P&t Contraceptives

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Estrogen only contraception MOA

Back 1

Works by suppressing FSH which leads to no recruitment in follicles --> no ovulation

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Progestin only contraceptions MOA

Back 2

works by preventing ovulation by suppressing LH secretion thus preventing LH surge THUS preventing ovulation and thickening of endometrium.

Has estrogenic,anti-estrogenic effects

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Estrogenic side effects (when given @ high doses)

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Nausea, HA,wt gain in girl areas,growth of fibroids, increase HDL, LDL, PE(rare), thrombosis(rare)

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Progestigenic se

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wt gain, fatigue,INSULIN RESISTANCE

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COMBINED ORAL CONTRACEPTIVES

(COC)

comes in (main ingredients/dosage form)

examples of each 2 ingredients

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combination synthetic estrogen aand synthetic progestin.

-pill -patch -ring

Estrogens used:

Ethinyl estradiol (most used), Mestranol, Estradiol valerate

Progestins used (four generations):

1st

Ethynodiol diacetate

Norethindrone

Norethindrone acetate

Norgestrel (MORE Androgenic effects)

2nd

Levonogestrel (isomer of NOGESTREL) and also exhibits adrogenic activity

3rd

Norgestimate - less side effects but androgenic

Desogestrel -less side effects but androgenic causing

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We do have progestin only products which inhibit ovulation via suppressing LH surge, which again, leads to N O ovulation--> no ovulation means progesterone because don't have estrogen.

This 1st generation progestin only contraception is called :

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NORETHINDRONE

(has benefits like no cancer. acne/ pregancy,cysts, breast disease)

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Disadvantage to CHC

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CHC causes:

-risk of MI (esp over 35)

-stroke/thrombo embolisism

-hepatocellular carcinoma

-increase BP

-decrease milk in lactating women

-COC requires DAILY pill admin

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Cancer and COC

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ovarian /Endometrial = DEcreased risk

Cervical/Liver=Increased risk

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ABSOLUTE contraindications (4) of CHC:

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-thrombolic events

-stroke/Cerebro vascular disease

-Coronary artery disease

-carcinoma breast

-CANCER with estrogen

-pregnancy

-UNCONTROLLED HTN ABOVE 160

-Heavy smoker (more than 15)

-migraine with aura

-Hepatic tumors

-acute liver disease

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Relative contraindications (3)

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-Smoking less than 15

-migraines W/O aura

-controllled HTN

-fibroids in uterus

-breast feeding

-Diabetes with vascular complications

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Severe symptoms to counsel pts on birth control : Acronym

A.C.H.E.S

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A= abdominal pain-- gall bladder/liver issue

C= chest pain -- clot/MI

H= headache -- stroke/uncontrolled HTN (160 above)

E= eye problems -- flashing lights/loss of vision/blood clot in retinal artery

S= severe leg problems -- DVT

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Monitoring in clinic:

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ANNUAL BP

&

CHECK FOR ADR (monthly)

ie: some BC has drosperinone in it which is like a diuretic spironlactone, so we monitor for elevated potassium levels. MAKE SURE THEY DONT HAVE KIDNEY DISEASE or ADRENAL DISEASE!!!

DO NOT USE WITH DRUGS THAT INCREASE POTASSIUM, like potassium sparing drugs--> ACE/ARBs.

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if pt is on a COC the amount of ethinyl estradiol should be ____

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The amount should be no more than 35 mcg

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If the patient has acne start them on a COC that

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is less adrogenic beased on personal prefrance. Adjust it

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Monophasic contraceptives are :

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fixed continuous does of estrogen and progestin

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Multiphasic pills :

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made of different doses of estrogen and progetsterone. made naturally to mimic womans menstural cycle. Reduces the risk of progetsterone associted side effects.

BUT no evidence shows freq is the root of the cause, Progestin seems to be more important than phasic formulation

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Hormone free interval pills are?

What kind of Contracetions are they found in?

Whats the break down?

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white pills that are sugar pills. Woman takes them so she can have withdrawl bleed and then start on it again witha new pack

popular :found in 28 day cycle packs . 21 active -->7 placebo

other: 24 active 4 placebo

26 active: 2 placebo

This means period will be shorter

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Continuous OCs(2) -->

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28 days of active tablets taken continuously NO hormone free interval . NO PERIOD

We also have low dose estrogen so you in place of the hormone free interval so you dont get your period but you also dont have so much estrogen being pumped into you

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unique contraceptives:

Seasonal/seasonique,quartette

who is it good for?

