Term
| When is the highest period of fertility? |
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Definition
5 days before ovulation to the day of ovulation.
Leads to the start of the luteal phase - an LH surge and a steady increase in progesterone |
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Term
| What hormones are the follicular phase and luteal phase dependent on? |
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Definition
Follicular phase - FSH and estrogen dependent. Proliferation of the uterus
Luteal phase - LH and progesterone dependent. Secretory phase of the uterus --> decidualization |
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Term
| What are general points on contraception? |
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Definition
- Does not protect against STDs
- Cigarette smoking increases CV risk, especially over 35
- Renal dosing not required except over 35
- Caution in severe hepatic impairment. |
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Term
| What are the estradiol components in COCs? |
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Definition
- Ethinyl Estradiol - improved bioavailability
- Estradiol valerate - new addition
- Mestranol - weaker, a prodrug |
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Term
| What types of progestin can be in COCs? |
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Definition
- Related to testosterone - has androgenic effects. Estranes and gonanes
- Related to progesterone - less androgen effects. Only medroxyprogesterone in US
- Related to spironolactone - Drospirenone. Anti-androgenic (good), and anti-aldosterone (avoids water retention), but causes hyperkalemia. |
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Term
| What is special about drospirenone? |
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Definition
Anti-androgenic, avoids edema
Have to watch SCr and K levels.
Higher risk for VTE! |
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Term
| What are the MoAs for Progestin and Estrogen? |
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Definition
- Estrogen - Inhibits FSH - no dominant follicle. Increases concentration of progestin receptors. Stabilizes endometrium.
- Progestin - Inhibits LH and ovulation (primary mechanism). Thickens cervical mucous. Atrophy of the endometrium = breakthrough bleeding |
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Term
| Which component if COCs is primary for contraception? |
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Definition
| Progestins - main effect is to inhibit LH and ovulation. |
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Term
| What is the benefit of extended phase contraceptives? |
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Definition
| No efficacy difference, but may have less irregular bleeding and reduced follicles. |
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Term
| What is continuous COC dosing? |
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Definition
| Do not have a placebo period, completely avoiding menstruation. Benefits for endometriosis, bleeding disorders, migraines. |
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Term
| What is the purpose of a higher dose of estrogen in COCs? |
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Definition
Better to treat androgenic side effects - acne. 50 mcg is the cut off.
Migraines are responsive to estrogen. |
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Term
| What are the options for starting an OC cycle? |
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Definition
- First day start - on the first day of menses, recommend 7 day backup
- Sunday start - first sunday after menses. Avoids weekend bleeding
- Quick start - Any point, minimizes confusion.
May use 7 day backup. |
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Term
| How do you deal with missed birth control pills? |
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Definition
- 1 pill - take missed pill ASAP and resume schedule
- 2 pills - If during week 1-2, take 2 pills daily x2days then finish pack. Use backup x7days. If during week 3, start a new pack
- 3 or more pills missed - start a new pack. and use backup method. |
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Term
| What are common adverse events of COCs? |
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Definition
- Estrogenic - nausea, increased breast size, EDEMA, increased BP. Use lowest estrogen dose possible
- Progestogenic - breast tenderness, HA, incr BP
- Androgenic - Weight gain, ACNE, oily skin, Incr LDL |
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Term
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Definition
Estrogen increases SHBG, which bind androgen = less androgenic effects.
Give increased estrogen or drospirenone. |
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Term
| What causes breakthrough bleeding? |
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Definition
2 risk factors - inconsistent use and smoking. A fluctuation in estrogen levels causes breakthrough bleeding.
- High incidence after first starting. If early cycle, increase estrogen dose. If late cycle, increase progestin or stop and have a period.
- Unexpected after many months - pregestin based fragility.
- Continuous dosing? Use pulse dose estrogen. |
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Term
| What are SERIOUS adverse events associated with COCs? |
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Definition
A - Abdominal pain - gall bladder, liver
C - Chest pain - MI
H - Headache - stroke, HTN, migraine
E - eye problems
S - severe leg pain - DVT |
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Term
| Why does VTE happen with COCs? |
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Definition
estrogen stimulates clotting factor synthesis - a 2 fold increase in risk.
Risk factors - obesity, increased dose, genetic disorder, and smoking.
- Does not increase risk as much as pregnancy!
- Progestin risk negligible, except for Drospirenone! |
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Term
| What determines risk for arterial thrombosis with COCs? |
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Definition
- Age, smoking, and CV risk factors
- Use lower doses and screen patients
- Be careful if a smoker and over age 35.
