B8.012 Contraception

Question 1

what imparts a greater risk than any method of contraception?

Answer 1

pregnancy

Question 2

method of emergency contraception with ethinyl estadiol

Answer 2

100 mcg within 72 hours of intercourse
inhibits ovulation, disrupts follicle development, interferes with maturation of corpus luteum
does NOT prevent implantation of fertilized egg (not abortive)
best results within 12 hrs

Question 3

other emergency methods of contraceptions

Answer 3

0.75 mg levonorgestrel (plan b, next step, one step)
ulipristal
copper IUD

Question 4

0.75 mg levonorgestrel

Answer 4

2 pills 12 hr apart or a single dose
up to 72 hours after intercourse
OTC for age >17

Question 5

ulipristal

Answer 5

slightly more effective, can use up to 120 hours
prescription needed
binds to progesterone receptors and delays ovulation

Question 6

copper IUD insertion for emergency contraception

Answer 6

within 7 days of intercourse
prevents fertilization, but also blocks implantation of fertilized egg
10 years of BC

Question 7

general principle about emergency methods of contraception

Answer 7

better if available

**write script in advance if someone wants it

Question 8

components of precontraceptive evaulation

Answer 8

history
pregnancy test (if indicated)
BP, weight, BMI
chlamydia screen
pap/pelvic if >21

Question 9

is a pap/pelvic required for BC?

Answer 9

no
not for anyone <21
if you want an IUD there will be a pelvic exam and cervical inspection prior to insertion

Question 10

when is a pregnancy test NOT indicated

Answer 10

<7 days after start of normal menses
no intercourse since last menses
correctly using reliable method
<7 days after spontaneous or induced abortion
<4 weeks post partum
breastfeeding and amenorrheic and <6 months post partum

Question 11

sterilization methods

Answer 11

tubal ligation and vasectomy

failure rates <1%

Question 12

advantages of sterilization

Answer 12

permanent
cost effective over time
safe

Question 13

disadvantages of sterilization

Answer 13

permanent
expensive up front
no STI protection

Question 14

intrauterine device

Answer 14

inhibits sperm motility
prevents implantation
approval rate 98%
20x more effective than OCPs with no increased risk of thromboembolism

Question 15

IUD options

Answer 15

copper TCu-380A
levonorgestrel releasing devices: thins uterine lining, less bleeding
mirena
skyla
liletta

Question 16

copper IUD

Answer 16

no hormone
more bleeding/cramping than others
good for 12 years

Question 17

mirena

Answer 17

good for 7 yeas
20 mcg/day
good choice for breastfeeding moms

Question 18

skyla

Answer 18

good for 3 years
smaller than mirena
14 mcg/day

Question 19

liletta

Answer 19

good for 4 years
19 mcg/day
available for $75 for low income women

Question 20

insertion of IUD

Answer 20

at end of menses or 6-8 wks after childbirth
no harm to future fertility
can be inserted immediated after childbirth

Question 21

risks of IUD

Answer 21

uterine rupture

infection

Question 22

side effects of IUD

Answer 22

copper: increased bleeding and cramping
LNG: amenorrhea or spotting

Question 23

contraindications to IUD

Answer 23

pregnancy
undiagnosed vaginal bleeding
unresolved pap/suspected cancer
active genital infection
distorted uterine cavity
high risk for STI
decreased resistance to infection
wilson's/ copper allergy
sickle cell: increased bleeding

Question 24

etonogestrel implant

Answer 24

nexplanon
subQ progesterone
thickens cervical mucus, prevents endometrial thickening, suppresses ovulation
lowest failure rate for reversible contraception

Question 25

insertion of nexplanon

Answer 25

1st 5 cays of cycle or immediately postpartum | good 24 hours to 5 years

Question 26

side effects of nexplanon

Answer 26

heavy menses amenorrhea spotting weight gain

Question 27

medroxyprogresterone (depo shot)

Answer 27

inhibits ovulation by decreasing gonadotropins thickens cervical mucus dose 150 mg IM every 3 months pregnancy rate 1/100 women

Question 28

who is the depo shot good for

Answer 28

chronic medical problems sickle cell (decreases crises) forgets pills or cant take estrogen

Question 29

side effects of depo shot

Answer 29

``` amenorrhea spotting weight gain bone loss hair loss nausea delayed return to fertility depressed mood ```

Question 30

black box warning on depo shot

Answer 30

should be used for >2 years only if other methods are inadequate loss of bone density

Question 31

contraindications to depo shot

Answer 31

``` thromboembolic or liver disease stroke vaginal bleeding/pregnancy MI breast cancer severe hypertension ```

