Gyn and Obs

Pharmacology
notes
1/30/2021
Prepared by: Sharifullah Momand

Contents
CONTRACEPTIVE ........................................................................................................................................... 1
Barrier Contraceptive:................................................................................................................................... 1
Estrogen-progestin contraceptive ................................................................................................................ 1
Progestin-only contraceptive ........................................................................................................................ 2
Etonogestrel implant .................................................................................................................................... 2
Intrauterine Device (IUD): ............................................................................................................................. 2
Emergency contraception (EC): .................................................................................................................... 3
Hormonal contraceptives overiew................................................................................................................ 4
Overview of nonhormonal contraceptive method ....................................................................................... 5
 CONTRACEPTIVE
Barrier Contraceptive:
Male condom
1. creates a barrier that prevents contact with genital lesions, penile, vaginal, and anal discharge
a. if used correctly and consistently, condoms may reduce the risk of pregnancy and
acquiring or transmitting sexually transmitted infections (STIs)
2. effectiveness
a. with typical use, there is an 18% pregnancy rate
3. advantages
a. reversible, accessible, protection against STI , cost
4. disadvantages
a. reduced sensitivity during intercourse, latex sensitivity
Female condom
1. another barrier mode of contraception that may reduce the risk of pregnancy and STIs
2. effectiveness
a. with typical use, there is a 21% pregnancy rate

Estrogen-progestin contraceptive
1. can also be a ring and patch
2. mechanism of action:
a. inhibition of the midcycle luteinizing hormone (LH) surge impairs ovulation
3. effectiveness
a. with typical use, there is a 9% pregnancy rate
4. side effects include
a. hypercoagulability (DVT and PE)
b. elevated triglycerides
c. hypertension
d. cholelithiasis and cholecystitis :caused by increased gallbladder stasis
e. depression
f. nausea
g. drug interactions: metabolized via CYP450
h. hepatic adenoma
5. contraindications
a. ≥ 35 years of age and smoking ≥15 cigarettes/day
b. venous thromboembolism
c. ischemic heart disease
d. stroke history
e. breast cancer
f. cirrhosis, migraine with aura
6. non-contraceptive benefits
a. reduce the risk of ovarian and endometrial cancer

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 b. can treat acne and hirsutism
c. first-line for endometriosis-related pain

Progestin-only contraceptive
1. can also be injected and implanted subcutaneously
2. mechanism of action
a. endometrial decidualization and eventual atrophy leads to
i. endometrium being less suitable for implantation
b. thickening of cervical mucous leading to
i. decreased permeability for sperm
c. impairs tubal peristalsis and motility
3. effectiveness
a. with typical use, there is a 9% pregnancy rate
4. benefits
a. can serve as an alternative contraceptive in women with contraindications to estrogen
or if estrogen causes additional health risks
b. can be used immediately post-partum
c. protective against the development of endometrial cancer
5. side effects
a. menstrual irregularity, amenorrhea, weight gain, headache, nausea, abdominal pain,
vomiting, reduction in bone density, bloating, dizziness

Etonogestrel implant
1. A small progestin rod that is a reversible mode of contraception
a. placed subdermally in the upper arm to provide long-acting (three years) contraception
2. Efficacy
a. with typical use, there is a <1% pregnancy rate

Intrauterine Device (IUD):

3. Types of IUDs
a. copper IUD
i. mechanism of action
1. sterile inflammatory reaction due to foreign body exposure
a. this is toxic to the sperm and ova
2. copper also results in an enhanced cytotoxic inflammatory response in
endometrial tissue and impairs
a. migration of sperm and its viability
b. acrosomal reaction
ii. efficacy
1. with typical use, there is a 0.5-0.8%
iii. provides contraception for up to 10-years

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 iv. also has post-fertilization contraceptive effects
b. levonorgestrel IUD
i. mechanism of action
1. sterile inflammatory reaction due to foreign body exposure
a. this is toxic to the sperm and ova
2. levonorgestrel also results in cervical mucus thickening, endometrial
decidualization, and glandular atrophy
a. results in impairment of implantation
ii. efficacy
1. with typical use, there is a 0.1-0.2% pregnancy rate
iii. provides contraception for up to 5-years
4. Contraindications
a. uterine cavity distortions
i. e.g., bicornuate uterus and cervical stenosis
b. pelvic infection of acute onset
i. e.g., pelvic inflammatory disease, mucopurulent cervicitis, and endometritis
c. pregnancy
d. Wilson's disease
i. also in patients with a copper allergy
ii. hormone releasing IUD would be preferred in these cases
e. unexplained uterine bleeding
f. current breast cancer
i. it is contraindicated to use the levonorgestrel IUD

