Contraception Flashcards
1
Q
Why is contraception used? Failure rate of not using contraception?
A
- prevent unintended pregnancies
- space pregnancies
- prevent pregnancy when it is dangerous or life threatening to the mother (valvular heart disease, ischemic heart disease, SLE, sickle cell disease, severe liver disease, thrombogenic mutations)
- failure rate of not using contraception: 85%
2
Q
How many pregnancies in US in 2006 were unintended? How many were terminated?
A
- 49% of 6.7 mill pregnancies unintended (80% of pregnancies in 19Yo and younger and 28% in married couples)
- 43% of unintended pregnancies in 2006 were terminated
3
Q
Reproductive life span of women and men?
A
- women: about 40 years of potential fertility, from menarche: avg age 12.5 to natural menopause avg age 51.5
approx half of avg US woman’s life span of 81.2 yrs - men: around 10-12 yo until death as long as vas deferens intact and able to ejaculate
4
Q
When is emergency contracpetion used?
A
- use of drugs to prevent pregnancy for women w/in 120 hrs of:
unprotected intercourse (includes sexual assault), failure of another method of contraception - consider at any time of menstrual cycle: higher probability of conception is 1-2 days b/f ovulation
5
Q
Emergency contraception in US?
A
- plan B: levonorgestrel 0.75 mg 2 pills to be taken 12 hrs apart, can be taken up to 24 hrs apart
- plan B one step or next choice one dose and other branded generics: single levonorgestrel 150 mg pill
- ella: ulipristal 30 mg - single dose, need Rx
- Yuzpe method: formulated using variety of combo oral contraceptives to achieve ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg, 2 doses in 12 hrs
- copper IUD: most effective but off label
6
Q
Access to oral hormonal EC (levonorgestrel)? Any prereqs, CIs? Cost?
A
- no need for pregnancy test or exam
- no medical CI
- access: approved for OTC availability for anyone of childbearing age
previously under 17 required a Rx, and some package inserts may state for 17 or older - cost: $40-50
7
Q
SEs of EC - levonorgestrel?
A
- N 24% and V 9% (higher with use of combined OCPs or Yuzpe method)
- irregular bleeding the month after tx
- less common: dizziness, fatigue, HA, breast tenderness
- no deaths or serious complications
- effective up to 120 hrs after event but take ASAP
8
Q
Prereq of admin of ulipristal or Cu IUD?
A
- pregnancy should be excluded b/f admin
- CIs and precautions exist for ulipristal and IUD
9
Q
Efficacy of EC?
A
- pooled data est at least 74% of expected pregnancies prevented
- Cu IUD: failure rate less than 1%
- ulipristal: failure rate 1.4%
- levonorgestrel: failure rate 2-3% (effectiveness may be less in overwt and obese woman)
10
Q
EC MOA?
A
- oral methods: inhibiting or delaying ovulation
- levonorgestrel is ineffective after ovulation has occurred
- Cu IUD: interfering with fertilization or tubal transport, preventing implantation by altering endometrial receptivity (less hospitable enviro for fertilization)
- use of oral hormonal EC doesn’t interrupt a pregnancy and has no adverse effects on pregnancy or fetus
11
Q
EC counseling for your pt?
A
- obtain pregnancy test if no menses 3-4 wks after EC
- discuss risk of pregnancy and STIs with unprotected sex
- encourage pt to start a regular contraceptive method or review correct use of current one
- EC is a back up, not a primary contraceptive method
12
Q
What are considerations for choosing a contraceptive method?
A
- efficacy (failure rate)
- safety (risks with consideration of health hx)
- SEs (to include effect on menses)
- convenience (correct use and access to care)
- cost
- personal lifestyle and pattern of sexual activity
- reversibility
13
Q
What are goals for teaching pts about contraception?
A
- dispel misconceptions
- review major SEs and risks, particularly as relate to her health hx
- compare options to maximize choice appropriate to lifestyle and ability to use correctly
- educate on proper use
- distinguish b/t contraception and protection from STIs
- encourage pts to talk about birth control issues with partner
- pt’s personal needs change over time, so helpful for pt to be aware of all options
- discuss EC with all pts
14
Q
Categories of contraception?
