PASS NAPLEX NOW Chapter 14 Contraception
Nextstellis (Estetrol + Drospirenone)
* 14.2 mg estetrol & 3 mg drospirenone - Taken 24 days followed by 4 days of placebo * "Estetrol is a newer form of estrogen". It may have less impact on certain tissues such as the breast or metabolic changes as lipids than ethinyl estradiol * Note: 3 mg of drospirenone has similar antimineralcorticoid effects as 25 mg of spironolactone. Check K+ if combined with other K+ raising meds (ACEIs, ARBs, TMP/SMX, etc.) May be less effective in patients with a BMI of > 30
Contraindications from the World Health Organization
* Age > 35 & smoke > 15 cigs/day * HTN * Migraines * Diabetes with end-organ disease * Chest pain * Postpartum women no sooner than 21 days (3 weeks) after delivery and if they have risk factors for DVT, they should wait 42 days (6 weeks)
Norethindrone-only (Minipill) Counseling and Drug Information
* All 28 pills are the same, no inactive pills * Not as effective as COCs, but a lot safer (no estrogen) Contain less progestin than COCs: * Fewer progestin-related side effects * More breakthrough bleeding & spotting * Some stop having periods for several months at a time Good for special populations * Cannot tolerate estrogen (history of CHD or emboli) * During lactation (estrogen decreases milk production and postpartum women are in hypercoagulable state)
Monophasic COC (SOME OF THE MORE POPULAR MONOPHASICS)
* Altavera; Apri; Cryselle-28; Notrel; Junel; Lessina; Levora; Femcon Fe*; LoEstrin; Lybrel; Microgestin; Minastrin 24 Fe*; Necon 1/35; Marlissa; Reclipsen; Vyfemia; Yasmin; YAZ; Zovia; Ocella
Four Phases: Natazia (Estradiol valerate & Dienogest)
1) Estradiol valerate 3 mg (2 tabs) 2) Dienogest 2 mg + estradiol valerate 2 mg (5 tabs) 3) Dienogest 3 mg + estradiol valerate 2 mg (17 tabs) 4) Estradiol valerate 1 mg (2 tabs) 5) Inert (2 tabs) Back-up form of contraception for the first 9 days of the first cycle (NOT SEVEN) FDA-approved for heavy menstrual bleeding
IUD Benefits
1) Highly efficacious 2) Easy to use 3) Safe for most women 4) Long-acting 5) Rapidly reversible 6) Few side effects 7) Avoidance of exogenous estrogen
Which monophasic COC are chewable?
1) Minastrin 24 Fe 2) Femcon Fe
COC Counseling Points
1) Review how pills are labeled 2) Pills do not protect against STDs; use condoms 3) Stress the importance of daily compliance 4) S/E will ↓ with consistent use after 3 months 5) Contact MD if experience ACHES: * A - Abdominal pain (severe) * C - Chest pain, cough, SOB * H - Headache, dizziness, numbness * E - Eye problems (vision loss/burning) * S - Severe leg pain (calf or thigh)
What are some examples of Extended cycle regimen?
1) Seasonique 2) LoSeasonique - DSC 3) Quartette
The Generations of Progestins
1st Generation: Norethindrone acetate (NE), Ethynodiol diacetate (ED) 2nd Generation: Levonorgestrel (LNG), Norgestrel (NG) 3rd Generation: Desogestrel (DSG), Norgestimate (NGM) Other types of Progestin: Drospirenone (risk of venous thromboembolism with drospirenone
COC Drug Interactions (CYP3A4 Inhibitors / Inducers)
3A4 Inhibitors: will ↑ estrogen --> ↑ estrogen S/E such as HA, nausea 3A4 Inducers: will ↓ estrogen * If the patient is on anticonvulsants, RECOMMEND: Hormone-releasing systems (Mirena, LNg 20) or Depo-Provera or non-hormone contraception COCs ↓ Lamotrigine concentration by ~ 50%
Bacterial Vaginosis
A common cause of abnormal vaginal discharge: Grayish white vaginal discharge, a bothersome "fishy odor" & ↑ pH Treatment options * Metronidazole 500 mg oral BID x 7 days * Metronidazole gel intravaginally QD x 5d * Clindamycin 300 mg PO BID for 7 days * Clindamycin 2% cream intravaginally QHS x 7 days Alternative * Secnidazole (Solosec) 2 g packet PO single dose * Tinidazole 2 g PO x 3 days OR Tinidazole 1 g PO QD x 5 days
What is a hysterectomy?
