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Special Populations - Contraception Part 2 (Exam 1)

Terms in this set (179)

Xulane transdermal patch dosing?
6mg norelgestromin/75mcg ethinyl estradiol patch applied weekly
-usual cycle is 3 weeks (1 patch/week)
1 advantage and 2 disadvantages of Xulane?
Disadvantage: reduced efficacy in >90 kg women, gives higher overall estrogen exposure

Advantage: immediate return to fertility
Side effects of Xulane?
Black box warning: cardiovascular side effects increased in women who smoke cigarettes with increased risk >35 years old and number of cigarettes smoked

Application site reactions
Xulane missing/lost patch rules: on patch 1 and missed 1 day (>24 hrs or time unknown)?
Apply new patch and use backup contraception x 7 days

Use emergency contraceptive if unprotected intercourse in the last 5 days
Xulane missing/lost patch rules: on patch 2 or 3 and missed <3 days (>72 hrs)?
Apply new patch, skip hormone free week

No need for emergency contraceptive
Xulane missing/lost patch rules: on patch 2 or 3 and missed > 3 days (>72 hrs or time unknown)?
Apply new patch, skip hormone free week, and use backup contraception x 7 days

Use emergency contraceptive if unprotected intercourse in last 5 days
Xulane forgot to change patch rules: on patch 1 or 2 and the old patch was left on for 8-11 days?
Change patch, skip hormone free week

No emergency contraceptive
Xulane forgot to change patch rules: on patch 1 or 2 and the old patch was left on for 12+ days?
Apply new patch, skip hormone free week, and use backup contraception x 7 days

Use emergency contraception if unprotected intercourse in last 5 days
Xulane forgot to change patch rules: on patch 3 and the old patch was left on for <14 days?
No problem as long as new patch is started on time

No emergency contraceptive needed
What is Twirla?
Transdermal patch containing levonorgestrel and EE 30 mcg/day applied weekly
-usual cycle is 3 weeks (1 patch/week)
Twirla estrogen content compared to Xulane?
Lower hormone levels, potentially allowing for reduced side effects
Twirla's efficacy is reduced in women with a BMI ___________
25-30 kg/m2
Side effects of Twirla?
Black box warning: cardiovascular side effects increased in women who smoke cigarettes with increased risk >35 years old and number of cigarettes smoked
Contraindication of Twirla?
BMI ≥ 30 kg/m2 contraindicated due to increased risk of VTE and reduced efficacy
Twirla missing/lost patch rules: on patch 1 and missed 1 day (>24 hrs or time unknown)?
Apply new patch and use backup contraception x 7 days

Use emergency contraceptive if unprotected intercourse in last 5 days
Twirla missing/lost patch rules: on patch 2 or 3 and missed <2 days (<48 hrs)?
Apply new patch, skip hormone free week

No EC
Twirla missing/lost patch rules: on patch 2 or 3 and missed >2 days (>48 hrs or time unknown)?
Apply new patch, skip hormone free week, and use backup contraception x 7 days

Use EC if unprotected intercourse in last 5 days
Twirla forgot to start patch rules?
Start new patch as soon as you remember

Use EC if unprotected intercourse in last 5 days
Twirla forgot to change patch rules: on patch 1-2 and the old patch was left on for <9 days?
Change patch, skip hormone free week

No EC needed
Twirla forgot to change patch rules: on patch 1-2 and the old patch was left on for 9 days or longer?
Apply new patch, skip hormone free week, and use back up contraception x 7 days

Use EC if unprotected intercourse in last 5 days
Twirla forgot to change patch rules: on patch 3 and the old patch was left on for <14 days?
No problem as long as new patch is started on time

No EC needed
Where to place birth control patches?
Hip, buttock, scapula area, deltoid area

NOT by breast area
Monitoring/conseuling points on birth control patches?
-how to start
-application site rotation
-adverse effects
-black box warning
-return to fertility
-number of days backup contraceptives should be utilized
-efficacy diminished in >90 kg or 30 kg/m2 patients
-STD protection
-follow up (same as oral contraceptives)
What if a patient chooses to skip patch free week?
It is okay to skip the patch free week. Have to make sure it's written this way on the script so no insurance rejections
A patient is using Twirla (levonorgestrel and EE) continuously for her contraceptive therapy. She has used the patch 4 weeks continuously (1 patch placed each Monday). Today, she realizes she never switched out her patch and is now 36 hours late on patch change. What should she do?
Normally, the patch has 3 weeks on, then 1 week of placebo without need for backup contraception, where patient has menses.