A
- hormonal
- IUD
- barrier
- permanent
15
Q
Why is there contraception failure?
A
- inappropriate use
- failure to use (influence of cost and access)
- failure of method (correct use failure rate)
16
Q
Typical use failure rate of hormonal methods?
A
- oral pills: 9%
- transdermal patch: 9%
- injections: 6%
- IUD less than 1%
- subdermal implants less than 1%
- intravaginal ring 9%
17
Q
OCP - MOA: estrogen?
A
- suppression of GnRH (hypothalamus) - inhibits the midcycle surge of gonadotropin LH - prevents ovulation, suppresses FSH secretion which prevents ovarian folliculogenesis
- stabilizes endometrium to minimize breakthrough bleeding - low dose (20, 30 or 35 mcg) or high dose (50 mcg)
18
Q
OCP- MOA: progestin?
A
- (a 19-nortestosterone or drospirenone):
suppresses LH secretion and therefore, suppresses ovulation (less potent than estradiol) - thickens cervical mucus which inhibits sperm migration
- creates an atrophic endometrium unfavorable to implantation
- impairs normal tubal motility/peristalsis
19
Q
Older progestin effects? Newer progestin effects?
A
- older: more androgenic - norethindrone, norethindrone acetate, levonorgestrel
these lower HDL cholesterol - newer: less androgenic effects - norgestimate, desogestrel, drospirenone, less effect on carbs and lipid metabolism, more effective at reducing acne and hirsutism, possible increase risk of thromboembolism
20
Q
Diff generations of progestins?
A
- 1st gen: norethindrone (acetate), ethynodiol diacetate
- 2nd gen: levonorgestrel and dl-Norgestrel (higher androgenic but more effective than 3rd in countering thrombotic effects of estrogen)
- 3rd gen: desogestrel - may have increased risk of VTE
- unclassified: drospirenone (yasmin and yaz) less androgenic but risk of VTE up to 3x compared to levonorgestrel
21
Q
What are advantages of new progestins?
A
- higher HDL and lower LDL
- higher SHBG - result: decreased free testosteron levels and estrogen effects
- greater affinity to progesterone binding sites
- reduced amenorrhea
22
Q
Non-contraceptive uses of OCPs?
A
- endometriosis: reduce pelvic pain
- tx for acne and hirsutism
- tx for heavy, painful or irregula periods
- reduce occurrence of recurrent ovarian cysts
- PCOS (acne, hirsutism, unopposed estrogen influence to endometrium)
- PMS/PMDD
- decreased risk of ovarian cancer
- decreased risk of ovarian cancer**
- decrease menstrual migraine (with continuous or extended cycle)
23
Q
Why would higher dose estrogen pills be rx?
A
- 50 mcg
- b/c of spotting or absence of withdrawl bleeding that can’t be managed on lower dose
- tx other problems:
AUB
reduce recurrent ovarian cysts
historically higher dose estrogen BCPs used for acne b/f less androgenic progestins available
24
Q
Diff types of OCP preps?
A
- monophasic
- multiphasic (biphasic or triphasic) - changes in E and P throughout month
- extended cycle: withdrawal flow q 12 wks
- POP or mini pill
25
Diff OCP cycles?
- 21 days on, 7 days off (most formulations)
- 24 days on, 4 days off (drospirenone containing forms)
- 84 days on, 7 days off - extended cycle - seasonale, introvale (estradiol and levonorgestrel)
- seasonique and Loseasonique take on 91 day cycle, but intead of placebo 10 mcg of ethinyl estradiol taken for 7 days - use in pts with endometriosis, PMDD, or women who prefer less menses
26
Typical choices for pill formulations depends on?
- typically start with monophasic in younger or less compliant pt but generally it doesn't matter much
- perimenopausal women are usually started on lower estradiol pill
- androgenic influence of progestin may be taken into consideration
- breastfeeding women: POP
- ift they have used a formulation in past that's worked - be reluctant to mess with success!
27
Before beginning an OC what should be done? Diff methods for starting? F/U?