A hysterectomy removes the uterus & may also remove the cervix (total) and the vaginal (radical)
How to choose the right OCP? Consider the whole patient & other issues
Acne: Orthro Tri-Cyclen, Estrostep, and Yaz are approved for acne. But most COCs are helpful because estrogen decreases testosterone levels * Yaz contains 25 mg of spironolactone which is an androgen receptor blocker Weight gain: Estrogen may initially cause weight gain due to water & sodium retention but long-term weight gain isn't likely * Pills with androgenic activity sometimes stimulate appetite. If this is suspected, suggest trying a pill that is less androgenic
Drug Interactions with COCs (CYP3A4 Inducers)
Antibiotics / Antifungal (Griseofulvin) CYP3A4 Inducers * Rifampin (potent CYP3A4 inducer) decreases serum ethinyl estradiol & progestin levels. A nonhormonal contraceptive is recommended * Anticonvulsants (CYP3A4 inducers: phenytoin, phenobarbital, carbamazepine, oxcarbazepine) shown to ↓ COC hormone concentrations by ~ 40% - Should NOT use hormonal contraceptives (except Depo-Provera / IUD). If must use COC, some clinicians may recommend COC with 50 mcg of the estrogen
Norethindrone-only (Minipill) Examples & Instructions
Aygestin, Camila, Errin, Nora-BE; Deblitane; Heather; Incassia; Jencycla; Lyleq; Lyza; Norlyroc; Sharobel * Norethindrone: 0.35 mg Important to take at the same time every day * Initiated on the first day of menses * Use backup for 2 days if > 3 hours late on dose
Beyaz (Drospirenone / Ethinyl estradiol / Levomefolate calcium)
Beyaz raises folate levels Beyaz is a 24/4 regimen consisting of: * 24 days of: Drospirenone 3 mg, Ethinyl estradiol 20 mcg, Levomefolate calcium (Metafolin) 451 mcg * 4 days of: Metafolin only
Other OB/Gyn Meds & Uses Cont.
Infertility: Clomiphene (Clomid) - SERM; inducing ovulation and improving fertility. 50 mg PO QD x 5 days. Begin on the fifth day of the menstrual cycle * Letrozole (Femara), an aromatase inhibitor, "off-label" for ovulation induction in women with polycystic ovary syndrome (PCOS) * CetroRelix (Cetrotide): (SQ) GnRH Antagonist * GaniRelix (Fyremadel): (SQ) GnRH Antagonist For heavy menstrual bleeding * Tranexamic acid (Lysteda - Brand is DSC): two 650 mg tabs TID for up to 5 days during monthly menstruation. May cause thrombotic events
MONOPHASICS EXAMPLEs
Loestrin 1/20 ----> EE: 20 mcg + Norethindrone 1 mg Microgestin 1/20 ---> EE 20 mcg + Norethindrone 1 mg Generic of Lybrel ----> EE: 20 mcg + Levonorgestrel 90 mcg Altavera ----> EE 30 mcg + Levonorgestrel 0.15 mg Zovia 1/35 -----> EE: 30 mcg + Ethynodiol 1 mg Femcon Fe ---> EE: 35 mcg + Norethindrone 0.5 mg
Alternative Progestin Forms
Medroxyprogesterone acetate * Depo-Provera (150 mg IM) every 3 months * Depo-SubQ Provera 104 every 3 months * Provera (2.5 mg, 5 mg, 10 mg tabs) PO not used for contraception; used for abnormal uterine bleeding Candidates for use * Indicated for contraception/endometriosis * Contraception of > 1-year duration is desired * Patients in whom estrogens should be avoided * Non-compliant w/COC (forgetful) * When breastfeeding is desired * Patients with a history of seizures * When amenorrhea is desired * AVOID in patients w/ h/o depression or headaches
Bremelanotide (Vlyessi)
Melanocortin receptor agonist for hypoactive sexual desire disorder (HSDD) in premenopausal women Dose: SQ 45 min. before anticipated sexual activity. Max: one within 24 hours or eight doses per month S/E: nausea (40%), flushing, injection site reactions & HA * 1% reported darkening of the gums & skin, including the face & breasts, which did not go away in about 1/2 the patients after stopping treatment. Dark skin patients were more likely to develop this side effect
Missed Pills COC
Missed 1 Pill: Anytime (2 pills ASAP), (EC if other doses missed in the past month) Missed 2 Pills: Week 1-2 or 3 (Weeks 1-2: 2 pills NOW & 2 the next day; Backup for 7 d (recommend EC for sex in past 5 days). Weeks 3: Continue pack, skip the placebo straight to a new pack. Backup for 7 days Missed 3 Pills or >: Weeks 1-2-3 (Finish active tabs, then start a new pack. Backup contraception for 7 days. EC for sex in past 7 days. Review Missed Doses COC * One dose missed: --> 2 tablets ASAP * 2 tabs missed: - 1st or 2nd week: --> 2 tabs ASAP; 2 pills the next day; Backup for 7 days. - Week 3 or three consecutive doses missed: --> Finish pack, skip placebo days straight to a new pack. Backup for 7 days
FLibAnSeriN (Addyi)