Since this patient has technically had 3 weeks of continuous patch wearing, these 2 missed doses would be considered her "off week" and she would have the whole week (till next Monday) to get a new patch on (could also make a new patch day)
• she DOES NOT need backup
Is emergency contraception a long term solution for contraceptive therapy?
NO
-They disrupt the menstrual cycle.
-They do not increase fertility, but delay ovulation and increase difficulty in identifying/avoiding high fertility time for patients.
-If a patient requires an emergency contraceptive frequently, it is important to counsel on more reliable/less expensive options.
What are the two vaginal ring options?
1. NuvaRing
2. Annovera
What is in the NuvaRing?
15 mcg/day ethinyl estradiol and 120 mcg/day etonogestrel
-etonogestrel is a metabolite of desogestrel (3rd generation progestin)
How often to insert NuvaRing?
3 weeks in, 1 week out
Storage of NuvaRing?
Prior to insertion, must be stored in the refrigerator

The package insert allows for 4 months at room temperature
Benefit of NuvaRing? Disadvantage?
+ Immediate return to fertility

- Possibly increased risk of VTE
BBW of NuvaRing?
Cardiovascular side effects increased in women who smoke cigarettes with increased risk if >35 years old and number of cigarettes smoked
Missed dose of NuvaRing: Insert late (after out > 7 days)?
Insert ring and use backup contraceptive for 7 days

Use EC if unprotected intercourse in last 5 days
Missed dose of NuvaRing: Week 1 and expulsion/removal >3 hours?
Rinse and reinsert ring and use backup contraceptive for 7 days

Use EC if unprotected intercourse in last 5 days
Missed dose of NuvaRing: Week 2 and expulsion/removal >3 hours?
Rinse and reinsert ring

Use EC only if ring removed >72 hours
Missed dose of NuvaRing: Week 3 and expulsion/removal >3 hours?
Insert NEW ring immediately and restart cycle

Use EC only if ring removed > 72 hours
What is in Annovera?
Segesterone/ethinyl estragiol
-recently approved in August 2018
How often to insert Annovera?
3 weeks in, 1 week out

However, the same ring may be utilized for an entire year (13 cycles)
Storage of Annovera?
No refrigeration required

Ring should be cleaned with mild soap and warm water, gently dried, and stored in case during drug free week
BBW of Annovera?
Cardiovascular side effects increased in women who smoke cigarettes with increased risk if >35 years old and number of cigarettes smoked
Do vaginal rings need to be taken out for intercourse?
No!!!, but can if want to
Missed dose with Annovera: Insert late (after out > 7 days)
Insert ring and use bckup contraceptive for 7 days

Use EC if unprotected intercourse in last 5 days
Missed dose with Annovera: <2 hours cumulative in 21 day time
Rinse and reinsert ring, no backup needed

No EC needed
Missed dose with Annovera: > 2 hours at once or cumulative in 21 insertion period
Insert ring and use backup contraceptive for 7 days

Use EC if unprotected intercourse in last 5 days
How to start vaginal rings?
Insert at any time
AEs of vaginal rings?
-risk of expulsion
-risk of VTE
-estrogen SEs
Monitoring/counseling points for Vaginal rings?
-How to start
-AEs, BBW
-return to fertility
-number of days back up contraceptives should be utilized
-prolonged expulsion of ring
-storage
-STD protection
-follow up (same as OC's)
Other names for depo-medroxyprogesterone acetate?
DMPA
-depo-provera
-depo-subq provera
What is in DMPA?
Progesterone only
ROA and Administration sites of DMPA?
Injections
-IM: gluteal or deltoid muscle
-SubQ: abdomen or thigh
How often are DMPA injections given?
Every 12 weeks (covered up to 14 weeks with subQ form)
Side effects of DMPA?
-weight gain (5 lbs every year pt is on this)
-delay of fertility (10-36 month delay, correlated to length of time on depo)
-menstrual irregularities (May bleed for 3-4 weeks continuously after first injection, then generally doesn't have a cycle at all)
BBW of DMPA?
Bone mineral density changes that may not be completely reversible, duration should be limited to 2 years

