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Flashcards in Contraception Deck (78):
1

What should be asked on sexual history? (Acronym)

Sexual History – SEX ASAP

  • Sexual active? Male, female or both?
  • EXes – how many partners in the last 3 months
  • Activities – types of sexual encounters – anal, S&M
  • STIs
    • Any symptoms that make you worried about having an STI now
    • Have you had any previous STIs?
    • What are you doing to avoid STIs?
  • Abuse
    • Sexual Abuse
    • Drug use? IVDU?
  • Pregnancies
    • What are you doing to avoid pregnancy? Barrier methods?
    • Have you had any pregnancies before?
    • When was your LMP

2

What is important to know on history before starting a patient on OCP? (AFP)

  • Menstruation
  • Pregnancy, breastfeeding, recent intercourse
  • Chronic disease (e.g. hypertension), drug allergies
  • Risk factors for VTE
  • Future pregnancy intention
  • Contraceptive experiences and preferences
  • Sexual health
    • Sexual practices, current and recent partners, condom use
    • Previous STIs

3

For patients being prescribed a contraceptive for the first time, what are 5 measures that should be done on physical examination?

  • Blood Pressure – follow-up visit in 6 weeks to re-check
  • Breast exam
  • Pelvic exam (if sexually active, otherwise do later)
    • Fibroids can grow
  • GC/C swabs if sexually active
  • Pap is needed if sexually active and >21 years old

4

According to the CDC, what is the only measure that should be done on physical examination prior to prescribing a contraceptive? (AFP)

  • Blood pressure
  • Pelvic examination before IUD (Bimanual exam and Cervical inspection)

5

As part of the Choosing Wisely Campaign, what does the AAFP recommend for the physical exam prior to prescribing OCPs? (AFP)

  • Do NOT require a pelvic exam or other physical exam
  • ONLY measure Blood Pressure

6

How can you be reasonable certain that a woman is not pregnant and what is the NPV for pregnancy? (AFP)

NOT pregnant if BOTH conditions met (99% NPV = routine pregnancy testing NOT needed)

  1. The patient has no signs or symptoms of pregnancy
  2. The patient meets AT LEAST ONE of the following:
    1. Is 7 days or less after start of her normal menses
    2. Has not had intercourse since the start of her last normal menses
    3. Has been correctly and consistently using a reliable method of contraception
    4. Is 7 days or less after a spontaneous or induced abortion
    5. Is within 4 weeks postpartum
    6. Is fully or nearly fully breastfeeding (exclusively breastfeeding or most feeds (>85%) are breastfeeds, amenorrheic, and less than 6 months postpartum)

7

What are 5 physiologic contraceptive methods and their effectiveness?

  • Abstinence – 100% effective
  • Chance – 10% effective
  • Calendar/Rhythm – 75% effective
  • Withdrawal – 75% effective
  • Lactational amenorrhea – 98% effective if breastfeeding q4h and no menses

*** No STI protection with any except abstinence ***

8

What are 4 barrier contraceptive methods and their effectiveness?

  • Condom – 90% effective, 95% effective with spermicide
  • Female condom – 80% effective
  • Sponge – 90% effective
    • Poor STI protection
  • Diaphragm – 90% effective with spermicide
    • Must be left in for 6 hours after intercourse
    • Poor STI protection

9

What is the effectiveness of the combined oral contraceptive pill?

  • 97% effective with typical use
    • No STI protection – advise to use concurrent condoms

10

What are the absolute and relative contraindications to estrogen use?

 

Absolute

Relative

Head

Migraine with aura*

Migraine and >35

 

Previous Stroke

 

 

Breast

Cancer or undiagnosed lump

 

 

Heart

CAD

 

 

Valvular heart disease

 

 

Abdominal

Severe Cirrhosis or Liver Tumor

Mild Cirrhosis

 

Pregnancy

Gallstones - currently

 

<6 week PP & breastfeeding

 

 

Undiagnosed vaginal bleeding

 

 

Vascular

HTN SBP >160 or DBP >100

Controlled HTN

 

Diabetes with end-organ

Smoker >35 (<15 cig/day)

 

Previous DVT

Sickle Cell, SLE, IBD

 

Smoker >35 (>15 cig/day)

 

*aura of visual scintillations <1h can be acceptable

11

What are 4 conditions in which an OCP is contraindicated in a patient with a past history of migraine? (DFCM Open)

  • Smoker
  • Migraine worse on OCP
  • Migraine with aura or neurological symptoms
  • Other risk factors:
    • Hypertension
    • Age >35
    • DM
    • Atrial fibrillation
    • Cardiomyopathy
    • Thrombophilia
    • Dyslipidemia

12

What are 6 adverse effects of estrogen excess and 5 adverse effects of progesterone excess from OCP?