Mixed 5-HT1A Agonist / 5-HT2A Antagonist for pre-menopausal women w/ hypoactive sexual desire Dose: 100 mg PO QHS S/E: HYPOTENSION, SYNCOPE, Sedation DI: Addyi is a major CYP3A4 substrate * CI w/ CYP3A4 inhibitors (HYPOTENSION) * If initiating Addyi after CYP3A4 inhibitor: start Addyi 2 wks after the last dose of the 3A4 inhibitor. Starting 3A4 inhibitor: start 2 d after the last dose of Addyi. Contraindicated with alcohol / hepatic impairment Addyi is available only via ADDYI REMS program due to the increased risk of SEVERE HYPOTENSION and syncope IMPORTANT INFORMATION L = Liver A = Contraindicated with Alcohol S = Serotonin, Syncope, CYP3A4 Substrate N = Take it at NIGHT QHS
The types of Oral Contraceptive Regimens
Monophasic: Constant estrogen & progestin dose throughout the cycle (all active pills are the same) Biphasic: 2 different doses are given over the cycle. (e.g., constant estrogen; progestin ↑ in the late cycle) Triphasic: 3 different doses throughout the cycle (e.g., progestin/estrogen varies in 3 phase cycle (Q 7 Days) Quadriphasic: Four different doses throughout the cycle Extended cycle: Hormone (estrogen, progesterone, or both) used for an extended, continuous cycle to reduce or eliminate the withdrawal bleeding Noncyclic regimen Progestin-only: Daily low dose progestin ("mini" pill)
Treatment of menopausal symptoms with hormone therapy
Most women have menopause ranging between 45-55 yrs old (average age is 51) * Low estrogen levels may cause hot flashes, vulvovaginal atrophy, vaginal dryness, and dyspareunia. Hormone therapy helps relieve menopausal symptoms; most patients stop hormone therapy within 2 years of being on it
Spermicide
Nonoxynol-9 is the active ingredient in most spermicidal creams, jellies, foams, gel, film & suppositories * MOA: causes the sperm to be immobilized Lactic acid, citric acid, potassium bitartrate (Phexxi) * MOA: gel maintains an acidic pH to ↓ sperm motility - 1 applicator inserted immediately before or up to 1 hour before vaginal intercourse - May be used during menses; with miconazole, hormonal contraceptives, condoms, & diaphragms - Avoid: use with recurrent UTI; vaginal rings - May cause vaginal burning, and itching even in partners
Missed Pills Progestin-Only
Norethindrone * 2-3 hrs late: take pill ASAP; Back up for 2 days Drospirenone (Slynd) * 4 mg tabs for 24 days followed by 4 days of placebo. If one pill missed, take it ASAP. Backup is NOT required when a dose is taken up to 24 hours late * ≥ 2 tabs missed: take tab ASAP; nonhormonal contraception taken until 7 continuous days are taken
Describe the Female Cycle
On ovulation day (day 14), the egg is released from the ovary. Progesterone production ↑ about a day after ovulation, along with the resultant rise in the body temperature Progesterone - and body temperature - remain relatively high throughout the rest of the cycle; however, if the patient does not become pregnant, both will gradually decrease and ultimately menstruation will take place on cycle day 28
Dyspareunia (Pain with Intercourse)
Ospemifene (Osphena) * Indication: menopausal-related dyspareunia "Genital Pain during or after sexual intercourse" * MOA: selective estrogen receptor modifier (SERM) - Osphena has estrogenic effects on vaginal tissue while raloxifene & tamoxifen do not. Just like other SERMs, Osphena can cause hot flashes & blood clots * Dose: 60 mg orally QD with food * DDI: metabolized by CYP3A4 & CYP2C9 * Pregnancy Category X * Other choices: If worried about clot formation, recommend low-dose vaginal estrogens: Vagifem, Estring, Estrace or Premarin. A non-estrogen: Intrarosa. Also, for mild symptoms, recommend a vaginal lubricant
Absolute Contraindications for COC's
Package Insert * Thrombo-embolic disorder or history (DVT, CVA) * History of breast/uterus or any estrogen-dependent neoplasia * Undiagnosed vaginal bleeding (? uterus CA) * Liver issues: Cholestatic jaundice of pregnancy or history of jaundice, hepatic adenomas/carcinoma. It is contraindicated by pre-existing hepatic disease * Pregnancy
Other OB/Gyn Meds & Uses
Pregnancy termination: Mifepristone (RU-486) * Misoprostol (Cytotec): also used for Cervical ripening * Dinoprostone (Cervidil, Prepidil): also used for Cervical ripening Labor Induction: Oxytocin (Pitocin) IV - Causes the uterus to contract used to induce labor Immune Globulin: Rho [D] Immunoglobulin (RhoGAM): prevention of hemolytic dz of newborn if mom Rh(-) / baby Rh(+)
Components of COCs (Progestins)