(Since progesterone only, no estrogen to keep bones strong)
Due to the BBW of DMPA, can patients use it for more than 2 years?
Risk vs. benefit converstaion after 2 years of using DMPA
AVOID DMPA in what patients?
Patient is planning to become pregnant in the next 3 years
Monitoring/counseling for DMPA?
-how to start
-AEs (weight gain, menstrual cycle distrubances)
-bone mineral density concern (BBW)
-number of days back up contraceptives should be utilized
-delayed return to fertility
-STD protection
-follow up (same as OC's)
Long acting reversible contraception is best to recommend for what pateints?
-teens
-all women taking teratogenic medications
What is the name of the subdermal progestin implant?
Nexplanon (68 mg etonogestrel)
-placed under the skin of the upper arm
-progestin only - good for estrogen CI
What does Nexplanon contain?
Releases 60 mcg/day etonogestrel for the first month down to 25-30 mcg/day
How long does Nexplanon last?
3 years
Return to fertility with Nexplanon?
Immediate!!
Best time to insert Nexplanon if no previous hormonal contraception?
-insert between days 1-5 of menstrual cycle
-if inserted any other time, backup method x 7days
Best time to insert Nexplanon if patient was previously on an oral contraceptive?
Insert within 7 days after taking last active OC tablet
Best time to insert Nexplanon if previous progestin only contraception?
-insert without skipping any progestin-only OC days
-insert on same day progestin-only IUD removed
-insert on day DMPA due
Side effects of Nexplanon?
-Menstrual irregularities including prolonged bleeding, spotting, and frequent bleeding
-weight gain
-acne
-breast tenderness
Can Nexplanon be used in obese patients?
Caution in women >130% of their IBW due to decreased efficacy after the 2.5-3 year mark
Monitoring/counseling for Nexplanon?
-how to start (consider trial on POP first)
-AEs (weight gain, acne, breast tenderness, menstrual cycle disturbances)
-number of days back up should be utilized
-diminished efficacy in women with >130% IBW at 2.5-3 year mark
-STD protection
-follow up (same as OCs)
Why should a patient consider a trial of a POP before starting Nexplanon?
Due to progestin side effects such as depression, anxiety and constipation
Name of the intrauterine copper contraceptive?
ParaGard
MOA of ParaGard?
Copper makes the uterus a hostile environment
Advantages of ParaGard?
-insertion may be done within 10 minutes postpartum
-no hormones!!!!!
-provides 10 years of protection and may be used as emergency contraceptive
Side effects of ParaGard?
-heavier menstrual bleeding
-dysmenorrhea
-cramping and pain
-risk of expulsion
-uterine perforation
Avoid ParaGard in women with....
Heavy menstrual bleeding, dysmenorrhea or menorrhagia
How to start ParaGard?
3 best times for insertion:
-during menstrual cycle
-during ovulation
-postpartum

(Cervix is opened in these times)
Monitoring/counseling points for ParaGard?
-how to start
-AEs (menstrual cycle disturbances)
-NO NEED for backup contraceptives since this is an EC
-follow up
Follow up with ParaGard?
-string check every 3 months (by patient), annually by provider
-annual physical, pelvic, and breast exam, blood pressure check
-cervical cancer screening in women 21-65 years of age every 3 years
-HPV vaccine if not previously given (may be administered between ages 13-45 years of age)
What are the names of the hormone-containing IUDs?
1. Mirena
2. Kyleena
3. Liletta
4. Skyla
Dose of medication in Mirena?
Levonorgestrel (releasing 20 mcg/day initially, down to 9 mcg/day over the next 5 years)
Duration of Mirena?
Up to 5 years
-extended 7 year efficacy for pregnancy protection (not for menorrhagia)
Which of the hormone-containing IUDs are approved for menorrhagia (aka heavy menses)
Only Mirena decreases menorrhagia (5 year duration for this indication, not 7)
Amenorrhea in hormonal IUDs?
-20% of users in the 1st year have amenorrhea
-60% of users in the 5th year have amenorrhea