  • Estrogen
    • Menorrhagia
    • Dysmenorrhea
    • Breast cystic change
    • Headaches
    • Nausea
    • Hypertension
  • Progesterone
    • Low mood
    • Fatigue
    • Libido decreased
    • Breast pain
    • Weight gain and appetite increased

13

When do adverse effects of the combined OCP typically resolve?

  • 3 months

14

What % of women experience irregular bleeding when starting a combined OCP? (DFCM Open)

  • 10-30% in the 1st month

15

What should be rule out if irregular bleeding persists for >3 months in women started on a combined OCP? (DFCM Open)

  • Rule out:
    • Poor compliance
    • Uterine/Cervical pathology
    • Malabsorption
    • Pregnancy
    • Smoking
    • Other meds
    • Infection (especially Chlamydia infection if new onset spotting in regular OCP user)

16

How should irregular bleeding be managed in women started on a combined OCP? (DFCM Open)

  • 7-day trial of oral estrogen OR switching to OCP containing different type of progestin

17

How should breast tenderness and nausea be managed in women started on a combined OCP? (DFCM Open)

  • Switch to lower estrogen OCP

18

How should no withdrawal bleed during pregnancy be managed in women started on a combined OCP? (DFCM Open)

  • Rule out pregnancy
  • Switch to OCP containing different type of progestin (levonorgestrel) or higher dose estrogen

19

What are 4 serious adverse effects of combined OCP use?

  • VTE: 3-4-fold risk (1 in 10,000)
  • Stroke: 2-fold risk
  • Breast Ca: 0 to 1.5-fold risk (3 in 1,000)
  • Hypertension

20

By how much do higher risk contraceptives increase the risk of VTE? (TFP)

  • 1 extra VTE per year for 2000 women (e.g. 2000 patients would need to switch to lower risk combined OCP to prevent 1 VT per year)
    • Limited evidence as no RCTs
    • Uncertain whether risks vary with different hormonal contraceptives

21

How does the risk of VTE compare for non-users, IUD with progestin, progestin only pills, transdermal estrogen, vaginal ring, 3rd generation progestins and OCP? (TFP)

  • 4-5/10,000 woman years (non-users, progestin-only pills, progestin IUD)
  • 10/10,000 woman years (combined OCP with 2nd generation progestin – levonorgestrel or norethisterone)
    • 2x
  • 20/10,000 woman years (transdermal estrogen, vaginal ring, OCP with 3rd generation progestin – desogestrel, gestodene, drospirenone, cyproterone)
    • 2x
  • 29/10,000 woman years for pregnancy

22

What are 3 other factors that influence VT risk in women on OCP? (TFP)

  • Age = age 45-49 6x risk age 15-19
  • Obesity = BMI 35+ 4x risk BMI 20-25
  • Smoking = 2x risk

23

What are 8 potential non-contraceptive benefits of the combined OCP?

  • Cycle regulation
  • Decreased dysmenorrhea
  • Decreased bleeding/anemia
  • Decreased acne/hirsutism
  • Increase bone density
  • Decreased Ovarian Ca (50%)
  • Decreased Endometrial Ca (50%)
  • ?Colorectal cancer protection

24

What are 6 potential drugs that can interact with OCPs and cause failure?

  • Anticonvulsants – Topamax, Carbamazepine, Phenytoin
  • St. John’s wart
  • SSRIs – Fluoxetine, Fluvoxamine
  • Fluconazole
  • Grapefruit juice
  • Antibiotics – Erythromycin, Rifampin, Ritonavir

25

How do estrogen and progesterone act as contraceptives physiologically?

  • Estrogen
    • Suppresses FSH
  • Progesterone
    • Thins endometrium
    • Thickens cervical cap
    • Alters tubal transport
    • At high dose (Depo) suppresses ovulation
    • Causes FSH suppression

26

On average when does fertility returns after cessation of OCPs?