Progestins * DLNG (d,L norgestrel) - Cryselle-28; Elinest; Low-Ogestrel * DSG (desogestrel) - Apri; Azurette; Cyred EQ; Enskyce; Isibloom; Juleber; Kalliga; Kariva; Mircette; Pimtrea; Reclipsen; Simliya; Velivet; Viorele; Volnea * ED (ethynodiol diacetate) - Kelnor 1/35; Kelnor 1/50; Zovia 1/35 (28) * LNG (levonorgestrel) - Afirmelle; Altavera; Amethia; Amethyst; Ashlyna; Aubra EQ; Aviane; Ayuna; Balcoltra; Camrese; Camrese Lo; Chateal EQ; Daysee; Delyla; Dolishale; Enpresse-28; Falmina; Fayosim; Iclevia; Introvale; Jaimiess; Jolessa; Kurvelo; Lessina; Levonest; Levora 0.15/30 (28); LoJaimiess; Lutera; Marlissa; Portia-28; Quartette; Rivelsa; Seasonique; Setlakin; Simpesse; Sronyx; Trivora (28); Twirla; Tyblume; Vienva * NE (norethindrone): Alyacen 1/35; Alyacen 7/7/7; Aranelle; Aurovela 1.5/30; Aurovela 1/20; Aurovela 24 FE; Aurovela Fe 1.5/30; Aurovela FE 1/20; Balziva; Blisovi 24 Fe; Blisovi Fe 1.5/30; Blisovi FE 1/20; Briellyn; Charlotte 24 Fe; Dasetta 1/35; Dasetta 7/7/7; Finzala; Fyavolv; Gemmily; Generess FE; Hailey 1.5/30; Hailey 24 Fe; Hailey FE 1.5/30; Hailey FE 1/20; Jinteli; Junel 1.5/30; Junel 1/20; Junel FE 1.5/30; Junel FE 1/20; Junel Fe 24; Kaitlib Fe; Larin 1.5/30; Larin 1/20; Larin 24 FE; Larin Fe 1.5/30; Larin Fe 1/20; Layolis FE; Leena; Merzee; Mibelas 24 Fe; Microgestin 1.5/30; Microgestin 1/20; Microgestin 24 Fe; Microgestin FE 1.5/30; Microgestin FE 1/20; Minastrin 24 Fe; Necon 0.5/35 (28); Nortrel 0.5/35 (28); Nortrel 1/35 (21); Nortrel 1/35 (28); Nortrel 7/7/7; Nylia 1/35; Nylia 7/7/7; Philith; Pirmella 1/35; Pirmella 7/7/7; Tarina 24 Fe; Tarina FE 1/20 EQ; Taysofy; Taytulla; Tilia Fe; Tri-Legest Fe; Vyfemla; Wera; Wymzya Fe * NEAC (norethindrone acetate) - Lo Loestrin Fe; Loestrin 1.5/30 (21); Loestrin 1/20 (21); Loestrin Fe 1.5/30; Loestrin Fe 1/20 * NGM (norgestimate) - Estarylla; Mili; Mono-Linyah; Nymyo; Sprintec 28; Tri-Estarylla; Tri-Linyah; Tri-Lo-Estarylla; Tri-Lo-Marzia; Tri-Lo-Mili; Tri-Lo-Sprintec; Tri-Mili; Tri-Nymyo; Tri-Sprintec; Tri-VyLibra; Tri-VyLibra Lo; VyLibra Progestins Pharmacology * Cycle Control * Thickens cervical mucus that slows sperm transport and ability to penetrate the ovum * Causes endometrial transformation
Four-phase extended-cycle oral contraceptive
Quartette: 91 total pills (84 active pills & 7 inactive pills) EE: 20 mcg x 42 days, 25 mcg x 21 days, 30 mcg x 21 days, 10 mcg x 7 days Levonorgestrel: 0.15 mg x 84 days
Safyral
Safyral raises folate levels Safyral is a 21/7 day regimen containing: * 21 days of Drospirenone 3 mg, Ethinyl estradiol 30 mcg, Levomefolate calcium 451 mcg tablet * 7 days of: Levomefolate calcium 451 mcg tablets
Seasonique / LoSeasonique
Seasonique EE: 30 mcg, Levonorgestrel: 0.15 mg * LoSeasonique EE: 20 mcg; Levonorgestrel: 0.15 mg * Take one tablet qd for 91 days, then repeat * During the first cycle of medication, start on the 1st Sunday after the onset of menstruation Both contain 84 days of the same hormones * Seasonique provides a low dose of estrogen (0.01 mg) for last 7 days instead of placebo. (Biphasic) * Seasonique is also worth a try for women who get menstrual migraines. These women are often given additional estrogen during the placebo days to prevent migraines
Annovera Vaginal Ring
Segesterone acetate (progestin) + ethinyl estradiol * Soft and flexible self-insertion similar to NuvaRing 3 weeks on, 1 week off... the same ring provides contraception for one year; the same ring can be reinserted after the week off period. The patient does not have to go to the pharmacy every month to get a new ring Not adequately evaluated in females with a body mass index of > 29 kg/m2 Warning: females > 35 y/o who smoke should not use Annovera
Twirla Patch (EE + Levonorgestrel)
Similar to Xulane (Ethinyl estradiol / Norelgestromin) patch * Start the first 24 hours of administration * If applied after the first 24 hrs of menstruation, nonhormonal back-up for 7 days of the first cycle * Apply one patch each week for 3 weeks (21 days); followed by one week "off" - patch-free * Both Twirla and Xulane have higher estrogen content compared to low-dose COC; may have a higher CLOT RISK, & contraindicated w/ BMI ≥ 30
Nuvaring Vaginal Ring
Soft & flexible self-insertion * Used for 21 days q month (3 weeks) * Very low daily dose of EE & etonogestrel REFRIGERATE * Store NuvaRing at room temp for up to 4 months * If NuvaRing is refrigerated, it can be used until the expiration date
Nexplanon (Alternative Progestin Form of Contraception)