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Extended cycle. Less frequent horone free intervals.

Appeals to woman with a lot of PMS side effects and heavy bleeding with anemia

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Yasmin, Safyral, Yaz, Beyaz

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Use full for woman who experience problems associated with producing TOO much androgens (male characteristicsd

WARNING : Drospirenone might increase potassium in pt. Avoid if pt has kidney liver or adrenal disease. Avoid with NSAIDS, other diuretics, potassium sparing drugs (ACE/ARBS)

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Lybrel/Amethyst

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This drug has no hormone free interval. BOth estrogen and progestin are taken 365 days !!

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These drugs are marketed to reduce breakthrough bleeding due to low estrogen. It has 10mcg of estrogen instead of placebo for 7 days:

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Seasonique, lo-seasonique, Quartette O

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All combined oral contraceptives LOWER testosterone but these drugs have an FDA treatment for ACNE

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ortho-tri-cyclin, YAZ, estrostep

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These COC are chewable !

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Femcon Fe & Minastron 24 Fe

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These COCs have a shorten hormone free interval which translates to shortened "period". 24 active and 4 placebo

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Loestrin 24 Fe 1/20, Yaz, Beyaz

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These drugs also have shortened menses, Instead the make up is 24 active, 2 low dose estrogen and 2 placebo(for women who need to pop a pill to stay in groove.)

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Lo loestrin FE & Lo minastrin Fe

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Drug or treating Pre -Menstraul dysphoric disorder (PMDD):

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YAZ

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These COCs has .451 mg levomefolate in it .... MARKETING PLOY

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Beyaz, Safyral

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This drug has Quatrefolic folate tablets in it (1 mg)

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Falessa Kit

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This drug is the first 4- phasic Oral Contraceptive, may induce less estrogen related adverse effects. Not studied in obese women

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NATAZIA

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Counseling pts on birth control

Patient comes in and complains of symptoms, they are only on their first cycle.

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Tell them SE are normal in first. Wait 2 or 3 cycles in to det if its good or bad.

COC should be evaluated first 3-6months

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WHen dispensing Birth control ALWAYS

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dispense package insert

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2 patients comes in, Kim and Khloe Kardashian. They want to know when they should start their new med and if they can take a 7 day break before they start it, (Both are going away for a ski weekend)

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Tell kim who is on 28 day Birth control, "NO you cant take 7 days off!!! EVER with these. If you do you would have to restart.

-For the 28 day birth control you mist START IMMEDIATLY after finishing other 28 day supply"

Tell Khloe, For the 21 day birth control you CAN take 7 days off (1 week) after finishing the 21 day birth control.

Discuss ACHES and side effects with them since the pharmacist didnt

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Kylie wants to know when to start her NEW BC since she is so young she dont know

there are 3 options

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1. Sunday start

Start on the first sunday after the beginning of your period

2. Day 1 start: Take 1st tablet in the coc pack on the FIRST day of meses

3. Quick start

IMMEDIATE any day start (good for poor compliance)

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ever pregnant kourtney came in asking when she can start hers

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YOu can start at least 21 days after you have your umpteenth baby. Risk for DVT is low if you do this

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Kris comes in talking about something she heard on Dr. OZ ....non-hormonal back up contraceptives. She wants to know if her daughters should use it to

Back 36

The use of additional non-hormonal back up is only needed in certain cases.

1. If you begin your birth control as a sunday starter or quick starter = (especially if you begin 5 days after period) you should use condom or whatever.

2. If you miss more than one pill per cycle of your birth control

3. If you have diarrhea or vomiting

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Her friend is on Natzia she wanted to know if she could micro manage her reproductive life too-

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Well tell your friend, when on natazia you MUST USE back up for at least 9 days .

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ALways tell pts

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TAke the birth control at the same time everyday!!

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Kendal comes in and says she missed 1 PILL because of a show she did- she is panicking

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Its ok , if you miss ONLY 1 pill or even start your new cycle of meds one DAY later than last time ITS O K!!! Just take it ASAP. NO need for backup

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If 2 pills are missed within the first 2 weeks of a new cycle (you have MORE THA 7 LEFT) you :

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Tell them 2,2,1

Take two pills the day you remebered, two pills the next and one pill until you finish

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If 2 pills or 3 are missed again, EXCEpt now its during the 3 rd week (less than 7 pills left) of cycle you have two options:

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1. Throw out pack and start again on that same day OR

2. Take one pill a day until the next sunday (birth control holy grail day) and then throw away and start a new pack

IN both cases, use backup contraceptives for the next 7 days