- minimal screen: careful medical hx and BP and BMI
- 3 methods for starting:
1. quick start: start day Rx regardless of day of cycle once pregnancy ruled out
2. sunday start: start 1st sunday after period begins
3. start 1st day of menses
- with quick start or sunday start, must use backup method for 7 days after starting pill
- a POP should be started in first 5 days of menses
- good idea to rx 3-4 months and have woman return to check BP, confirm taking correctly and eval SEs
28
What education should you give to pt b/f they start OCPs?
- when to start pill
- impt of taking it same time q day esp POP (taken in 3 hr window)
- if miss 1 pill take ASAP, contraceptive benefit not compromised
- if 2 pills missed - double up for 2 days, use back up method for rest of cycle
- high risk time for conception if next pill cycle not started on time (already had 7 pill free days)
- may have nausea for first couple days - can take with food
- ask pt to notify with increasinly severe or frequent HAs, SOB or chest pain or swelling of extremity
- menses generally shorter, lighter and with less cramping
29
What is Ortho-Evra? Downside of this?
- contraceptive patch
- changed q 7 days for 3 wks and then 1 wk off for menses
- delivers constant level of 20 mcg ethinyl estradiol and 150 mcg of norelgestromin daily
- resultant serum levels of EE 66% higher than 35 mcg oral pill. In 2008, FDA revised labeling to state possible higher risk of thromboembolism
30
How does the nuvaring work?
- delivers 15 mcg estradiol and 120 mcg estonogestrel daily for 3 wks intravaginally
- remove for 1 wk then insert new one
- if it falls out or needs to be removed - rinsse with cold or warm (not hot) water and reinsert w/in 3 hrs
31
What are absolute CIs for estrogen contraception?
- hx of thromboembolic event or stroke or known thrombogenic mutation (factor V leiden)
- known CVD, cardiomyopathy, BP 160/100 or greater, complicated valvular heart disease
- SLE with + antiphospholipid abs
- women 35 or older who smoke
- migraines with aura
- women 35 or older with migraines
- hx of cholestatic jaundice with pill use
- hepatic carcinoma or benign adenoma, any active liver disease or severe cirrhosis
- current breast cancer
- first 21 days postpartum (increased risk of clotting)
- Undx AUB
32
Careful consideration b/f use of estrogen?
- HTN (younger than 35, nonsmoker, eval cumulative RFs for CAD/stroke)
- anticonvulsant therapy
- migraines w/o aura (younger than 35, eval cumulative RFs for CAD/stroke)
- diabetes (eval cumulative RFs for CAD/stroke)
- hx of bari surgery with malabsorptive procedure like Roux en Y (possible decreased efficacy with oral pills)
- psychotic depression
- UC (may increase with years of use)
- obese, older than 35
33
Efficacy of hormonal pills, patch and ring?
failure rates:
- theoretical/correct use: less than 1%
- typical use: 9%
34
HC SEs?
- nausea/bloating
- breast tenderness
- spotting/break through bleeding (BTB): MC (10-30% in first 3 months)
- amenorrhea (about 5% after several yrs, more common with 20 mcg estradiol pill) - goal with extended or cont. delivery
- fatigue
- HA: may occur in early cycles and generally improve with subsequent cycles
- depression/moodiness
- decreased libido
- **low dose doesn't cause wt gain
35
How common is BTB as HC SE?
- MC SE
- independent of progestin
- can add extra estrogen or switch to more estrogenic progestin
36
Tx of amenorrhea if not desired?
- try prep with more estrogen
37
Estrogen - adverse effects of excess or deficiency?
```
- excess:
N/V
bloating/edema
HTN
migraine
breast tenderness
decreased libido
wt gain
heavy menstrual flow
leukorrhea
- deficiency:
early cycle spotting/BTB
amenorrhea
vaginal dryness
```
38
Progestin - adverse effects of excess or deficiency?
```
- excess:
acne
increased appetite/wt gain
fatigue
HTN
depression
hirsutism
vaginal yeast infections
- deficiency:
late BTB
amenorrhea
heavy menstrual flow
```
39
CVD risks assoc with E-P contraception?