Subdermal Etonogestrel Rod implant (Progestin) * Released over 3 years * Inserted/removed by minor procedure * Effect reduced by inducers (anticonvulsants, Griseofulvin, rifampin, St. John's wort) * When long-term contraception is desired Side Effects * Risk of thromboembolism; DVT/PE/CVA * Implantation site tenderness
Breakthrough Bleeding
The #1 reason people D/C * More often in smokers (smoking is an inducer) * Encourage women to continue for 3 months before deciding to stop * If bleeding occurs in early cycle (days 1-10 of active pill), the patient may have estrogen deficiency; so recommend higher estrogen dose for EARLY bleeders. Early - Estrogen = Earli-Est * If bleeding after the 10th day, the patient may have progestin deficiency; use OCP w/more progestin for LATE bleed * Recommend one with more estrogen & progestin for MID-cycle bleed (days 10-21)
Progesterone alone products
Used for Amenorrhea & Dysfunctional Uterine Bleeding (DUB) * Medroxyprogesterone: Provera / Depo-Provera * Micronized progesterone: Prometrium - Contraindicated in peanut allergy * Progesterone vaginal insert tablet: Endometrin * Progesterone Gel: Crinone * Norethindrone: Micronor, Camila, Errin, Nora BE, Aygestin. Labeled indications: Contraception, amenorrhea and abnormal uterine bleeding, endometriosis * Drospirenone (Slynd): Contraception
Yeast Infection
Vulvovaginal candidiasis is one of the most common causes of vulvovaginal itching and thick, white, cottage cheese-like discharge * A yeast infection is an overgrowth of yeast that lives in the vagina. It is NOT a sexually transmitted disease. * More likely in women who are pregnant or diabetic * Does NOT cause fever/chills/abdominal/back pain * Vaginal applications can be used during menstrual period. Your patient should NOT have intercourse, use tampons, douches, spermicides or other vaginal products while using any of the applications. Condoms & diaphragms may be damaged and fail to prevent pregnancy or STDs
Questions regarding Xulane Patch
When to start wearing the patch? * The patch is usually started on the 1st day of the menstrual cycle or the 1st Sunday after the patients' period (the same way they would start the pill) What if the patch falls off? * If the patch is off or almost off for < than 24 h, they should put it back on or replace it with a new one * If > 24 hours, they need to apply a new patch asap * Start a new 4-wk cycle w/a new patch change day * Use back up for one week (7 days) to prevent pregnancy
How to choose the right OCP? Consider the whole patient & other issues (Women with co-existing medical condition, women w/diabetes, women with h/o DVT/PE, CAD, CHF or CVA; Women w/ Migraines & Depression)
Women with co-existing medical condition * Women < 35 years with well-controlled HTN can start a trial of COC with LOW ESTROGEN < 35 mcg of EE; however, the best recommendation is to suggest a progestin-only or non-hormonal contraceptive Women w/diabetes: COC should be limited to non-smoker, < 35 y/o, without HTN, retinopathy, or other vascular dz. DM with vascular disease or DM for > 20 yrs; * Cooper IUD is preferred. Oral progestins, implants, and levonorgestrel-releasing IUDs are acceptable alternatives Women with h/o DVT / PE, CAD, CHF, or CVA: Estrogen products are NOT recommended. USE MINI-PILL. Women w/ Migraines & Depression: considered relative contraindications for progesterone, specially Depo-Provera
Xulane Patch
Xulane patch: The patch looks like a square Band-Aid (less than 2" x 2") * Combination of EE & norelgestromin * ONCE a week, 3 weeks on, 1 week off * Releases about 60% more estrogen into the bloodstream than the average COC Xulane: EE 0.53 mg & norelgestromin 4.86 mg (releases EE 35 mcg & norelgestromin 150 mcg per day)
Yasmin / Yaz (Progestin: Drospirenone)
Yasmin 0.03 mg EE + 3 mg Drosperinone * 21 tablets of 3 mg drospirenone + 0.03 mg (EE), 7 inert white tablets YAZ 0.02 mg EE + 3 mg Drosperinone * 24 tablets of 3 mg drospirenone + 0.02 mg (EE), 4 white inert tablets Drsosperinone increases the risk of hyperkalemia: avoid K+ sparing diuretics, ACEI, ARB, Heparin & NSAIDs YAZ has fewer placebo days: SHORTER periods Higher thrombosis risk with drospirenone & desogestrel compared to levonorgestrel & norethindrone
Hormone Combinations used for HT
HT has less estrogen than OCPs; the estrogen is estradiol * Prempro & Premphase: Estradiol + Medroxyprogesterone * Activella: Estradiol + NE * Angeliq: Estradiol 0.5 mg + Drospirenone 0.25 mg * Climara Pro: Estradiol + Levonorgestrel (weekly) patch * CombiPatch: Estradiol + NE (twice per week) (in the pharmacy stored REGREGERATED), RT: 6 months * Estratest (generic) / Covaryx: Estradiol + Methyltestosterone * Prefest: Estradiol + Norgestimate * Bijuva: Estradiol + Progesterone