  • 3 months

27

What are 3 different combined OCPs and their differences?

  • Yaz (20mcg, 24/4) and Yasmin (30mcg,21/7) have a progestin (Drospirenone) with anti-androgenic properties
    • Better weight control, less acne and good for hirsuit women
    • Must monitor K+
    • VTE studies: perhaps 2x higher risk
      • VTE risk in pregnancy is double that of Yaz VTE risk
  • Alesse (20mcg, 21/7)
  • Seasonale (30mcg, 84/7)
    • Seasonique (30mcg, 84/7) – with 10mcg during placebo period
    • LoSeasonique (20mcg, 84/7)

28

What combined OCP can be given for perimenopausal women?

  • Mircette (20mcg, 21/2/5) has 10mcg estrogen during 5 placebo days to reduce hot flashes which typically recur in perimenopause
    • Also reduces the chance of ovulation if patient misses first active pill

29

What are the different types of combined OCPs? (DFCM Open)

  • 21/28 cycle = 21d of OCP + 7d of placebo
    • Monophasic (same dose of estrogen+progestin for 21d)
    • Biphasic (same dose of estrogen but 2 different dose of progestin during 21d)
    • Triphasic (same dose of estrogen but 3 different dose of progestin during 21d)
  • Continuous Regimen
    • 84d of OCP + 7d of placebo
    • e.g. Seasonale or Seasonique

30

What are 6 advantages of a continuous regiment of combined OCP compared to a 21/28 cycle? (DFCM Open)

  • Fewer withdrawal bleeds
  • Decreased:
    • Pelvic pain
    • Headache
    • Bloating
    • Breast tenderness
  • Better control of endometriosis/PCOS

31

What are 3 different ways to start an OCP? (DFCM Open)

  • 1st day start (start 1st day of cycle)
    • No back-up contraception requires, more SEs
  • Quick start (start immediately)
    • Back-up contraception required for 1 week, less SEs
  • Sunday start (start 1st Sunday after menses)
    • Back-up contraception required for 1 week if starting >5d since LMP

32

Why should combined OCPs be deferred until at least 6 weeks postpartum? (AFP)

  • Increased risk of VTE
  • Progestin-only methods can be safety started immediately postpartum

33

How should a patient be started on an OCP based on the first day of their last menstrual period (LMP)?

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34

What would you recommend for a patient that missed taking their OCP?

  • One Pill
    • Take when remember, even if take 2 pills on the same day
    • No backup protection needed
  • Two Pills in first 2 weeks
    • 2 pills the day you remember, 2 pills the next day
    • Backup protection for 7 days and consider emergency contraception
  • Two Pills during 3rd week or 3 Pills at any time
    • Throw out pack and start a new pack
    • Backup protection for 7 days and consider emergency contraception

35

Other than the combined OCP, what are 6 other contraceptive methods?

  • Patch
  • Ring
  • Progestin-only Pills
  • Progestin Depot
  • IUD
  • Surgical

36

What is the contraceptive patch, its contraindications, adverse effects and use?

  • EVRA Patch (35mcg/day)
    • Same contraindications as OCP
    • Same side effects as OCP
      • Also have skin reactions
    • As effective as the pill for contraception and non-contraceptive benefits
    • Apply ONE patch each week x3, then 1 patch-free week
      • Apply to buttock, upper/outer arm, upper/outer torso – not to breast
      • Always use the same day for patch change over – i.e. Monday
    • If forget to apply a new patch
      • <48h – no need for backup
      • >48h – start today and use backup contraception for 1 week
        • Consider emergency contraception if unprotected sex
    • If forget to remove patch
      • Remove when you remember and apply a new patch on the regular day

37

What is the contraceptive ring, its contraindications, adverse effects and use?

  • Nuva Ring (15mcg/day)
    • Same contraindications as OCP
    • Same side effects as OCP
    • As effective as the pill for contraception and non-contraceptive benefits
    • Left in place for 3 weeks, removed for 1-week ring-free
    • Can stay in during sex, but can be removed for up to 3h
    • If forget to remove ring at end of week 3
      • Remove when you remember and re-insert after 1 week

38

What is an example of a progestin-only pill and how effective is it?

