepatitis
• Surgery or orthopedic injury with prolonged immobilization

Question 24

RELATIVE contraindications for OCPs

Answer 24

• Migraine without aura
• HTN
• Heart, kidney, or gallbladder disease
• DM
• Cholestasis during pregnancy
• Sickle cell disease (S/S or S/C type)
• Lactation

Question 25

Progestin-only Pills contain ___ or ___ ; not widely used in US

Answer 25

Progestin-only Pills contain **norethindrone** or **norgestrel** ; not widely used in US

Question 26

Progestin-only Pills are slightly __ effective than combined OCPs but have no risk of \_\_\_\_

Answer 26

Progestin-only Pills are slightly **less** effective than combined OCPs but have no risk of **thromboembolic events** * ↓ dysmenorrhea, ↓ menstrual blood loss, ↓ premenstrual syndrome symptoms * Unscheduled bleeding and spotting are common

Question 27

Progestin-only pills effectiveness d/t ____ which decreases sperm penetration and endometrial alterations impairing implantation are highly efficacious but block ovulation in only 60% to 80% of cycles

Answer 27

Progestin-only pills effectiveness d/t **thickening** **cervical** **mucus** which decreases sperm penetration and endometrial alterations impairing implantation are highly efficacious but block ovulation in only 60% to 80% of cycles

Question 28

list non-oral hormonal contraceptives

Answer 28

* the Patch * the Ring * the Progestin Injection * the Progestin Implant * the Intrauterine Systems

Question 29

Transdermal patch & Transvaginal delivery system contain ___ and \_\_\_

Answer 29

Transdermal patch & Transvaginal delivery system contain **ethinyl** **estradiol** and **a progestin**

Question 30

Depo-Provera is a progestin-only injectable contraceptive contains \_\_\_ given IM every ___ and extremely effective

Answer 30

**Depo-Provera** is a progestin-only injectable contraceptive contains **depot medroxyprogesterone acetate (DMPA)** given IM every **3 months** and extremely effective

Question 31

Progestin ___ (Depo-Provera) diffuses out **\_\_\_,** providing circulating levels that **prevents** **ovulation** through **negative feedback**

Answer 31

Progestin **injection** (Depo-Provera) diffuses out **over time,** providing circulating levels that **prevents** **ovulation** through **negative feedback**

Question 32

Depo-Provera AE: high incidence of ___ and \_\_\_ significant irreversible ___ with long-term use **(black-box warning)**

Answer 32

* **menstrual irregularities** * **weight gain** * significant irreversible **loss of bone mineral density** with long-term use **(black-box warning)**

Question 33

Progestin impants

Answer 33

* 4cm-long implant, containing a **progestin** * Placed under skin of upper arm * Effective for 3 years * Major AE: irregular menstrual bleeding

Question 34

Intrauterine systems - contains \_\_\_\_

Answer 34

* contains **Levonorgestrel** * has a polyethylene body with a levonorgestrel reservoir * Effective for 5 years

Question 35

list non-oral contraceptives

Answer 35

* Barrier contraceptives * condoms, diaphragms, cervical caps, spermicides * Intrauterine Devices (IUD) * Fertility Awareness-Based Methods * Sterilization

Question 36

Emergency postcoital contraception (available without a prescription for consumers ≥17)

Answer 36

* **Plan B & Next Choice** * 2 tablets of levonorgestrel * first tablet within 72 hrs, second 12 hrs later * **Plan B One-Step** * 1 tablet of levonorgestrel * take within 72 hrs * AE: nausea, vomiting

Question 37

Emergency postcoital contraception | (prescription only)

Answer 37

* **Ella** * contains **ulipristal acetate** (selective progesterone receptor modulator (SPRM)) * **progesterone** **antagonist** → inhibits/delays ovulation * 1 tablet taken within 5 days * AE: nausea, vomiting

Question 38

Emergency postcoital contraception (Non-hormonal)

Answer 38

Copper IUD - has to be inserted within 5 days of intercourse