- thrombotic, not atherosclerotic, older than 35 who smoker or have HTN, women who have taken OCPs are not at increased risk for CVD later in life
40
HTN risk assoc with E-P contraception?
- OCPs can cause mild elevation of BP
| - overt HTN can occur and is assoc with increased risk of MI and stroke
41
Stroke risk assoc with E-P contraception?
- ischemic: possible extremely low increased risk, estrogen dose dependent.
Other RFs: smoking, older age, HTN, migraine with aura, obesity, prothromboti mutations
- hemorrhagic stroke: no assoc but another form of contraception should be used
42
Carb and lipid metabolism change in OCP use?
- OCPs can cause mild insulin resistance; probably progestin effect
- Estrogen: serum TGs (oral) and HDL increase, LDL decreases
- progestin: decrease HDL, increase LDL
43
Risk of VTE with OCP use?
- dose dependent risk with estrogen
- risk varies with type of progestin
- older and obese women more at risk
- impt to take careful personal and family hx of DVT or PE
44
Increased risk of what kind of stones in E-P contraception?
- cholithiasis
45
What cancers - assoc with EP contraception?
- breast cancer (data conflicting) - large studies show no assoc, may increas breast cancer risk in carriers of BRCA1 and possibly BRCA2
- cervical cancer: low increased risk, increasing with duration of use
most indicate HPV neg OCP users don't have increased risk
in HPV positive women, metabolite of estradiol can act as cofactor with oncogenic HPV
46
Hormonal contraceptive drug interactions? Where are these metabolized?
- metabolized in the liver
- drugs that increase liver microsomal enzyme activity accelerate OC metabolism and may decrease efficacy:
phenobarbitol, phenytoin, carbamazepine, barbituates, griseofulvin, primidone, topiramate, oxcarbazepine
(anticonvulsants that don't effect metabolism: gabapentin, lamotrigine, levitracetam, and tiagabine)
- st johns wort can increase hormonal contraceptive metabolism by including cytochrome P450 system
- rifampicin (only proven antimicrobial shown to decrease efficacy of OCs), but no other abx, antifungal or antiparasitic proven to decrease effectiveness
- impt to counsel pt!!
- fluconazole and possible grapefruit juice may decrease metabolism of estrogen resulting in higher serum EE level
- OCs reported to decrease plasma concentrations of lamotrigine
- antiretroviral - esp ritonavir boosted protease inhibitors lower progestin levels with POP and implants - some meds of this category increase and others decrease contraceptive steroids
47
What drugs (and juice) may decrease metabolism of estrogen?
- fluconazole and possible grapefruit juice may decrease metabolism of estrogen resulting in higher serum EE level
48
Other progestin only methods of contraception?
- depoprovera injection
- progestin implant (nexplanon)
- progestin IUD (mirena, skyla)
49
MOA of progestin only contraception?
- inhibition of gonadotropin secretion
- with resultant inhibition of follicular maturation and ovulation
- thickens cervical mucus
- creates thin, atrophic endometrium
- ovum transport may be slowed by reduced ciliary action in tubes
50
When shoud progestin only or not hormonal contraception be used?
- breast feeding (at least until breast milk well est)
- hepatic disease: acute viral hepatitis, hepatocellular adenoma, liver cancer, severe cirrhosis, sx gallbladder disease, cholestasis related to COC
- postpartum: first 6 wks (high risk for clots)
- age over 35 and smoker or HTN
- hx of DVT/PE/retinal artery occlusion
- anticipated major surgery: takes at least 6 wks for procoag effects of estrogen to reverse
- migraine HA: with aura, any age, w/o aura older than 35 or younger than 35 with onset after starting OCP
- thrombogenic mutations (factor V leiden, prothrombin)
- heart disease: ischemic (CAD), or multiple RFs, complicated valvular disease, peripartum cardiomyopathy, CHF
- SLE with + or unknown antiphospholipid abs or nephritis or known vascular disease
51
Advantages of progestin only HC?