- Stroke risk increases >35 |
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Term
| Do OCs cause breast cancer? |
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Definition
No cause and effect
May raise pre-menopausal rate by 20% |
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Term
| When should OCs NOT be used (3 and 4)? |
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Definition
- within 1 month of giving birth, 21 days if not breast feeding
- If over 35 and a smoker
- Multiple CV risk factors
- HTN, especially elevated, and vascular disease
- History of DVT, major surgery, genetic mutation
- History of stroke, cardiomyopathy
- SLE w/ positive antibodies
- Migraine - and over 35 or with an aura. A risk factor for stroke.
- Current breast cancer |
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Term
| What drugs interact with COCs? |
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Definition
- Ritonavir increases, use EE dose less than 30
- Anticonvulsants, use EE dose less than 30
- Many antibiotics |
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Term
| What are the advantages to vaginal contraception? |
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Definition
Nuvaring - EE 15 mcg + etonorgestrel
Eliminates unpredictable GI absorption
Avoids first pass - decr estrogen dose needed
Lower effects on clotting and lipids, lower irregular bleeding
Much steadier exposure to estrogen
**Still has thrombosis risk due to 3rd gen progestin |
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Term
| How is nuvaring administered, and when should backup be used? |
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Definition
If out of the vagina for >3 hours during week 1 or 2, reinsert and use backup for 7 days.
If during week 3, either start a NEW ring or wait until after period, using the backup method. |
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Term
| What is the benefit and use of the ortho-evra patch? |
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Definition
| Replaced every week for 3 weeks at a different site. Application sites: abdomen, butt, shoulder, upper arm. Very steady concentrations of estrogen |
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Term
| What should a woman do if the patch is missed? |
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Definition
If detached for <24 hours, reapply and keep schedule
If > 24 hours start a new patch and replace in 7 days. Use the backup method.
**Still has thrombosis risk due to 3rd gen progestin |
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Term
| What is the MoA of the progestin-only pill? |
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Definition
- Cervical mucous thickens, impervious to sperm
- Decidualization of endometrium, not receptive to implantation
- FSH/LH not suppressed, ovulation may still occur. |
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Term
| How is the progestin-only pill administered? |
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Definition
- Must be taken every day AT THE SAME TIME
- Start on the first day of menses using backup. Do not use sunday start.
- If a pill is missed or taken 3 hours late, resume and use backup for 2 days. |
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Term
| What is the most common AE of progestin OC? |
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Definition
- Irregular bleeding due to atrophy
- Higher failure rate in younger women due to compliance
- Ectopic pregnancy more common. |
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Term
| When should progestin-only OC not be used? |
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Definition
- Stroke and MI
- Current breast cancer
- Ritonavir and anti-convulsants |
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Term
| Unlike estrogen, when can progestin-only OC be used? |
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Definition
- post partum, no effect on milk production
- CAN be used in smokers
- DVT and HTN
- Migraines
- Good candidates: women who are lactating, women w/ decreased libido |
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Term
| What is the MoA of contraceptive injection? |
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Definition
POTENT inhibition of LH surge --> no ovulation
Cervical mucous thickening
Decidualization of endometrium
- Medroxyprogesterone forms a high peak that remains high for months
**AE: breakthrough bleeding. reduces after the first year. Tx with pulse dose estrogen. LOSS IN BMD
Hard to resume fertility. |
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Term
| What are the benefits of medroxyprogesterone injection? |
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Definition
- High efficacy, no room for error. THE choice for seizure disorders
- Positive effect on milk production |
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Term
| What are contraindications to medroxyprogesterone use? |
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Definition
- Pregnancy
- Genital bleeding
- Breast cancer - associated.
- VTE or stroke
- Liver dysfunction |
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Term
| What is the MoA of etonorgestrel implant? |
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Definition
Progestin - inhibits ovulation and thickens cervical mucous.
- If no proceeding contraceptive use, inject between days 1-5 of menses
- Switch from COC - within 7 days of last pill.
- Switch from progestin-only - any day of the month.
** AE: irregular bleeding |
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Term
| What types of IUDs exist? |
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Definition
- non-medicated copper IUD/Paragard - 10 years, interferes with sperm and implantation. Can increase bleeding by 55%
- Levonorgestrel/Mirena - 5 years, decidualization and thickening of cervical mucous. Can cause sepsis, amenorrhea |
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Term
| What is the MoA for emergency contraception? |
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Definition
- Levonorgestrel - within 3 days, may prevent ovulation by inhibiting LH surge
- COC - no longer recommended, high incidence of N/V
- Ulipristal/Ella - progesterone receptor modulator - antagonist and partial agonist. Delays ovulation and prevents implantation. Works after 5 days |
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