  • Micronor (0.35mg Norethindrone)
  • 90% effective

39

What are 3 indications for the progestin-only pill for contraception?

  • Lactating women
  • Contraindications to estrogen
    • Smoker >35 years
    • Migraine with focal neurological symptoms
  • Intolerant to estrogen AE

40

What are 3 absolute and 3 relative contraindications to progestin-only pills?

  • Absolute
    • Pregnancy
    • Unexplained vaginal bleeding
    • Current diagnosis of breast cancer
  • Relative – LIVER disease
    • Severe cirrhosis
    • Active viral hepatitis
    • Benign hepatic adenoma

41

What are 4 potential benefits of the progestin-only pill?

  • Amenorrhea – 50% with injection, 10% with pill
  • Reduced dysmenorrhea and bleeding
  • Decreased endometrial cancer
  • Reduced symptoms of endometriosis, PMS and chronic pelvic pain

42

What are 8 potential AE of progestin-only pills?

  • Irregular bleeding (Inter-menstrual)
  • Amenorrhea
  • Functional ovarian cysts
  • Headache
  • Decreased libido
  • Nausea
  • Breast tenderness
  • Weight gain in 50% (10 lbs)
    • 50% lost weight or maintained

43

What is the effect on weight for progestin-only contraceptives according to the Cochrane review? (AFP)

  • Little evidence
  • Mean weight gain was < 2kg (4.4 lb) for up to 12 months

44

What are 2 risks specific to progesterone injections for contraception?

  • 9-month delay in fertility
  • Decreases BMD

45

Are their placebo pills for progestin-only pills?

  • No – take continuously

46

What are 4 disadvantages of progestin-only pills compared to combined OCP?

  • Slightly higher failure rates
  • More breakthrough bleeding
  • Does not reliably suppress ovulation – not as good for dysmenorrhea
  • Must take at the SAME TIME each day
    • 3-hour delay requires backup contraception

47

What should a patient do if they miss taking a progestin-only pill?

  • 1 pill >3-hours – take pill as soon as remember and use backup for 48h
  • 2 pills – take 2 pills per day for 2 days and use backup for 48h

48

What is an example of a progestin depo, how effective is it and how does it work?

  • Depo-Provera 150mg IM q12weeks
  • 99.7% effective
  • High dose progestin suppresses LH surge and ovulation

49

How should a patient be started on Depo-Provera?

  • 1st day of menses to avoid inadvertently giving when pregnant

50

What should a patient do if they miss an injection of Depo-Provera?

  • <14 weeks – can still give injection
  • >14 weeks – no sex in last 10 days and negative beta-hCG – give injection
    • Requires a backup method for 2 weeks
    • If she has had sex, can still give injection (not teratogenic)
      • Repeat beta-hCG in 2 weeks

51

What are 3 indications to an IUD for contraception?

  • Contraindications to OCP
  • Long-term protection (5-years)
  • Do NOT have to remember to take

52

What are 7 absolute and 3 relative contraindications to an IUD?

  • Absolute
    • Pregnancy
    • Current or recurrent of <3 months of PID or STI
    • Distorted uterine cavity
    • Unexplained vaginal bleeding
    • Cervical or Endometrial cancer
    • Breast Cancer (Mirena)
    • Copper allergy (Nova T)
  • Relative
    • Risk factors for HIV
    • 48h – 4 weeks postpartum
    • Ovarian cancer

53

What are 9 potential adverse effects of levonorgestrel-releasing IUDs? (AFP)

  • Headaches
  • Nausea
  • Hair loss
  • Breast tenderness
  • Depression
  • Decreased libido
  • Ovarian cysts
  • Oligomenorrhea
  • Amenorrhea

54

What % of women using the 20mcg LNG-IUD report oligomenorrhea or amenorrhea after 2 years of use? (AFP)

  • 70%

55

How effective are the Mirena IUD and Nova T IUD for contraception?

  • Mirena = 99.9%
  • Nova T = 99.3%

56

What is the difference between a NovaT IUD, Jaydess IUD and Mirena IUD? (DFCM Open)

  • NovaT = Copper
  • Mirena = Levonorgestrel 20 mcg/day
  • Jaydess = Levonorgestrel 6 mcg/day

57

Compare and contrast the Mirena IUD and Nova T IUD by contraceptive effects, non-contraceptive benefits and adverse effects.

