Review Questions #6: Oral Contraceptives

What effect does estrogen have on lipid levels? A. Decreases HDLs, and increases both LDLs and Triglycerides. B. Increases HDLs, and decreases both LDLs and Triglycerides. C. Decreases both HDLs and Triglycerides, and increases LDLs. D. Increases both HDLs and Triglycerides, and decreases LDLs.

Alright, you're off to a good start! Estrogen increases HDLs, and decreases both LDLs and Triglycerides. This effect is believed to be the reason women have lower rates of cardiovascular disease pre-menopause and higher rates post-menopause.

Hypermenorrhea A. Is characteristic of an excess estrogen. B. Is attributable to an excess progestin. C. Is diagnostic of an estrogen deficiency. D. May result from either estrogen or progestin deficiency.

Superb! Hypermenorrhea or excessive menses is characteristic of both estrogen and progestin deficiencies. The diagnosis cannot be made simply on the presence of this one sign, additional laboratory testing would be needed to determine the specific cause.

Norplant (levonorgestrel) is known to decrease sex hormone binding globulin (SHBG). What side effect is likely to result from this activity? A. Hirsutism. B. Galactorrhea. C. Improvement in acne. D. Hypotrichosis.

A decrease in SHBG will result in higher levels of free testosterone which can cause: acne, hirsutism, weight gain, nervousness, decrease HDLs, and increase LDLs. Galactorrhea (or excessive milk flow) can occur with Norplant. If it occurs, other causes such as pregnancy, pitutitary adenoma, and breast malignancy should be ruled out before assuming it¿s a medication side effect. Hypotrichosis is an abnormal deficiency of hair. Hypertrichosis is an abnormal excess of hair. An abnormal excess of hair in women especially in unusual places is hirsutism. Hence we usually talk of androgenic effects on women in terms of hirsutism instead of hypertrichosis.

Which of the following contraceptive methods is BEST for an individual with a history of seizure disorder and who is on Dilantin (phenytoin)? A. Depo-Provera (medroxyprogesterone acetate). B. Ortho Tri-Cyclin 21 (norgestimate + ethinyl estradiol). C. Norplant (levonorgestrel). D. Estrostep (norethindrone acetate + ethinyl estradiol).

Wow!! Depo-Provera is the only contraceptive that has no drug interactions and few medical contraindications. The other options are discussed further in other answers.

Because Norplant (levonorgestrel) is an invasive procedure and carries with it the risk of infection, A. This procedure should be performed in a sterile operating room. B. Patients should be given prophylactic antibiotics before and after surgical placement. C. Patients with a history of estrogen positive breast cancer should not use this type of contraception. D. Caution should be used for individuals with mitral valve prolapse as they would be at increased risk for bacterial endocarditis.

Because Norplant (levonorgestrel) is an invasive procedure and carries with it the risk of infection, caution should be used for individuals with mitral valve prolapse as they would be at increased risk for bacterial endocarditis. The procedure can be performed in a medical office. For most individuals (except those at risk for SBE¿subacute bacterial endocarditis), it can be inserted without prophylactic antibiotics. This contraceptive is a progestin only formulation that would work well for women in whom estrogen is contraindicated.

All of the following are natural estrogens (occur within the body) EXCEPT: A. Estriol. B. Estrone. C. Estrace. D. Beta-estradiol.

Estriol is a placental estrogen and metabolite of estradiol and estrone. Beta estradiol is the primary and most potent natural estrogen sybthesized from cholesterol in the ovary. Estrone is another major ovarian estrogen but is much less potent than beta estradiol. Estrace is a synthetic estrogen used for Hormone Replacement Therapy.

Once the follicle has released the oocyte, it develops into the corpus luteum, which produces A. Estrogen. B. Progestin. C. Both estrogen and progestin. D. Neither estrogen nor progestin.

Excellent! Prior to ovulation the developing follicle secretes only estrogen. Ovulation occurs with the mid-cycle Luteinizing Hormone (LH) surge. After ovulation, the empty follicle under stimulation of LH develops into the corpus luteum, which secretes both estrogen and progestin acting as a negative feedback to inhibit secretion of FSH and LH.

The PRIMARY mechanism by which estrogen prevents pregnancy is by A. Inhibiting secretion of follicle stimulating hormone and suppressing ovulation. B. Decreasing peristalsis in the fallopian tube altering transport of ova and sperm. C. Inhibiting release of luteinizing hormone from the anterior pituitary. D. Thickening cervical mucus and thinning the endometrium.

Good for you! The PRIMARY mechanism by which estrogen prevents pregnancy is by inhibiting secretion of follicle stimulating hormone and suppressing ovulation.