Emergency contraception (EC):

5. EC involves the use of drugs or a device to prevent pregnancy
a. EC is also known as "postcoital contraception" and "morning-after pill"
6. Indications
a. recent unprotected intercourse
b. recent possible failure of a different mode of contraception (e.g., condom breakage)
7. Options
a. copper IUD
i. the most effective method of emergency contraception
ii. must be inserted within 5-7 days of unprotected intercourse
iii. requires office visit for placement
b. ulipristal
i. a progestin receptor modulator and delays ovulation
ii. must be taken within 120 hours after intercourse
1. remains highly effective
iii. the most effective oral EC
iv. requires a prescription
v. for adolescents requesting emergency contraception with ulipristal, parental
consent is not necessary
c. levonorgestrel
i. recommended to be taken within 72 hours after intercourse

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 1. still is effective up to 120 hours after intercourse
a. efficacy is reduced
ii. available over-the-counter
iii. preferred over the estrogen-progestin regimen
iv. for adolescents requesting emergency contraception with levonorgestrel,
parental consent is not necessary
8. Efficacy trend
a. copper IUD > ulipristal > levonorgestrel

Hormonal contraceptives overiew

Overview of hormonal contraceptive method
Type Description Indications
Combined Short-acting, reversible Contraception
oral oral contraceptive Hyperandrogenism
contraceptive containing estrogen and progestin (e.g., acne,hirsutism)
(COC) Monophasic or multiphasic Menstrual cycledisorders
(e.g., menorrhagia,
Oral dysmenorrhea) Symptom
contraceptive control in endometriosis,
pill leiomyomas
Progestinonly Short-acting, reversible Contraception for
contraceptive oral contraceptive women in whom
pills (minipill) containing low doses of estrogencontaining
norethindrone contraceptives are
contraindicated
Short-acting, reversible Patches are considered as
Contraceptive transdermal patch effective as COC
that provides sustained low doses pills Only require
Contraceptive patch
of estrogen and progestin application to the skin
once a week Similar
indications as for COC
Short-acting, reversible �exible Similar indications
Vaginal ring vaginal ring that contains ethinyl as for COC
estradiol and etonogestrel
Intramuscular or Subcutaneous Long-term and
Injectable progestin injection administered every reversible
3 months.
Need to be replaced every 3 to
Intrauterine device with
5 years (varies with type of
progestin
device).
The device (�exible plastic rod) is
Subdermal progestin implant usually inserted subdermally in
the upper arm and lasts 3 years.

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Overview of nonhormonal contraceptive method
Overview of nonhormonal contraceptive method
Method Pros Cons
Behavioral methods
Lactational Reversible Requires strict schedule of breastfeeding without
amenorrhea Inexpensive formula supplementation No protection from
sexually transmitted infections
Coitus Reversible Inexpensive High risk for human error No protection from
interruptus Readily available sexually transmitted infections Semen may enter
No side effects vagina before ejaculation
Fertility Reversible Inexpensive High risk for human error Requires regular periods
awarenessbased Readily available No protection from sexually transmitted
methods No side effects infections
Vaginal None No evidence of effectiveness; likely highly
douche unreliable No protection from
sexually transmitted infections
Intrauterine device
Nonhormonal Reversible Requires insertion by a health
copper device Can be used as Professional Risk of
emergency pelvic in�ammatory disease (
contraception PID) No protection from sexually
transmitted infections
Barrier methods
Diaphragm Reversible Initially requires professional
May result in
urinary retention if not correctly
Risk of toxic shock syndrome
(if left inside for > 24 hours) No
protection from sexually transmitted
infections
Condom Reversible Affordable High risk for poor compliance
Easily accessible Prevents Risk of incorrect use and
sexually transmitted infections complications thereof
(including HIV) Female condom: placement
Surgical sterilization
Vasectomy Permanent Outpatient surgical procedure May
contraception be irreversible Possible surgical
Complications No protection from
sexually transmitted infections

By: Sharifullah Momand