- compared to estrogen: fewer CIs and fewer drug interactions
- injection, implant and progestin IUD all long acting
- noncontraceptive benefits (also applies to estrogen):
scanty or no menses (decreased anemia)
decreased cramps
decreased risk of endometria cancer, PID
decrease of endometriosis pain
low risk of ectopic pregnancy
52
Progestin only - disadvantages?
- menstrual cycle disturbances: early on irregular bleeding and spotting, eventually most women become amenorrheic
- possible wt gain: altered carb metabolism - anabolic effect with increased appetite - greatest with DMPA
- possible moodiness/aggravation of depression
- bone density decrease:
usually is reversible, BBA: to limit use to 2 yrs if possible, although no proven increased fracture risk (no indication for DXA)
- increased risk for DM 2 in some high risk pop:
latino women on POP
navajo women on DMPA
53
Diff formulations of DMPA and administration?
- 150 mg/1 ml for IM injections
- 104mg/0.65 ml for SQ: slower adn more sustained absorption
- admin q 3 months (13 wks with 1-2 week grace period)
- first 7 days of menses, no need for preg test or back up
- quick start: day of visit with negative preg test, use back up for 7 days, consider EC if unprotected IC in prior 120 hrs
- safe to use immed post delivery
54
How long may fertility be delayed after DMPA shot d/c? Uses?
- may be delayed up to 18 months after last injection (delay related to increased BMI, not duration of use)
- SE: usually stop or decrease w/in several months: wt gain, dizziness, HA, nervousness, libido decreased, menstrual irregularities (unpredictable bleeding or amenorrhea - up to 75%) - going to be there for 3 mo
55
Clinical advantages of DMPA?
- sickle cell anemia: decrease in painful crises
| - has intrinsic anticonvulsant effect - may be good choice for woman with seizures
56
What are the progesterone implants used?
- implanon/nexplanon: single rod with slow release of 68 mg of etonogestrel, lasts for 3 yrs, inserted in upper arm subdermally in office, irregular bleedin was primary reason of d/c
- jadelle: 2 rods with levonorgestrel, lasts for 5 yrs, FDA approved but not marketed in US
57
Why does teh IUD have a hx negative publicity?
- b/c of original braided/multifilament tail increased risk of PID, FDA didn't approve use in nulliparous women or more than 1 sexual partner
58
MOA of IUD?
- not precisely known but primary effect appears to be prevention of fertilization
- fb rxn creates sterile inflammatory changes toxic to sperm and ova and inhibits ovulation
- may protect against endometrial cancer
59
How does the progestin IUD work? SEs?
- levonorgestrel
- Mirena approved for 5 yrs and skyla approved for 3 yrs
- local progestin effect: creates amenorrhea at 24 months in 50%, decreased menstrual flow even wtih anticoag use, may decrease risk of PID due to thickened cervical mucus, has been used off label for endometrial protection
- SEs: irregular bleeding, breast tenderness, mood changes, acne
60
Non-hormonal IUD? MOA? SEs?
- paraguard: T shaped, exposed surface w/ copper which releases copper continuously into uterine cavity, this interferes with sperm transport and prevents fertilization of ova
- polyethylene monofilament string at end, frame contains barium for detection by X-ray, MRI ok
- approved for 10 yrs
- advantage to women who can't use hormonal methods - can be used for emergency contraception
- SE: heavy menses, dysmenorrhea
61
IUD ideal candidates?
- not planning a pregnancy for at least 1 yr
- want to use a reversible form of contraception
- want to or need to avoid estrogen
- want minimal user effort and/or privacy
62
Complications of IUD?
- uterine perforation, embedding, cervical perforation
- incidence 1/1000 in experienced hands
- perf of 1 of 3 sites:
uterine fundus (MC)
body of uterus
cervical wall
63
IUDs disadvantages and cautions?
- PID: 1% incidence in first 3 wks only
- menstrual problems
- expulsion: 2-10% in first yr
- pregnancy complication if conception occurs
64
How common is expulsion of IUD? Rfs?
- 2-10% in first yr
- 30% chance of recurrence
- RFs: nulliparity, heavy menses, severe dysmenorrhea
- counsel to check for string after each menses
65
Clues of possible expulsion of IUD?