Emergency Contraception
* Contraceptive methods used after intercourse but before implantation (before pregnancy). * Often referred to as the Morning after pill * Birth control pill taken in high doses within 72 hours up to 5 days of unprotected intercourse * Dose not cause abortion (not same as RU486) * Will not alter established pregnancy * Does not protect against STDs * May inhibit implantation, delay ovulation, or inhibit fertilization Levonorgestrel 1.5 mg tabs [All are OTC with NO restrictions of age] * (Aftera; Curae; EContra One-Step; Her Style; My Choice; My Way; New Day; Opcicon One-Step; Plan B One-Step; React; Take Action) All methods: must be used ASAP within 72 hours of unprotected sexual intercourse; treatment is still moderately effective if used within 5 days S/E: Nausea/vomiting; consider repeating the dose if vomiting occurs within 2 hours
Estrogen alone products used for HT: Ok to use if h/o hysterectomy
* Estrogen PO: *Premarin, Estrace * Estrogen vaginal cream: *Premarin cream, Estrace Premarin cream 0.5 g daily; reduce to twice per week * Estradiol vaginal ring: Estring, Femring (Estradiol acetate) (replace after 90 days) * Estradiol vaginal tab: Vagifem (1 tab qd x 2 wk, then 1 tab 2x qw) * Estradiol vaginal soft gel insert: Imvexxy (Once 2x qw) Estradiol transdermal patch: Menostar (once a week), *Climara (QW), *Fempatch (QW), *Vivelle, *Vivelle Dot, Alora, Minivelle (twice a week) * Estradiol transdermal spray: Evamist * Estradiol transdermal gel: Divigel, Estrogel, Elestrin
Hormone Therapy (HT)
* Hormone therapy (HT) is used for menopausal symptoms & ↓ the risk of osteoporosis & fractures. HT is safe for healthy, symptomatic women who are within 10 years of menopause or < 60 years old, and who do not have contraindications (history of breast cancer, CHD, stroke, or active liver disease) HT has been linked to certain cancers: * Breast cancer * Endometrial cancer: risk ↑ for women on estrogen alone. Add a progestin for women with an intact uterus
Depo-Provera Side Effects
* Irregular bleeding and spotting for up to 7 days during 1st few months of therapy * Amenorrhea * Weight gain (IM: > 10 lbs at 24 months) * Delayed fertility upon D/C (9 mo - 1 yr) * Headache, Nervousness, Depression * Risk of bone loss with prolonged administration may be irreversible
Diaphragms Instructions
* Leave in 6 h after sex, but take out ASAP afterward * Never in for > 24 hours * Can be inserted up to 6 hours prior to intercourse * Do not use during menses * Toxic shock syndrome (fever, vomiting, Aches) * Wash with mild soap with warm water, dry with a towel, and store in a plastic container * Don't use oil-based products such as petroleum jelly * If the patient gains or loses > 10 pounds, her diaphragm fitting should be checked * Manufacturers of silicone diaphragms recommend replacement every two years
BMI > 25 kg/m2 / Weight ≥ 75 kg
* Levonorgestrel-based emergency contraception may be less effective in women ≥ 75 kg (165 pounds) * Efficacy of levonorgestrel EC may ↓ as BMI ↑ above the normal range (25 kg/m2) or at weights ≥ 75 kg May recommend a copper-releasing IUD as first-line therapy to prevent pregnancy. If the IUD is not an option, ulipristal might be more effective than levonorgestrel * Don't let a patient's weight deter you from recommending EC. FDA recommends taking EC as soon as possible after unprotected sex
Clinical Comments regarding IUD/IUS (Intrauterine Device)
* Pelvic inflammatory disease (PID) is rare; the risk is greatest in the first 20 days * Early danger signs (PAINS): Period late: pregnancy, Abdominal pain, Infection exposure / abnormal vaginal discharge, Not feeling well, fever, chills, String missing
Drospirenone 4 mg (Slynd)
* Progestin-only pill "minipill" taken for 24 days, followed by 4 days of placebo * When starting, backup for 2 days unless it is initiated within the first 5 days of menstrual bleeding * If one pill is missed, take it ASAP. Backup is NOT required when a dose is taken up to 24 hours late. (unlike norethindrone which has to be taken on time; backup is needed for 2 days if 3 hours late) * If ≥ 2 active tabs are missed, tab should be taken ASAP and additional nonhormonal contraception taken until active tablets have been taken for 7 continuous days * Advise checking potassium if taking other potassium-raising meds (ACEIs, ARB, TMP/SMX...)