Which of the following peaks mid-cycle and is responsible for inducing ovulation? A. Gonadotropin releasing hormone (GnRH). B. Follicle stimulating hormone (FSH). C. Luteinizing Hormone (LH). D. Sex Hormone Binding Globulin (SHBG).

LH! Ovulation occurs with the mid-cycle Luteinizing Hormone (LH) surge.

Which of the following can be used in the treatment of acne? A. Estrostep. B. Norplant. C. Depo-Provera. D. Ortho Tri-Cyclen.

Ortho Tri-Cyclin is the only oral contraceptive approved for use in treating acne. Estrostep is a variable dose combined oral contraceptive designed to reduce the total monthly estrogen dose. Norplant is progestin only SQ implant that slowly releases its dose and is a good choice for long-term contraception. Depo-Provera is a progestin only intramuscular injection given every 12 weeks. This contraceptive formulation is good for individuals on seizure medications, the mentally ill or individuals who cannot take their own medications, and those with sickle cell anemia. Both Norplant and Depo-Povera are good choices for lactating women or women who cannot take estrogen. Norplant carries an increased risk of infection (not good for women with MVP) and may be difficult to remove. In addition, while it may be cost-effective when spread out over 5 years, if it must be removed because of side effects (irregular menstrual bleeding often being one of them), this can be a very costly method. Depo-Provera lacks reversibility. Once the injection is given, it takes 6-9 months for all of the medication to leave the system and the mean length of time from last injection to conception is 10 months.

Ortho-Novum 10/11 is a biphasic oral contraceptive formulation, biphasic means that it is A. A combination of two drugs estrogen and progestin. B. Taken for 21 days and then a placebo is given for 7 days. C. Composed of two different estrogen dosages within a 28 day cycle. D. Consists of two different progestin dosages over a 21 day period.

Ortho-Novum 10/11 is a combined oral contraceptive. COCPs consist of two componenets, estrogen and progestin. These two medications are taken in combined form for 21 days. Then a placebo pill (no inherent biologic activity) is taken for the last 7 days, which results in menstruation. Biphasic means that the progestin component has two different dosages during the 21 day regimen. The first 10 pills (10 days) have 35 micrograms of ethinyl estradiol and 0.5 mg of norethindrone. The next 11 pills (11 days) have 35 micrograms of ethinyl estradiol and 1.0 mg of norethindrone. An oral contraceptives with varying estrogen doses is called estrophasic and Estrostep is a specific brand name.

The dosing regimen for progestin only pills (POPs) involves A. Variable doses of progestin for 21 days then 7 days of placebo pills. B. Constant dose of progestin for 21 days then 7 days of placebo pills. C. Variable doses of progestin for 28 days. D. Constant dose of progestin for 28 days.

POPS work for 28 The dosing regimen for progestin only pills (POPs) involves a constant dose of progestin for 28 days. For example Ovrette, a pack comes with 28 tablets each tablet containing 0.075 mg of Norgestrel. It is extrememly important that patients take these at the exact time each day as variability in schedule may result in higher failure rates. The first dose is taken on day 1 (first day of menses).

One of your patients calls you on the phone and says she missed taking her Norgestrel (Ovrette) yesterday and wants to know what she should do. What is MOST important for you to tell her? A. Take yesterday's and today's doses together and she most likely will be fine. B. Throw out yesterday's pill and just take today's pill. C. Take two pills today and use a backup contraceptive method. D. Throw out the current pack of pills and she will need to start a new pack.

Prodigious!! As general guidelines go: If a patient misses 1 pill ¿ they should take it as soon as they remember. If they don¿t remember until its time for the next pill they should take both pills together. THEY SHOULD USE A BACK UP METHOD TO PREVENT UNPLANNED PREGNANCY. If a patient misses 2 pills ¿ they should take the first missed pill ASAP or if they don¿t remember until its time for the next pill, they should take two pills together. They should take the second missed pill with their regular dose on the next day. THEY SHOULD USE A BACK UP METHOD TO PREVENT UNPLANNED PREGNANCY. If a patient misses three pills ¿ for those on combined oral contraceptives who are first day starters, they should throw out the pack and start a new pack that same day. For those on combined oral contraceptives who are Sunday starters, take one pill every day until Sunday, then throw out the old pack and start with a new pack on that Sunday. Obviously, those who are on progestin only take the same dose every day for 28 days so there is no sense in throwing out the old pack and restarting. ALL SHOULD USE A BACK UP METHOD TO PREVENT UNPLANNED PREGNANCY.

What effect does progestin have on lipid levels? A. Decreases HDLs and increases LDLs. B. Increases HDLs and decreases LDLs. C. Decreases both HDLs and LDLs. D. Increases both HDLs and LDL

Progestin increases both HDLs and LDLs

Your patient is asking for information about preventing pregnancy. What should you consider FIRST before prescribing an oral contraceptive A. Which formulation would be best for her? B. Is she able to adhere to treatment? C. What dosage would be most appropriate for her? D. Are there reasons that she should not be on them?

