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Pharm II: contraceptives / menstrual Disorders (exam 3)

Terms in this set (69)

Progestins __ cervical mucus, delay sperm transport, and induce __ __. They also block the LH surge and thus inhibit __
thicken; endometrial atrophy; ovulation
What suppresses FSH release (which may contribute to blocking the LH surge and preventing ovulation) and also stabilize the endometrial lining and provide cycle control?
estrogens
what are the 3 synthetic estrogens in contraceptives? common dose?
ethinyl estradiol
mestranol (liver prodrug - less effective)
estradiol valerate

20-50mcg ethinyl estradiol
what should be obtained before prescribing a CHC?
medical history
BP
benefits of CHCs
-relief from menstrual problems
-menstrual regularity
-decreased iron deficiency anemia
-reduced risk of ovarian and endometrial cancer
-improved endo, uterine fibroids, benign breast dz
CHCs increase risk of what 2 cancers?
Breast and Cervical

(think BC- birth control)
typical oral contraceptive efficacy rate
92%
What is the timing for extended cycle OC regimens and who does this benefit?
active tablets for 84 days or longer with 7 days of inactive or estrogen only pills

those with severe PMS
how long should back up contraception be used after OC initiation?
7 days
OCs containing 20 to 25 mcg of ethinyl estradiol (EE) should be given to who? (4)
-Adolescents
-underweight women (less than 50 kg [110 lb.])
-women older than 35 years
-those who are perimenopausal
when do symptoms from OCs improve?
by the 3rd cycle
ACHES mnemonic for discontinuation of BC
Abdominal pain
Chest pain
Headaches
Eye problems
Severe leg pain
smoking increases risk of serious CV effects from what forms of contraceptives? what age is at increased risk?
oral hormonal contraceptives
transdermal
vaginal

women > 35
how long should estrogen containing hormonal contraceptives be avoided post partum? What about those with VTE risk factors?
21 days post partum (30 if breastfeeding)
42 days (doubled) for those with VTE risk factors
why should estrogen containing hormonal contraceptives be avoided post partum?
due to hypercoaguability of pregnancy and estrogen can affect milk supply
CHCs should not be recommended in women >35 years with what conditions?
migraine (with or without aura)
uncontrolled HTN
smoking
DM w/ vascular dz
big contraindication to oral contraceptives?
migraine with aura
BP contraindication to CHCs
160/100
Is a pt who has repeated BP of 144/96 a candidate for CHC?
no (risk outweighs benefit)
Who are progestin only oral contraceptives safe for?
women >35 who smoke or those who smoke more than 15 cigarettes a day
2 examples of diabetes stipulations that warrant avoidance of CHC
DM w/ vascular dz (nephropathy, retinopathy)

DM for longer than 20 yrs
How much more is the incidence of thromboembolism and mortality in current OC uses compared to non users?
3 times more
CHCs should be avoided in what 2 autoimmune conditions? What can a pt have instead?
SLE or antiphospholipid antibodies (and vascular complications!)

use progestin only contraceptives
common drugs that reduce efficacy of OCs
rifampin
phenobarbital
carbamazepine
phenytoin
Pt is taking phenobarbital for seizure disorder. What contraception options does she have?
injectable medroxyprogesterone
IUDs
non hormonal options
What population are transdermal contraceptives less effective in?
pts who weigh > 198 lbs
BBW ortho evra
smoking and CV events
VTE risk
ethinyl estradiol pharmacokinetic profile
What contraception might the below population benefit from?
- Breastfeeding
- intolerant to estrogens
- concomitant medical conditions in which estrogen is not recommended.
- Women with adherence issues
injectable progestins
progestins thin the _______, while thickening _________
endometrium; cervical mucus
The manufacturer of Depo-provera recommends excluding pregnancy if lapse of ___________ or more weeks between IM injections; what about SC formulation?
IM - 13 or more weeks
SC - 14 or more weeks
Which form of BC is not recommended for women desiring pregnancy in the near future?
depo-provera
depo-provera BBW that ties into less than 2 year recommended use unless other contraceptives fail?
short term bone loss but greater with increasing use
What is a good contraceptive choice for a woman with sickle cell dz
DMPA → studies have demonstrated reduction in sickle cell pain crises
What two other disorders may DMPA may add an additional benefit to?
sickle cell dz
seizure disorders
examples of LARCs
nexplanon
IUDs (copper, mirena, skyla, kyleena)
T/F LARCs are highly efficacious and effects are quickly reversible upon removal
true
How long can copper IUD be left in place?
10 years (new data suggests 12 years)
copper IUD pros/cons
pro- highly effective for emergency contraception