(40% that don't have amenorrhea = still ovulating. However, some of these patients are still ovulating, but have amenorrhea because the progestin is too high to allow endometrial tissue buildup)
Why isn't there a BBW for bone mineral density loss with hormonal IUDs even though they only have progesterone, just like Depo?
Most patient's are still ovulating on these!!! (Aka have estrogen)
Dose in Kyleena?
Levonorgestrel 17.5 mcg/day initially down to 9 mcg/day over the 5 years
Duration for Kyleena?
Up to 5 years
Dose in Liletta?
Levonorgestrel 20 mcg/day initially down to 14.3 mcg/day over the 6 years
Duration of Liletta
Up to 6 years
Dose in Skyla?
Levonorgestrel 14 mcg/day initially down to 6 mcg/day over the 3 years
Duration of Skyla?
Remove by the end of year 3
The lower progestin dose in Skyla causes.....
Increased spotting
-increased likelihood of regular menses
Advantages of hormonal IUDs?
-immediate return to fertility
-trials did not exclude nulliparous (patients that never gave birth) unlike the copper IUD
-no risk for loss of bone mineral density
Disadvantages of hormonal IUDs?
-physician must insert and remove device
-risk of expulsion
-risk of uterine perforation
-risk of ectopic pregnancy (RARE)
-spotting in first 6 months
How long should a hormonal IUD be trialed?
6 months (contrast to 3 months for OC's)
Cost consideration for IUDs?
$600-800 and requires a provider to place
-Liletta and Skyla generally cost less than Kyleena, Mirena, and ParaGard
When should back up contraceptive be used around insertion of a hormonal IUD?
-should be used for 7 days post insertion of hormonal IUD
-unnecessary if placed within 5 days of menses onset, switched from another contraceptive, or placed immediately following child birth or an abortion
CIs to IUDs?
-current pregnancy
-immediately following a post septic abortion
-purulent cervicitis
-current pelvic inflammatory disease
-current cervical cancer
-untreated endometrial cancer
-altered uterine shape
IUDs have pain with placement, and increased pain with placement for patients who are ....
Nulliparous

-less pain typically during postpartum period
There is no good data to minimize discomfort with insertion of IUDs. Routine use of what 3 things is not recommended?
-lidocaine 2% gel
-NSAIDs
-misoprostol (may increase cramping and nausea)
Monitoring/counseling points for IUDs?
-how to start
-AEs (menstrual cycle disturbances, ectopic pregnancy)
-number of days backup contraceptive should be used
-STD protection
-follow up (string check, physical, pelvic, breast exam, BP check, cervical cancer screening, HPV vaccine)
What are the ingredients in the non-hormonal contraceptive gel?
Lactic acid, citric acid, potassium bitartrate
(Brand name: Phexxi)
MOA of non-hormonal contraceptive gel?
Lowers pH and decreases sperm motility
Directions for use of non-hormonal contraceptive gel?
Administer 1 prefilled applicator dose (5 grams) immediately before or up to 1 hour prior to each episode of vaginal intercourse
-may be used during any part of the menstrual cycle
Effectiveness of non-hormonal contraceptive gel?
86% effective with typical use, 93% with perfect use
Can the non-hormonal contraceptive gel be used with other contraceptives?
Do NOT use with vaginal ring