Ulipristal (Ella) - RX ONLY
* Selective Progesterone Receptor Modulator (agonist/antagonist) to delay/inhibit ovulation & prevent implantation * Just like Plan B One-Step, Ella does NOT interfere with pregnancy after implantation - 1 tab (30 mg) PO ASAP within 120 hours (5 days) after unprotected intercourse (with or without food) - If vomiting within 3 hours, repeat dose Stays effective for 5 days/levonorgestrel's efficacy decreases after 3 days * Patients should use contraceptives for the rest of their cycle since ovulation may be delayed
Painful sexual intercourse due to vaginal atrophy
* The primary indications for the treatment of vaginal atrophy are vaginal dryness, burning, dysuria, & urinary frequency * 1ST: RECOMMEND MOISTURIZERS/LUBRICANTS Vaginal Therapy: Because systemic absorption is low, vaginal estrogens generally do not relieve vasomotor symptoms. * Estring (vaginal ring replaced every 90 days) * Vagifem (vaginal tab), Imvexxy (softgel vaginal insert) * Vaginal creams (Premarin, Estrace) * Ospemifene (Osphena) a SERM that acts as an estrogen agonist in the vagina * Prasterone (Intrarosa) (QHS vaginal insert) - DHEA which is converted in vaginal tissues to estrogens & androgens
IUD Contraindications
1) Active pelvic infection 2) Pregnancy 3) Wilson's disease or copper allergy (use hormone-releasing, LNg, IUDs) 4) Unexplained uterine bleeding 5) Breast cancer (LNg IUDs)
IUD / IUS (Intrauterine Device) Examples
1) Copper IUD (ParaGard) - 10 years * Sometimes used as an emergency contraceptive * Inserted within 5 days of unprotected intercourse 2) Levonorgestrel IUS (Mirena) - 5 yrs - IUS 3) Levonrogestrel IUS (Skyla) (IUS) - 3 yrs * IUD with progestogen is referred to as an intrauterine system (IUS) 4) Levonorgestrel (Liletta) (IUS) - 3 years 5) Levonorgestrel (Kyleena) - 5 years
Vaginal Candidiasis Treatment
Candidiasis is caused by an overgrowth of yeast Vaginal applications: * Clotrimazole (OTC) - Cream (1%): Insert 1 applicatorful QHS x 7 days. May also apply externally BID for 7 days for itching & irritation * Miconazole [(Aloe Vesta Antifungal [OTC] Antifungal [OTC]; Azolen Tincture [OTC]; Baza Antifungal [OTC] Cruex Prescription Strength [OTC]; Desenex [OTC]; Fungoid Tincture [OTC]; Lotrimin AF Deodorant Powder [OTC]; Lotrimin AF Jock Itch Powder [OTC]; Lotrimin AF Powder [OTC]; Micaderm [OTC]; Micatin [OTC]; Miconazole 3; Miconazole 3 Combo-Supp [OTC]; Miconazole 7 [OTC]; Miconazole Antifungal [OTC]; Micotrin AP [OTC]; Mycozyl AP [OTC]; Zeasorb-AF [OTC] (OTC)] * Tioconazole (Monistat 1 Day) (OTC) * Terconazole (Rx) * Butoconazole (Gynazole-1) (Rx) Oral: Fluconazole (Diflucan): 150 mg tab single dose * Ibrexafungerp (Brexafemme): 300 mg Q12h x 2 doses
Diaphragms
Caya: one size; reusable silicone device; does NOT require a pelvic examination for fitting; requires an Rx Milex wide-seal arching: silicone, made of different sizes require a prescription that specifies the device size ALL DIAPHRAGMS ARE DESIGNED TO USED WITH SPERMICIDE: Nonoxynol-9 contraceptive gel
What does a pregnancy test check for?
Checks for Beta-hCG level
What does an ovulation test check for?
Checks for a rise in Luteinizing hormone (LH). Elevated quantities cause ovulation: the time when an egg is ovulated from the ovary, ready to accept a sperm
Counseling on COCs (when do I start the package?)
Day 1 starters - Start 1st day of menstrual bleeding. This prevents ovulation in the 1st cycle eliminating the need to use an alternative method for contraception during the 1st cycle Sunday starters- Start 1st Sunday after menstrual bleeding begins. * This prevents menstrual periods on weekends * Backup method is necessary for the 1st 7 days of pill use
Biphasic COC (Mircette, Kariva, Viorele, Pimtrea) Regimen
Days 1-21: (EE - 0.02 mg; Desogestrel - 0.15 mg) Days 22-23: (2 inactive tablets) Days 24-28: (EE - 0.01 mg)
Biphasic COC (Lo Loestrin Fe) Regimen
Days 1-24: (EE - 0.01 mg, NEA - 1.0 mg) Days 25-26: (EE - 0.01 mg) Days 27-28: (Ferrous fumarate 75 mg (2 brown tabs) 10 mcg, 1 mg norethindrone, 75 mg ferrous fumarate * 24 tabs of 1 mg Norethindrone + 10 mcg EE (24 days) * 2 tabs of 10 mcg EE (2 days) * 2 tabs containing 75 mg of ferrous fumarate (2 days)
Depo Clinical Comments
Dosage * 150 mg deep IM injection in the deltoid or gluteal site. First injection is given during day 1-5 of cycle or after ruling out pregnancy. - Reinjection given Q13wks (about Q3 months) Depo-Provera 104 SQ * 104 mg every 3 months (every 12 to 14 weeks) Advantages * No estrogen side effects. NO INCREASED RISK OF BLOOD CLOTS. Decreased seizure frequency, increases hemoglobin and red cell survival in patients with sickle cell disease, increased quantity of protein content in breast milk, decreased risk of endometrial cancer, low failure rate (0.3%), ok with anticonvulsants