cons- increased menstrual blood flow and dysmenorrhea
How many yrs can levonorgestrel IUD be left in place?
5 years
1st line emergency contraception
progestin only (plan B)

progesterone receptor modulator products (Ulipristal)
Plan B (levonorgestrel) EC is most efficacious if used within ______ hrs
72 hrs
Ulipristal highlights
- Rx only
- Emergency contraception up to 5 days after unprotected intercourse
Pt has had 2+ missed doses of OCPs, how long should she use back up contraception?
until pills have been taken for 7 consecutive days
average delay in ovulation after stopping OCPs
1-2 weeks
general recommendations on pregnancy after discontinuing OCP
after 2-3 normal menstrual cycles
What contraception is most effective for treating heavy menstrual bleeding
levonorgestrel IUD
32 yo female who presents with complaints of irregular menses. She is hirsute around the jaw line, her BMI is 32kg/m2 and her waist circumference is 40 inches. A pelvic US reveals polycystic ovaries. Which of the following is most appropriate?

A combo OC containing EE and drospirenone

A combo OC containing EE and LNG

Metformin 850mg PO BID

LNG-IUD
A combo OC containing EE and drospirenone

or Spironolactone if OC contraindicated, with back up BC

Metformin would be given if patient wanting to get pregnant
Improved insulin sensitivity in pts with PCOS may result in a reduction in circulating androgen concentrations, increased ovulation rates and improved glucose tolerance. This may occur with what treatment?

estrogen therapy alone

combined OC

Medroxyprogesterone acetate (MPA)

Metformin
Metformin
What is the management of adolescent with dysmenorrhea who is not sexually active?
NSAIDs
What is provided for hypoestrogenic conditions associated with primary or secondary amenorrhea?
estrogen replacement (with a progestin) (OC or patch)
tx of amenorrhea related to hyperprolactinemia
bromocriptine (dopamine agonist)
MOA:
◦Inhibits pituitary release of gonadotropins
◦Transforms proliferative into secretory endometrium
Medroxyprogesterone tablets (Provera)
2 indications for progesterone micronized
- secondary amenorrhea
- postmenopausal endometrial hyperplasia in women receiving continuous estrogen
medroxyprogesterone tablet indications
- secondary amenorrhea
- abnl uterine bleeding
- postmenopausal endometrial hyperplasia prevention
These are BBW for what treatment?
- increased endometrial CA risk in pts with intact uterus
- not be used for CV and dementia prevention; increased stroke and DVT risk in postmenopausal women
conjugated estrogen
conjugated estrogen BBW for estrogen plus progestin
should not be used for CV and dementia prevention → increased stroke and DVT risk in postmenopausal women
what is the first choice tx in women with AUB-O who do not desire pregnancy?f
hormonal contraceptives
Which PCOS treatment induces ovulation and has been associated with reduced miscarriage rates in this patient population?
Metformin
3 general pharmacologic options for PCOS?
hormonal contraceptives
metformin
clomiphene
clomiphene citrate MOA?
SERM
which medication for PCOS/AUB has AEs of ovarian enlargement, vasomotor flushing, breast tenderness, hypertriclyceridemia?
Clomiphene citrate
contraindications to clomiphene citrate?
◦Pregnancy and breastfeeding
◦Hepatic dz or impairment
◦Non PCOS related ovarian cysts
◦Pituitary tumor
◦Endometrial CA
◦Organic intracranial lesion
◦Uncontrolled thyroid disease
what is the most effective tx to reduce menstrual flow?
LNG IUD (79-97%)
2 examples of nonhormonal therapies for primary HMB for those not desiring contraception?
NSAIDs (1st)
tranexamic acid OR
luteal phase progesterone
tx for dysmenorrhea (in order)
topical heat
monthly NSAIDs
HC x 2-3 cycle
depo MPA or LNG-IUD
first line pharmacologic for PMS/PMDD?
SSRIs- citalopram, escitalopram, fluoxetine, paroxetine, sertraline

*continuously or through the luteal phase
What is associated with an increased risk of congenital abnormalities when taken during the first trimester of pregnancy?
paroxetine
alternative tx for PMDD
Venlafaxine (SNRI)

YAZ (monophasic OC 20mcg EE and drospirenone)
tx option when all else fails for PMDD?
leuprolide (GnRH agonist)

Cons- $$ / IM admin / hypoestrogenism
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