1. Physiology of menstrual cycle
    • Typically 28 d cycle
    • First half is first 14 days - follicular phase - follicles are recruited and one becomes dominant - stimulated by FSH which is higher in follicular phase - inverse relationship with estrogen
    • Second half is next 14 days - luteal phase - increase in estrogen triggers LH spike around day 14 and ovulation occurs - LH and FSH then stay low and estrogens and progestins are high
    • If fertilization doesn't occur, estrogen and progestin levels decrease and eventually the endometrium sheds - menstruation
  2. MOA of combination oral contraceptives
    • Estrogen component inhibits FSH secretion preventing the development of a dominant follicle
    • Progestin component inhibits LH surge, preventing ovulation; creates atrophied endometrium unreceptive to implantation; thickens mucus to interfere with sperm transport; alters fallopian tube secretions making it harder for the egg to travel
  3. Advantages and disadvantages of combination OCs
    • Advantages:
    • less iron deficiency anemia
    • decreased cramps
    • decreased rate of ectopic pregnancy
    • decreased PID rate by 60%
    • protection vs. endometrial and ovarian cancer by 40-50%
    • suppression of development of functional ovarian cysts
    • protection vs. fibrocystic breast disease by 40%
    • increased bone mineral density
    • less menstrual cycles

    • Disadvantages:
    • compliance
    • increased risk of thromboembolism and stroke
    • increased TGs
    • increased BP
    • no STD protection
    • increased risk of benign hepatocellular adenomas
    • possible increase in breast cancer risk
    • conflicting results re: cervical cancer risk
  4. SEs d/t excess estrogen
    • nausea
    • bloating/edema
    • cervical mucorrhea, polyposis
    • HTN
    • migraines
    • breast tenderness/fullness
    • (like pregnancy sx)
  5. Sx d/t deficiency of estrogen
    • Breakthrough bleeding early to mid cycle (days 1-10)
    • hypomenorrhea
    • increased spotting
  6. Sx d/t excess of progestin
    • increased appetite
    • wt gain
    • tiredness, fatigue
    • hypomenorrhea
    • acne, oily scalp
    • hair loss, hirsutism
    • depression
    • monilial vaginitis
    • breast regression
    • (androgenic SEs)
  7. Sx d/t deficiency of progestin
    • Breakthrough bleeding in late cycle (days 10-28)
    • amenorrhea
    • hypermenorrhea
  8. Counseling on combination OCs
    • Dosing regimen
    • Compliance
    • When birth control effective
    • Missed doses (one - take as soon as remember then take next one at normal time that day - alternative methods unnecessary; missed two - take two on day remembered and take two the next day - use backup method for rest of cycle; missed more than two - start a new pack like first starting - start on Sunday if a Sunday starter, or others just begin immediately - use backup method for whole cycle)
    • Adverse effects
    • ACHES - abdominal pain, chest pain, headaches, eye problems, severe leg pain
    • No protection vs. STDs/HIV
  9. Counsel on "morning after" emergency contraception
    • Prevents implantation
    • Plan B One Step or Next Choice - otc for women > 17 - can take 2 tabs together or separate by 12-24 h
    • Ella - rx only - also delays ovulation - progesterone receptor antagonist/agonist
    • Others - 2-4 doses of OCs
    • Efficacy 79-85%
    • WHO recommends levonorgestrel only
    • Use within 120 hours of unprotected intercourse (< 72 h is better)
    • ACHES
    • Nausea, vomiting
    • Would not prevent ectopic pregnancy
    • Teratogenicity unknown
  10. Advantages and disadvantages of progestin-only contraceptives
    • Advantages:
    • May be used in lactating women
    • may be used in women with CV risk, HTN, HAs, smokers, CVA, liver impairment/tumor, current DVT
    • avoids estrogen SEs
    • decreased PID rate

    • Disadvantages:
    • usually d/t too little estrogen
    • increased amenorrhea or freq spotting
    • increased risk of ectopic preg because ovulation not inhibited
    • not as many MOAs - efficacy d/t endometrial and cervical mucus changes
    • may incr risk of T2DM in pts who had gestational diabetes
    • must take qd @ same time - if dose missed, backup needed
  11. IM progesterone advantages and disadvantages
    • Advantages:
    • low failure rate (higher dose, so 4 MOAs)
    • decr or no menses or cramps
    • decr yeast infx, ectopic pregnancy, PID
    • no suppression of lactation (may give 6 wk postpartum)
    • no incr risk of thromboembolism - ok to use with HTN, CV risk, etc
    • passive
    • no estrogen SEs
    • Less drug intx
    • may be alternative for pts on anticonvulsants

    • Disadvantages:
    • return of fertility possibly delayed (10-18 mo)
    • breakthru bleeding possible
    • weight gain
    • decreased HDL, increased TG
    • office visit required
    • decr bone mineral density (BBW to limit use to < 2 yr and add Ca and D)
  12. Counsel on a progestin only contraceptive
    • Dosing regimen - start on first day of menses
    • Compliance v. important - qd, same time
    • Back-up protection until next menses
    • Missed dose: even if 3 h late, must use another method for next 48 h. If missed 2 + doses, skip missed doses and use a backup method until next menses
    • AEs
    • No protection vs STDs/HIV
Card Set
Exam6 Therapeutics Women's Health - Contraception Dr. Bailey