Question 32

combo OCPs

Answer 32

``` estrogen/progesterone pills estrogen is usually ethinyl estradiol -high dose: 50 mcg -low dose: 15-35 mcg multiple types of progesterone may be started at any time id reasonably certain that patient is not pregnant ```

Question 33

when should you not use combo OCPs

Answer 33

first 4-6 weeks postpartum, even longer if breastfeeding

Question 34

progesterone types of OCPs

Answer 34

1st gen: norethindrone 2nd gen: levonorgestrol, norgestrel 3rd gen: norgestimate, desogestrel 4th gen: drospirenone

Question 35

1st gen progesterone OCPs

Answer 35

norethindrone | lowest rate of thromboembolism

Question 36

2nd gen progesterone OCPs

Answer 36

levonorgestrel, norgestrel | most start with these, best tolerated

Question 37

3rd gen progesterone OCPs

Answer 37

norgestimate, desogestrel | less androgenic, longer half life, less metabolic effects on carbohydrates and lipids

Question 38

4th gen progesterone OCPs

Answer 38

drospirenone spironolactone analogue, less bloating increased risk for VTE

Question 39

mechanism of action of OCPs

Answer 39

``` negative feedback to HP axis -inhibits mid cycle LH surge -prevents ovulation thickens cervical mucus slows fallopian tube motility make uterus inhospitable pregnancy rate 5/100 women highest failure rates in 15-24 year olds ```

Question 40

benefits of OCPs

Answer 40

protective against ovarian/uterine cancer fewer ectopics relieve dysmenorrhea increase bone mass decrease acne decrease fibrocystic breast disease/ breast pain decrease PID decrease functional ovarian cysts, fibroids decrease iron deficiency anemia may decrease RA improve symptoms of PCOD (hirsutism)

Question 41

risks/side effects of OCPs

Answer 41

``` serious risks rare VTE -greatest in first 2 years -increased risk with drospirenone stroke and MI -risk in smokers >35 -HTN important additive risk -smokers with migraine have 6x stroke risk NO proves risk for breast cancer increase in chlamydia infections decrease in PID ```

Question 42

drugs that cause OCP failure

Answer 42

rifampin anticonvulsants griseofulvin HIV meds

Question 43

minor side effects of OCPs

Answer 43

``` headache breakthrough bleeding amenorrhea decreased libido acne breast tenderness nausea erythema nodosum ```

Question 44

contraindications for OCPs

Answer 44

``` smokers >35 migrain w aura migraine without aura but with other risk factors thromboembolic disorders cerebral vascular disease poorly controlled HTN cancer -breast -endometrial -liver tumors ```

Question 45

pills w decreased number of cycles

Answer 45

seasonale / seasonique / jolessa / quasense -active pills for 84 days then 7 or 4 days of inactive -4 periods per year lybrel/ quartette -active pills for entire year -expect breakthrough bleeding and/or amenorrhea

Question 46

transdermal hormones

Answer 46

transdermal patch to trunk or upper outer arm weekly for 3 weeks of cycle 3x risk thromboembolism lower efficacy in obese women

Question 47

vaginal ring

Answer 47

insert into vagina and stays for 3 weeks of cycle can remove for intercourse ethinyl estradiol 15 mcg and estonogestrel 120 mcg more vaginal discharge

Question 48

progestin only "minipill"

Answer 48

affects cervical mucus viscosity, fallopian tube mobility, endometrial thickness does not reliably inhibit mid cycle LH surge (not good) good w breast feeding more spotting, acne, hirsutism, oily skin

Question 49

specific uses for progestin only contraceptives

Answer 49

sickle cell disease coronary artery disease SLE (lupus) people w risk factors that preclude them from using combined OCPs

Question 50

barrier methods

Answer 50

``` condoms diaphragm cervical cap vaginal pouch sponge spermicides ```

Question 51

condoms

Answer 51

44% of sexually active women use pros: accessible, STI protection, erectile enhancement, prevent sperm allergy, inexpensive cons: reduced sensitivity, interruption, decreased pleasure, latex allergy, breakage

Question 52

diaphragm

Answer 52

latex cup with flexible rim, holds spermicide and covers cervix repeated intercourse requires more spermicide, must remain in place for 6 hours 15/100 pregnancy rate

Question 53

diaphragm advantages

Answer 53

no systemic side effects prevents STIs decreases risk of cervical dysplasia

Question 54

diaphragm disadvantages

Answer 54

interruption latex or spermicide allergy inability to correctly insert increased incidence of UTIs

Question 55

vaginal pouch

Answer 55

long thin polyurethane sheath with flexible ring for cervix and outer ring for labia stronger than latex may insert up to 8 hours prior to intercourse 20/100 preg rate

Question 56

vaginal pouch advantages

Answer 56

good protection for both partners does not require erect penis can use oil based lubricants

Question 57

vaginal pouch disadvantages

Answer 57

cumbersome | may be used only once

Question 58

sponge

Answer 58

soft sponge like device, slightly smaller in diameter than diaphragm 16-32/100 pregnancy rate

Question 59

spermicides

Answer 59

foam, creams, gels, films may be used alone or with barrier method failure rate 6-21%

Question 60

spermicide advantages

Answer 60

over the counter good back up method add lubrication quickly inserted

Question 61

spermicide disadvantages

Answer 61

allergies, increased yeast infections | pregnancy rate 30/100