- unusual vaginal d/c
- cramping or pain
- intermenstrual or postcoital spotting
- dyspareunia: for male or female
- absence or lengthening of IUD string
- presence of IUD at cervical os or in vagina
66
How common is pregnancy with IUDs? What should you do if pt is pregnant?
- 1/3 or fewer are due to undetected or partial expulsions
- confirm pregnancy intrauterine and not ectopic
- remove IUD promptly if not ectopic
- if IUD can't be removed - pregnancy continues with 50% incidence of septic abortion
67
When does PID occur in pts with IUDs? Should IUD be reinserted?
- serious complication
- occurs MC in first few weeks following insertion
- aggressive tx needed
- don't reinsert IUD in pt who is at high risk for recurrent PID or who has had PID in past 3 months
68
IUD CIs?
- severe uterine distortion
- acute pelvic infection
- known or suspected pregnancy
- wilson's disease or copper allergy (paraguard)
- unexplained AUB
- current breast cancer (mirena or skyla)
69
Advantages and indications for barriers?
- good choice for women who only need intermittent contraception
- STI protection
- decreased cervical neoplasia risk
70
Disadvantages and cautions for barrier use?
- allergy to spermicide, rubber, latex or polyurethane
- abnormalities in vaginal anatomy
- inability to learn correct technique
- hx of TSS
- repeated UTIs (diaphragm)
71
Characteristics assoc with higher risk of failure of barriers?
- frequent intercourse (more than 3x a week)
- less than 30 yo
- personal style or sexual patterns that make consistent use difficult
- previous contraceptive failure
- ambivalent feelings about pregnancy
72
Why does failure of barrier methods occur?
- lack of trained personnel to fit device and/or lack of clinical time to provide instruction in use
- full term delivery within past 6 wks, recent SAB or EAB or vaginal bleeding from any cause including menstrual flow (cap, sponge)
73
What is a diaphragm? How long does it have to be left in?
- female contraceptive device
- a dome shaped cup made of latex or silicone
- partially filled with spermicidal cream/jelly and then inserted deep into vagina to cover the cervix
- must be left in vagina for 6-8 hrs after intercourse, then needs to be removed
74
What women are not good candidates for the diaphragm? CI?
- allergic to latex/silicone or spermicides
- sig. organ prolapse
- frequent UTIs
- HIV infection or at high risk
- difficulty with insertion
- adolescents
- CI with hx of TSS
75
Advantages of the diaphragm?
- safe/reusable
- inexpensive ($70+$10 spermicide)
- may offer some protection against GC and Chlamydia (not HIV)
- immediately effective and reversible
- no hormonal SE
- can be used by women who are breastfeeding
76
Disadvantages of the diaphragm?
- must be willing to insert b/f each episode of coitus and left in place for 6 hrs after IC
- requires some skill to insert
- both the diaphragm and spermicide must be within reach within a few hours of coitus
- may increase frequency of UTIs
- refitting recommended after childbirth
- not available at all pharmacies
77
Efficacy of diaphragm use?
- correct use failure rate: 6%
- typical use: 12%
(typical OCPs: 9%)
78
How do you fit a diaphragm?
- sizes range from 50-105 mm in 5 mm increments
- sizing must be done after 6 wks postpartum or 2 wks post abortion:
measurement method or empirical method
- have to teach pt: insertion, removal and care
79
What is the cervical cap? Efficacy? SEs?
- reusuable, deep rubber cup that fits over the cervix, must be used with spermicide has to remain in for 6-8 hrs can be left in place for up to 48 hrs
- femcap is only one available in US
- efficacy: women who are nulliparous - 86%, parous women - 71%
- SE: UTIs, vaginal infections, TSS
80
What is the contraceptive sponge? Increased risk of?
- today sponge is 2 in wide circular disk, 3/4 in, thick that contains 1000mg of nonoxynol-9 and has attached loop for removal
- it is moistened with tap water, doesn't reqr a Rx, or fitting
- contraceptive benefit: for up to 24 hrs regardless of number of episodes of IC, must be left in place for 6 hrs after intercourse
- Increased risk of TSS
81
What is the femal condom? Efficacy?
