What is the optimal time period for intercourse to produce pregnancy?
- 2d before to 2d after ovulation
- every other day to allow sperm to mature fully between sessions
What is the relationship among the hormones during the menstrual cycle?
- Progesterone and Estrogen are inversely related to LH and FSH
- FSH and LH are high at the beginning of the cycle and Progesterone and Estrogen are are high later in the cycle
What is the MOA of combination oral contraceptives?
High doses of estrogen and progestin during the follicular phase and early luteal phase keep FSH and LH low, which means fewer follicles are produced and no dominant follicle is chosen
What type of estrogen is used in combination oral contraceptives?
What is the role of estrogen in contraceptives?
inhibit FSH secretion to prevent development of a dominant follicle
What is the role of progestin in contraceptives?
- inhibit LH surge so ovulation is prevented
- creates atrophied endometrium to prevent implantation
- thickens mucus to inhibit sperm transport
- alters fallopian tube secretions
What is the advantage of a Day 1 Start of oral contraceptives?
It's effective immediately so no back-up protection is needed
What is the advantage of a Sunday Start of oral contraceptives?
Avoids menses on the weekends
What are the advantages of combination oral contraceptives?
- Less iron deficiency anemia
- Decreased cramping
- Decreased ectopic pregnancy
- Decreased rate of PID
- Protection against ovarian and endometrial cancer
- Suppression of development of functional ovarian cysts
- Protection against fibrocystic breast disease
- may increase BMD in peri and postmenopausal women
- Less menstrual cycles
What are the disadvantages of combination oral contraceptives?
- Increase in thromboembolism and stroke risk
- Increased triglycerides
- Elevation of BP
- Increased risk of benign hepatocellular adenomas
- Increased risk of breast cancer (maybe)
- Increased risk of cervical cancer (maybe)
What are the SE of excess estrogen?
- Cervical mucorrhea, polyposis
- Breast tenderness/fullness
What are the SE of estrogen deficiency?
- Early-mid cycle breakthrough bleeding (day 1-20)
- Increased spotting
What are the SE of excess progestin?
- Increased appetite
- Wt gain
- Tiredness, fatigue
- Acne, oily scalp
- Hair loss or hirsutism
- Monilial vaginitis
- Breast regression
What are the SE of progestin deficiency?
- Late breakthrough bleeding (day 10-28)
What drugs decrease the efficacy of oral contraceptives?
- St. John's Wort
How should pts be counseled on missed doses of oral contraceptives?
- 1 dose: take as soon as remember even if it means taking two doses at once
- 2 doses: take 2 when you remember and 2 the next day, use alternative contraception for the rest of the cycle
- ≥2 doses: discard the rest of the pack, start a new pack using the same method as originally did, use alternative contraception for the rest of the cycle
What does ACHES stand for?
- Abdominal pain
- Chest pain
- Eye problems
- Severe leg pain
What are the "Morning After" emergency contraceptives?
- Plan B
- Ella (progesterone agonist/antagonist and also delays ovulation)
- Preven (high dose of esrogen - problem for VTE risk)
What are the advantages of progestin-only oral contraceptives?
- May be used in lactating women because it doesn't effect quantity or quality of milk like estrogen
- May be used in women with CV risk, HTN, headaches, smokers, CVA, liver impairment/tumor, current DVT
- Allows avoidance of estrogen-related SE
- Lower rate of PID
What are the disadvantages of progestin-only oral contraceptives?
- Increased amenorrhea or frequent spotting
- Increased chance of ectopic pregnancy because ovulation not inhibited
- Does not consistently suppress ovulation in lower doses
- Efficacy due to mucus changes only
- May increase risk of contracting DM in women who had gestational diabetes
- Must be taken every day at the same time - back-up protection for 2d needed if miss a dose (>3h late)
When do you start progestin-only oral contraceptives?
first day of menses, using back-up protection until next menses
What are the advantages of IM progesterone?
- Low failure rate
- Decreased or no menses or cramping
- Decreased yeast infections, ectopic pregnancy, PID
- No lactation suppression
- No increased risk of thromboembolism
- May be used in CV risk, HTN, migraines
- Passive contraception
- Avoids estrogen SE
- Less drug interactions (watch rifabutin, rifampin)
- May be an alternative for women taking anticonvulsants
What are the disadvantages of IM progesterone?
- Return of fertility may be delayed
- Possible breakthrough bleeding
- Wt gain of 1kg/yr
- Decreased HDL, increased triglycerides
- Office visit required
- Bone mineral density decreased - limit to < 2yrs