May be used with other contraceptives or barrier methods (i.e. condoms, vaginal diaphragms)
Advantages of non-hormonal contraceptive gel?
+immediate return to fertility
+no hormones
Side effects of non-hormonal contraceptive gel?
-cystitis and pyelonephritis
-vulvovaginal burning, pruritus, yeast infections, UTI
-partner may experience localized discomfort (burning, itching, pain)
MOA of lactational amenorrhea method of birth control?
Suckling results in a decrease in GnRH (GnRH tells anterior pituitary to release FSH, then LH is released once we have enough estrogen) --> LH and therefore ovulation would be prevented
For the lactational amenorrhea method, what 3 criteria must be met?
1. Menses must not have returned (any bleeding beyond the first 2 months is considered returned)
2. Must be exclusively breastfeeding (pumping DOES NOT count)
3. Baby must be <3 months old (sometimes <6 months is ok?)
Exclusively breastfeeding delays return of fertility. The length of time this lasts is unclear....
<6 months: 0-7.5% pregnancy rates reported
Natural Family Planning is also known as?
Fertility Awareness Based Methods
Examples of NFP?
-billings method
-ovulation method
-sympto-thermal method
-marquette method
Common theme in NFP methods is:
-patients must monitor the signs of fertility
-patient must abstain during fertile periods
NFP monitoring includes tracking....
-cervical fluid
-cervix position
-temperatures
-LH surges (with ovulation sticks)
Benefits of NFP?
-option for those with limitations to other contraceptive methods
-no hormones
-no side effects?
-limited costs
Cons of NFP?
-variable rates of efficacy
-no STD protection
-must be committed to the NFP system you use, or pregnancy risk increases
What app for NFP has been cleared by teh FDA?
Natural Cycles app
Things to consider when selecting the BEST birth control option?
-plans for future pregnancy (in a month, a year, 5 years, never?)
-contraindications (VTE history, diabetes, migraine history, cancer, smoking, hypertension, liver disease)
-other medications (are there any drug interactions?)
-body habitus (i.e. obese)
-preference (pill, patch, ring, injection, implant, IUD)
-compliance
Tier 3 contraceptives (less effective: more than 13 pregnancies per 100 women in one year)
Condoms, sponge, withdrawal, spermicides, diaphragm, non-hormonal vaginal gel: use correctly every time you have intercourse

Fertility awareness-based methods: abstain or use condoms on fertile days
Tier 2 contraceptives (4-7 pregnancies per 100 women in one year)
Injectable: get repeat injections on time
Pill: take a pill each day
Patch and ring: keep in place, change on time
Tier 1 contraceptives (more effective: less than 1 pregnancy per 100 women in one year)
Implant and IUD: after procedure, little or nothing to do or remember
Vasectomy: use another method for first 3 months
Tubal occlusion: after procedure, little or nothing to do or remember
Only _____________ protect against STIs/STDs
Condoms
% pregnancy within 1 year with Typical Use of hormone-free contraception?
% pregnancy within 1 year with Perfect Use of hormone-free contraception?
% pregnancy within 1 year with Typical Use of hormonal contraceptives?
% continuing use after 1 year with hormonal contraceptives?
Higher with IUDs or implant!!!!

Lower with injection, ring, patch, pills
In what 3 situations should emergency contraception be taken?
-after unprotected sex
-forced sex
-birth control failure
Oral emergency contraception will not disrupt a pregnancy that has....
Implanted
-will prevent an egg that has been fertilized from becoming implanted
-will help prevent ovulation
Options for emergency contraception?
1. Plan B One-Step (levonorgestrel)
2. Ella (Ulipristal Acetate)
3. Yuzpe method (combination estrogen and progestin)
4. Copper IUD
Plan B One Step ingredient and dose?
Levonorgestrel 1.5mg
Plan B One Step is most effective if taken within __________ of unprotected intercourse (some protection up to ___________)
72 hours

(5 days)
Plan B One Step OTC or Rx only?
Available without a prescription
MOA of Plan B One Step?
-inhibition of ovulation
-interfering with fertilization or implantation
SEs of Plan B One Step
Nausea and vomiting
Efficacy of Plan B One Step within 72 hours?
~90%
Ella ingredient and dose?
Ulipristal 30mg

*controversial due to similar structure to mifepristone (an abortion drug)
Ella is effective for up to _________ after unprotected intercourse
120 hours
Ella OTC or Rx
Prescription only
MOA of Ella?
Delay ovulation
SEs of Ella?
Nausea and vomiting
What is the Yuzpe regimen?
Patient will take 4-5 pills of current birth control (must be combination oral contraceptive), followed by another 4-5 pills 12 hours later
-exact amounts depend on the combined oral contraceptive
SEs of Yuzpe regimen?
HIGH rates of nausea and vomiting
Efficacy of Yuzpe regimen?
Efficacy within 72 hours ~75%