Safety first! The FIRST consideration should be: Are there reasons that she should not be on them? If there are no contraindications, then you should look at which formulation and dosage would be best always taking into consideration other variables might impact the patient¿s ability to adhere to a particular treatment. See the algorithm in your Edmunds text on page 677.

Which of the following oral contraceptives is pregnancy category X and likely to cause birth defects? A. Depo-Provera (medroxyprogesterone acetate). B. Ortho Tri-Cyclin 21 (norgestimate + ethinyl estradiol). C. Norplant (levonorgestrel). D. Estrostep (norethindrone acetate + ethinyl estradiol).

Terrific! Depo-Provera is pregnancy category X and carries an increased risk of polysyndactyly, chromosome abnormalitites, and hypospadias. None of the others listed carry any increased risk for congenital anomalies.

A patient you have not seen before presents with an ear infection for which you prescribed amoxicillin. You note in her chart that she has no known allergies and that she routinely takes a multivitamin, a calcium supplement, hydrochlorothiazide 50 mg, and Triphasil. What would be MOST important for you to teach your patient given her medication history? A. She should stop taking the multivitamin while she is on the antibiotic as taking both might upset her stomach. B. If the amoxicillin gives her diarrhea, she should take her TUMS with the antibiotic. C. She should not be on the Triphasil if she has a history of hypertension. Take her blood pressure and tell her to use another method of birth control. D. The antibiotic may reduce the effectiveness of her oral contraceptive. She should use a backup method of birth control while she is on the antibiotic until her next cycle.

Terrific!! The correct answer is D. Anti-infectives which disrupt the normal GI flora, including amoxicillin, ampicillin, chloramphenicol, neomycin, nitrofurantoin, penicillin V, sulfonamides, and tetracyclines, may potentially decrease the effectiveness of estrogen-containing oral contraceptives. Normally, GI bacteria hydrolyze estrogen conjugates that are eliminated via the bile. This hydrolyzation allows enterohepatic recirculation of the active estrogenic component to occur. A decrease in enterohepatic recirculation could compromise the effectiveness of estrogen-containing oral contraceptives. In addition, significant antibiotic-induced diarrhea may impair the oral bioavailability of oral contraceptives in some patients. The incidence of the interaction of anti-infective agents with OCs is unpredictable; cases of antibiotic-associated contraceptive failure have been reported, but are not well-documented. Patients should be made aware of this potential interaction. The use of an alternative method of contraception may be recommended during use of these antibiotics, especially ampicillin or amoxicillin. Depending on the length of antibiotic therapy, an additional contraceptive method may be needed for at least one OC cycle after the antibiotic is finished. The multivitamin is a great idea. If the multivitamin causes stomach upset, it should be taken with a meal. Amoxicillin can be given without regard for meals as well.

The MOST common side effect of the high dose of estrogen taken for emergency contraception is: A. Mastaglia. B. Breast enlargement. C. Nausea and vomiting. D. Vasomotor symptoms.

The MOST common side effect of the high dose of estrogen taken for emergency contraception is nausea and vomiting. Patients should be prescribed an antiemetic for relief at the time of ECP prescription. Mastaglia is breast pain. Breast tenderness is a symptom and breast enlargement is a sign of excess estrogen, but are not the MOST common side effect of this therapy. Vasomotor symptoms (hot flashes) are associated with estrogen deficiency which is not an issue in this case.

The PRIMARY mechanism by which progestin only pills (POPs) prevent pregnancy is by A. Preventing ovulation by decreasing the mid-cycle follicle stimulating hormone surge. B. Stimulating secretion of gonadotropin releasing hormone in the hypothalamus. C. Increasing secretion of luteinizing hormone by the anterior pituitary. D. Production of thick, sticky cervical mucus reducing sperm motility.

The PRIMARY mechanism by which progestin only pills (POPs) prevent pregnancy is by production of thick, sticky cervical mucus reducing sperm motility.

The most common complaint and primary reason for discontinuing contraceptive therapy for individuals who use progestin only formulations is A. Irregular menses. B. Weight change. C. Hypertension. D. Nausea.

The most common complaint and primary reason for discontinuing contraceptive therapy for individuals who use progestin only formulations is irregular menses. Weight change, hypertension, and nausea are more associated with the estrogen component in combined oral contraceptives.

Your patient has Systemic Lupus Erythematous (SLE), which oral contraceptive would be best for her? A. A monophasic combined oral contraceptive. B. An estrophasic oral contraceptive. C. All oral contraceptives would be contraindicated. D. A progestin only formulation.