- lines the vagina and shields introitus providing physical barrier during intercourse
- "reality" female condom only one available in US
- more problems with breakage, slippage, and incorrect penetration
- efficacy:
correct - 5% pregnancy rate
typical - 21%
82
advantages of male condoms?
- accessible and portable
- inexpensive
- male participation
- erection enhancement
- hygienic
- prevention of sperm allergy
- proof of protection
- decreased risk of STIs
83
Disadvantages of male condoms?
- reduced sensitivity
- interference with erection
- interruption of coitus
- latex allergy
- embarrassment
- breakage/slippage
- failure rate: 18% typical use, 2% correct use
84
Advantages and indications of spermicides?
- can be purchased OTC
- can be used w/o partner involvement
- immediate protection
- back up option
- midcycle use to augment other methods
- emergency measure if condom breaks
- provides lube
85
Disadvantages and cautions of spermicides?
- irritation
- vaginitis
- can irritate vaginal lining and enhance spread of viruses such as HIV if used 2x or more a day
- failure rate:
typical use: 28%
correct use: 18%
86
What is withdrawal? Failure rate?
- coitus interruptus
- requires men to withdraw b/f ejaculation
- failure occurs if withdrawal isn't timed correctly or preejaculatory fluid contains sperm
- failure rates:
correct use: 4%
typical use: 22%
87
How is lactation a form of contraceptive?
- breastfeeding delays ovulation
- assoc wtih subfertility, but can only be relied upon to prevent pregnancy when:
woman is less than 6 mo postpartum
she is breastfeeding EXCLUSIVELY
she is amenorrheic
88
How common is fertility awareness based methods? Why isn't it utilized very much?
- approx 1% of women in US use this method
factors contributing to low utilization:
-readily available info is limited
- provider bias against or lack of education about these methods
- complicated, user dependent with cooperative partner
- high failure rate
89
When is fertility awareness not recommended?
when menses less predictable:
- recent menarche
- recent childbirth
- approaching menopause
- recent d/c of hormonal contraceptives
- currently breastfeeding
- cycles shorter than 26 days or longer than 32
- women who are unable to interpret their fertility signs correctly
- women with persistent vaginal infections that affect the signs of their fertility
90
Diff fertility awareness methods?
- ovulation method: predicting fertile time based upon recent hx of cycle length, if cycle 26-32 days, then days 8-19 most fertile
- symptothermal: BBT and cervical mucus as well as other sxs of ovulation
- cervical mucus: increases in amt and is thin and slippery in several days b/f and at ovulation
- BBT alone: increases 0.5-1 degree F at time of ovulation but 2-3 days b/f ovulation s most fertile time
91
Efficacy of fertile awareness?
- correct use: less than 1%- 5%
| - typical use: 24%
92
Efficacy of sterilization?
- typical use: less than 1%
| - correct use: less than 1%
93
What determines approach and technique of surgical sterilization in women?
- timing does
- at time of C/sec: pomeroy technique
- early postpartum: minilaparotomy with general/regional/local anesthesia
- interval: laparoscopic - bipolar electrocautery (highest ectopic rate), clips, bands, tubal excision
- hysteroscopic as office procedure (essure) - high failure rates, infection, scarring
94
Advantages of tubal ligation?
- no absolute CIs
- women w/ developmental disabilities or their families/caregivers may request sterilization; be aware of federal and local regulations pertaining to ability to give informed consent
- laparoscopic tubal decreases risk of ovarian cancer even in women with BRCA1 and2
- if failure occurs - 33% of pregnancies are ectopic - compared to 20% with IUD failure
95
Factors assoc with regret after female sterilization?
- young age (30 or younger)
- change in relationship
- low parity
- not aware of availability of long acting reversible methods b/f having had tubal
- reversal usually not covered by insurance
96
What are the advantages of male sterilization (vasectomy)?
- safer, less expensive and lower failure rate than tubal ligation
- unlike tubal, if conception occurs, there isn't increased chance of ectopic pregnancy
- no increased risk of:
impotence
testicular or prostate cancer
atherosclerotic disease
immunologic disease