Not recommended because the patient wouldn't have their regular birth control to take after doing this
Copper IUD for emergency contraception?
-highly effective if inserted within 72 hours
-requires a MD appointment for insertion
-risk of expulsion
Can you use hormonal IUDs for emergency contraception?
Yes!! Mirena
-associated with less side effects
The acute drop in this hormone allows for menses onset
Progesterone
What is the most effective way to increase adherence when initiating an oral contraceptive?
Quick start
When would a patient on combination oral contraceptives need a back up contraceptive?
Miss 1 pill during week 1
Which of the following is true about ParaGard?
Ideal for women desiring no hormones
Which progestin generation has anti-androgenic activity?
4th generation
Which progestin has anti-androgenic activity?
A. Norethindrone
B. Levonorgestrel
C. Norgestimate
D. Drospirenone
D. Drospirenone
During week 1, how many hours can the vaginal ring (NuvaRing) (15 mcg/day EE, 120 mcg/day etonogestrel) be removed for at a time without needing emergency contraceptive therapy?
3 hours
The subdermal progestin implant (Nexplanon) can be left in place for how many years?
3 years
Which emergency contraceptive is easiest for patients to access due to OTC nature?
Plan B One Step (levonorgestrel)
Depression, fatigue, and irritability are associated with...
Progestin excess
Weight gain and constipation are associated with....
progestin excess
Which progestin generation has some androgenic activity, but isn't as potent as other progestins?
1st generation
Which progestin has the highest androgenic activity?
Norgestrel
What is the minimum number of days that combination and contraceptives must be taken for a patient using the quick start method to prevent pregnancy?
7 days
Late cycle breakthrough bleeding or spotting (cycle days 10-21) are associated with....
Progestin deficiency
How many months can the vaginal ring Annovera be removed from the refrigerator prior to using?
No refrigeration required ever
How many months can the vaginal ring NuvaRing be removed from the refrigerator prior to using?
4 months
T/F: The NuvaRing has a BBW for VTE risk with women who smoke
TRUE
Which progestin generation has less bloating and mood side effects compared to other generations?
3 (lowest androgenic activity, but higher estrogenic activity)
T/F: 40% of patients still ovulate with COC
FALSE
What is the minimum number of days that combination oral contraceptives must be taken for a patient using the quick start method to prevent pregnancy?
7 days
What starting dose of estradiol is typical for patients underweight and/or adolescent patients?
20 mcg
Nausea, cyclic weight gain with fluid retention and headache are associated with...
Estrogen excess
Early cycle breakthrough bleeding (cycle days 1-9) are associated with...
Estrogen deficiency
What is the minimum number of days that progestin only contraceptives must be taken for a patient using the quick start method to prevent pregnancy?
2 days
Which progestin generation has the lowest androgenic activity, but higher estrogenic activity?
3
T or F: 40% of patients still ovulate with the norethindrone progestin only pill
TRUE
T or F: Patient's should discontinue combination hormonal contraceptives if they develop a migraine with no history of migraine
TRUE
T or F: CYP3A4 inducers such as griseofulvin increase side effects associated with combiunation oral contraceptives
FALSE
-they decrease efficacy of combo OC's
What is the maximum (latest) time the progestin only pill - norethindrone - can be taken before an emergency contraceptive is needed?
3 hours
Depo-medroxyprogesterone acetate has a BBW for?
Bone mineral density changes
Which emergency contraceptive has the best efficacy amont these options if taken after 72 hours (up to 120 hours) post intercourse?
Ella (Ulipristol)
T or F: there may be decreased efficacy for patients that are >90 kg with the transdermal contraceptive patch (Xulane, norelgestromin/EE)
True
Which progestin genreation is levonorgesterel?
2
What is responsible for producing progesterone after a patient has ovulated?
Corpus luteum
Which emergency contraceptive is easiest for patients to access due to OTC nature?
Plan B One Step
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