 

 

Nova T (99.3%)

Mirena IUD (99.9%)

Contraceptive Effects

  • Inflammatory response in uterus
  • Cu is spermotoxic

 

  • Thins endometrium
  • Thickens cervical cap
  • Alters tubal transport

Non-contraceptive Benefits

  • Lower Endometrial Ca
  • Decreased Menorrhagia
  • 30% Amenorrhea
  • Decreased Dysmenorrhea
  • Decreased endometrial hyperplasia if on tamoxifen

Side Effects

  • Increased flow
  • Increased dysmenorrhea

 

  • Irregular bleeding

 

58

What are 4 potential risks associated with IUDs?

  • Uterine Perforation – 1 in 1,000
  • Unclear risk of PID
  • Expulsion 5% over 5 years (6.7% copper > 5.8% progestin)
  • Ectopic pregnancy

59

What should be done to the IUD in the case of an ectopic pregnancy?

  • Remove IUD – lowers risk of septic abortion
    • If cannot remove then get ultrasound to evaluate for perforation

60

When should an IUD be inserted during the menstrual cycle and when is it easiest?

  • Any point in the menstrual cycle
    • After pregnancy is excluded
    • Easiest if during menses
  • Copper = Any time in the menstrual cycle
  • Levonorgestrel = First 7 days of menses

61

Following removal of an IUD, when does fertility return?

  • 3-6 months

62

What are 3 possible causes for a lost IUD string and what should be done?

  • Causes: Expulsion (5%), Perforation, String in Cervical Canal
  • Exclude Pregnancy
  • Get ultrasound
    • If present, can leave it
    • If not, get AXR to evaluate for perforation

63

How should an STI be managed in a patient with an IUD?

  • If LOWER symptoms – treat STI
  • If suggestive of PID – remove IUD

64

Is the use of misoprostol recommended before IUD insertion to allow for easier insertion? (AFP)

  • No – no benefit and increased AEs
    • ACOG makes NO recommendation regarding its use

65

Are prophylactic antibiotics recommended before IUD insertion? (AFP)

  • No

66

How long after treatment for an STI should women with an IUD be screened? (AFP)

  • 3 to 6 months after treatment

67

How long after resolution of an STI should an IUD be inserted? (AFP)

  • 3 months

68

What are the risks of tubal ligation?

  • Bleeding
  • Infection
  • Failure
  • Low chance at reversing
  • Risk of damage to bladder/bowel, general anesthetic

69

What is the annual failure rate for surgical sterilization techniques? (AFP)

  • Abdominal tubal ligation (1 in 100 to 200)
  • Laparoscopic tubal ligation (1 in 100 to 200)
  • Male vasectomy = 1 in 100 overall (1 in 2,000 with confirmed azoospermia)

70

For patients starting long-term contraception what should you always counsel them about?

  • Emergency Contraception

71

What should be done for a patient that misses a period?

  • Pregnancy test and REPEAT in 2 weeks

72

What are the contraindications for emergency contraceptives?

  • None

73

When should you follow-up with a patient after taking an emergency contraceptive?

  • 3-4 weeks
    • Repeat pregnancy test vs Spontaneous menses
    • Contraception counseling

74

What are 3 options for emergency contraceptive use?

  • Yuzpe
  • Plan B
  • IUD

75

How should the Yuzpe regimen be used for emergency contraception and how effective is it?

  • Yuzpe
    • 2 tablets, then repeat in 12h
    • 100mcg Ethinyl estradiol and 500mcg Levonorgestrel q12h x2
    • Best within 24h (98% effective), can use up to 72h (30% effective)
    • AE: nausea and spotting

76

How should Plan B be used for emergency contraception and how effective is it?

  • Plan B
    • Progesterone only (Levonorgestrel 750mcg q12h x2), PO within 3 days
    • Alters endometrial lining to prevent implantation
    • Best within 24h (98% effective), can use within 72h (70% effective)
    • AE: less N/V, still spotting

77

How should an IUD be used for emergency contraception and how effective is it?

  • IUD – ONLY with COPPER – up to 99.9% effective
    • Use within 5 days

78

What should be done if there is no menstrual bleeding within 21 days of treatment with emergency contraception? (Toronto Notes)

  • Pregnancy test