Progestin: Drospirenone
Drospirenone/EE (Nikki; Ocella; Syeda; Vestura; YAZ; Yazmin) * Drospirenone/Estetrol (Nextstellis) Drospirenone is a spironolactone analog equal to 25 mg of spironolactone w/ anti-mineral-corticoid (anti-aldosterone), & anti-androgenic effects Good choice for women with polycystic ovary syndrome (PCOS), PMS, mood swings, acne, or excess hair growth Less water retention, but risk of hyperkalemia
Estrogen / Bazedoxifene (Duavee)
Duavee: Conjugated Estrogen + Bazedoxifene * Bazedoxifene is a SERM; inhibits estrogen's endometrial effects, an alternative to progestin Indications: Vasomotor symptoms associated w/ menopause * Prevention of postmenopausal osteoporosis * Duavee can be used when a female patient needs estrogen for menopausal symptoms; however, can not use progestin to protect from endometrial hyperplasia Dose: 1 tab QD (estrogens 0.45 mg / bazedoxifene 20 mg) Contraindications: history of arterial thromboembolic disease (e.g. stroke, MI); breast or uterine cancer, or liver disease)
How to choose the right OCP? Consider the whole patient & other issues (Dysmenorrhea, Bloating, Menstrual migraine)
Dysmenorrhea or PMS: Symptoms may improve with extended or continuous-cycle pills - (Seasonique, Lybrel; since the hormone-free interval is shorter Bloating: Recommend Yasmin or Yaz. Drospirenone has a mild diuretic effect. Yaz is the first OC approved for premenstrual dysphoric disorder Menstrual migraine: Extended or continuous-cycle pills (SEASONIQUE, Lybrel) can be helpful by preventing the drop in estrogen that triggers migraines. * Avoid using EE in women who have migraines WITH AURAS because of an increased risk of stroke * Women who develop migraine HA (w/ or without aura) or whose migraines worsen while using COC, should d/c the estrogen component
Lybrel (generic) / Noncyclic regimen
EE 20 mcg + Levonorgestrel 90 mcg * Lybrel is a non-cyclic oral contraceptive product that is given QD, without a hormone-free interval for a year or longer * No scheduled periods & possibly a lower incidence of PMS, headaches, and anemia * Up to 50% of women have spotting during the first 3 months. This decreases with continued use * A monthly cycle is not needed while on the pill. The pill suppresses endometrial thickening, so monthly bleeding isn't necessary to slough it off
Triphasic COC (Estrostep Fe - Brand is DSC; Generic Available)
EE: 20 / 30 / 35 mcg + NE: 1 mg
Triphasic COC (Enpresse, Levonest, Trivora-28)
EE: 30 / 40 / 30 mcg + LNG: 0.05, 0.075, 0.125
Triphasic COC (Tri-Sprintec, Tri-VyLibra, Tri-Nymyo, Tri-Mili, Tri-Linyah, Tri Femynor)
EE: 35 mcg + NE: 0.18, 0.215, 0.25
Triphasic COC (Necon 7/7/7, Nortrel 7/7/7)
EE: 35 mcg + NE: 0.5, 0.75, 1.0
Triphasic COC (Leena, Aranelle, Alyacen 7/7/7, Tri-Legest FE, Dasetta 7/7/7)
EE: 35 mcg + NE: 0.5, 1.0, 1.5
Endometriosis
Endometriosis is the presence of the tissue lining the uterus in other organs Medical treatment options include NSAIDs, COC, GnRH analogs, and GnRH antagonist GnRH analogs: Nafarelin (Synarel) (Intranasal) * Leuprolide (Lupron) (IM) * Goserelin (Zoladex) (SQ) * Triptorelin (IM) GnRH antagonist: Elagolix (Orilissa) (150 mg QD) - Indicated for endometriosis & endometriosis with dyspareunia Danazol (Oral) increases free testosterone levels * Danazol is a CYP3A4 inhibitor & may ↑ statins: SAL * Use of simvastatin with danazol is contraindicated. Max: 20 mg/d of lovastatin if combined with danazol
Adverse effects of COCs
Estrogenic: Nausea, bloating, edema, fluid retention, irritability, headache, weight gain, increased breast size, THROMBO-EMBOLIC EVENTS (PE, DVT, CVA), chloasma, melasma (skin pigment changes exacerbated by exposure to sunlight; tell patients to use sun protection to help with chloasma) Risk for clots (Estrogen) * Estrogen causes thickening of blood --> 3-6 x ↑ DVT risk. ↑ MI risk, especially if smoking & > 35 y/o * Low dose (< 50 mcg) poses less risk than older/higher dose formulations Progestational: * Breast tenderness, headache, hypertension, acne, oily skin, hirsutism, decreased libido * Progestins have a chemical structure similar to testosterone and thus have some androgenic activity Androgenic: * Acne, oily skin, INCREASED APPETITE, WEIGHT GAIN, DEPRESSION, fatigue, lethargy
Components of COCs (Estrogen)
Estrogens: * Ethinyl Estradiol (EE): 10-50 mcg of estrogen * Estradiol Valerate Estrogen pharmacology * Inhibits ovulation by suppressing the hypothalamic release of FSH & LH * Inhibits fertilized ovum implantation * Accelerates ovum transport, ↓ fertilization time * Cycle Control