This in the notes (and text I believe). I should have brought this one out more in class. Estrogen exacerbates SLE, thus a progestin only formulation is best for women who have this disease.

Your patient was on a progestin only pill which she had difficulty remembering to take at a regular time each day. Her urine pregnancy test just came back positive. She is worried about what effect taking her pills these last three weeks might have had on the baby. What should you tell her? A. She should have been more careful about taking her pills and there¿s no telling what will happen now. B. The oral contraceptive that she was on places her at increased risk of congenital anomalies and that a serum HCG should be performed as well as several other laboratory tests. C. Stop taking the oral contraceptive and she has nothing to worry about, she should just think about taking care of herself and the new baby now. D. The oral contraceptive that she was on places her at increased risk of an ectopic pregnancy but most likely caused no harm to her baby. You may want to order a serum HCG and that she should report any severe abdominal pain immediately.

Top Notch! I HOPE no one chose answer ¿A¿¿good grief¿get real!!! What did you learn in nursing school? J Individuals who have taken oral contraceptives while pregnant have no greater risk for congenital malformations than the general public. She would be at greater risk for a tubal or ectopic pregnancy as the ovum is more likely to implant somewhere else if the endometrium is not conducive to implantation. Thus it would be important for her to know what signs and symptoms to report. An ectopic pregnancy will show a lower serum HCG value than a normal pregnancy and can be a useful diagnostic test for this purpose. Answer ¿C¿ does not acknowledge her concerns and fears, and negates these feelings. Answer ¿B¿ is simply not true.

Your patient calls and says that since she has started taking her Ovral (ethinyl estradiol 50 mcg + norgestrel 0.5 mg) she has been experiencing severe headaches and some blurry vision. How should you respond? A. Have her check her blood pressure. If her BP is normal, tell her to take two aspirin and call you in the morning. B. Ask her when was the last time she had an eye exam and encourage her to make an appointment with her optometrist. C. Have her keep a pain log and record their frequency, duration, and severity as well as any other symptoms that she experiences. D. Change her medication to Lo/Ovral (ethinyl estradiol 30 mcg + norgestrel 0.3 mg) as the headaches are most likely due to the high estrogen. E. Tell her to stop taking her oral contraceptive, use a backup method for preventing pregnancy, and have her come in for further evaluation.

Very good! While hypertension is not an absolute contraindication to oral contraceptives. They should be used with caution in this population. Combined oral contraceptives may increase blood pressure. As long as her blood pressure is normal, no change is required, but careful monitoring is. The headaches and blurred vision could be a signal of something serious especially since they are associated with the start of treatment. Combined oral contraceptives carry the risk of stroke as well as idiopathic intracranial hypertension. She should immediately stop her oral contraceptive, use a back up method, and come in for further evaluation immediately. While answers ¿B¿ and ¿C¿ are bad things to do, they don¿t address the urgent situation. Answer ¿D¿ is a possibility as headache is a side effect of estrogen excess, but a closer evaluation should be made before changing the prescription. Answer ¿A¿ is just WRONG, WRONG, WRONG!!!

When comparing patients who take combined oral contraceptive pills (COCP) to patients who take progestin only pills (POP), those who take the POP A. Are more likely to experience a thromboembolic event. B. Experience lower rates of failure. C. Are less likely to have ovarian cysts. D. Have a higher risk of ectopic pregnancy.

Very impressive! Since progestin does not have the same effect on clotting factors as estrogen, there is a lower risk of thromboembolism. However progestin only pills do not suppress ovulation, there is a higher risk of ovarian cysts than with combined oral contraceptives that contain estrogen. They also have higher failure rates because of the limited effect of the contraceptive method (prevents ovulation in only 50% of patients) and the need for tight control of the dosing schedule. They also have higher rates of ectopic pregnancy. Since more than 50% of women continue to ovulate; and the fallopian tubes have altered transport and the endometrium is not conducive to implantation, the ovum is more likely to implant elsewhere. Formulations with estrogen carry a higher risk of thromboembolism because of estrogen¿s effect on clotting factor synthesis (increased). Individuals on combined oral contraceptives are less likely to experience ovarian cysts and ectopic pregnancy due to ovarian suppression. Because the contraceptive method both suppresses ovulation and inhibits implantation and does not require as strict a dosing schedule, it has a lower failure rate than progestin only.

The estrogen used in oral contraceptive formulations is A. Conjugated estrogens. B. Ethinyl estradiol. C. Estropipate. D. Mestranol.

Way to go! Almost all oral contraceptives use ethinyl estradiol which has a relatively long hal-life and high oral potency. A few use mestranol which is pharmacologically weaker and requires conversion to ethinyl estradiol. Conjugated estrogens and estropipate are used for hormone replacement therapy.