Contraception Flashcards
(109 cards)
1
Q
What percent of pregnancies are unintended?
A
49%
2
Q
What percent of the unintended pregnancies were terminated?
A
43%
3
Q
Has the rate of unintended pregnancy increase or decreased over the last 20 years?
A
increased (45 to 49%)
4
Q
how does being below poverty level effect unintended pregnancy?
A
it is 5 fold higher and continues to increase, while they’ve decreased among middle-income.
5
Q
what is the most effective contraceptive?
A
LARCs
-high initial price
6
Q
what to consider when prescribing contraception?
A
- efficacy
- convenience
- cost
- accessibility
- non-contraceptive benefits
- side effects
- medical contraindications
- reversibility
7
Q
Copper IUD preganacy rate in first year of use?
A
<1
8
Q
Levonorgestrel-releasing IUD pregnancy rate in first year of use?
A
<1
9
Q
Contraceptive patch, pill, ring pregnancy rate in first year of use?
A
9
10
Q
Etonogestrel implant pregnancy rate in first year of use?
A
<1
11
Q
DMPA pregnancy rate in first year of use?
A
6
12
Q
condom pregnancy rate in first year of use?
A
18
13
Q
diaphragm pregnancy rate in first year of use?
A
12
14
Q
What contraceptive cause unschedules bleeding/spotting?
A
all but condom and diaphragm
15
Q
rules of contraceptive choice:
A
- know pt medical status
- know reproductive desires
- quality of life?
16
Q
***what poses the greater health risk contraceptives or pregnancy?
A
pregnancy
17
Q
Most effective contraceptives:
A
Mirena, ParaGard, Skyla, Nexplanon, sterilization
*= LARCs
18
Q
Moderate effective:
A
Depo-Provera, OCs, Ortho Evra, NuvaRing
19
Q
Least effective:
A
Diaphragm, cervical cap, condoms, spermicide, withdrawal, periodic abstinence
20
Q
barrier contraceptive methods:
A
- diaphragm
- cervical cap
- female condom
- male condom
21
Q
Barrier method risks:
A
- no systemic risks
- UTI association (diaphragm)
- Possible local irritation from device or spermicide
22
Q
Barrier method efficacy:
A
12-18% failure with typical use
23
Q
Barrier method cost:
A
Low
24
Q
Barrier method Noncontraceptive benefits:
A
-STI protection w/ condom use
25
pregnancy risk with correct condom use?
2%
26
pregnancy risk with typical condom use?
18%
27
What time of condom reduces risk of STI's?
Latex (97% of us condom market)
28
Contraindications for latex condoms?
- oil-based lubricants
| - latex allergies
29
Natural membrane condoms positives:
-any type of lube
30
Natural membrane condom negatives:
- cost
| - porous, may allow STIs like HIV through
31
Synthetic condom positives:
- non-allergenic
- longer shelf life
- any lube
- probably effective against STI's
- cost slightly more than latex, but less than lamb
32
Male condom correct use:
- *Insert 40-year-old virgin meme here*
- erect penis
- start at tip, leave space for semen
- unroll condom all the way to the base
- immediately after ejaculation hold rim of condom and withdraw penis while still erect
- new condom every time :(
33
Female condom info:
- made of nitrile
- learning curve for use
- insert prior to erection and left after ejactulation
34
Diaphragm info:
- fitted by provider, needs Rx
- one edge tucked behind pubic bone, other edge in posterior fornix of vagina
- size: 6.5-8.5 cm (size changes after having baby)
- 12% prego rate
- cost 50$ but can use up to 2 years
35
Diaphragm use:
- use with spermicide
- inserted less than 2 hours before intercourse
- left in place 6 hours after intercourse
- learning curve
- does not rely on motivation of male partner
36
Diaphragm risks:
- increase incidence of UTI
- spermicide my increase susceptibility of HIV
- increased toxic shock syndrome if left in place for >24 hr
- device my shift with pelvic relaxation
37
Cervical Cap info:
- need Rx
- 3 sizes
- left in place 6-8 hrs post sex
- left in place up to 48 hrs
- less effective than diaphragm
- cost 60-75
38
Vaginal sponge info:
- effective 76-88%
- insert up to 24 hours before sex
- no STI protection
- can cause skin irritation
39
vaginal sponge benefits:
- no hormones
| - acne, headache, weight, menstruation not effected
40
what level of effectiveness are hormonal contraception?
-middle tier
41
What are hormonal contraception classified by?
- Hormone content: typically E+P vs P alone
| - Delivery system: pill, shot, vaginal insert, patch, intrauterine (LARC), implant (LARC)
42
delivery of Estrogen-progestin:
- combination OCs
- Transdermal patch (oath Evra)
- Vaginal ring (Nuva ring)
43
delivery of progestin-only:
- progestin-only OCs (minimills)
- DMPA (Depo-Provera)
- Implant (Nexplanon)
- IUD (Mirena, Skyla)
- Plan B (emergency)
44
3 actions in which E-P Contraceptives work:
- suppress ovulation
- Thinning of endometrium
- Thickening of cervical mucus
45
Efficacy of E-P?
correct use- <1
| Actual- 9%
46
Risks of E-P?
```
-most of risk comes from estrogen component
CV:
-MI
-stroke
-HTN
-Venous thromboembolism
Hepatic:
-Hepatic adenoma
CA:
-breast
-Cervical
Overall absolute risk is very small
```
47
How risky are E-Ps?
- not associated with an overall increase in cancer risk
- not associated with an increase in all-cause mortality and may result in a slight decrease in risk
- identification and exclusion or high-risk woman is the goal of prescribing
48
OCPs and cancer:
- reduce risk of ovarian cancer
- longer term use associated with increased risk of cervical cancer
- maybe slight increase in breast cancer risk?
49
***contraindications of E-Ps:
- smoker >35
- uncontrolled HTN
- Hx of stroke or ischemic HD
- Hx of VTE
- Inherited thrombophilia
- lupus (SLE)
- migraine w/ aura
- breat ca
- Cirrhosis
- liver tumor
50
side effects of E-Ps:
- Most common= breakthrough bleeding
- amenorrhea
- bloating
- N
- breast tenderness
- weight gain?
- HA, but no strong relationship in OCPs
51
why breakthrough bleeding in E-Ps?
- results from thinning of endometrium
- more common on low-dose or extended OCs
- may be caused by missed pills
- not associated with decreased efficacy
- expectant management for 3 cycles
52
Non-contraceptive benefits of E-Ps:
- decreased menstrual bleeding
- decreased dysmenorrhea
- improvement of pms symptoms (extended cycle)
- prevention of menstrual migraine (extended cycle)
- decreased benign breast disease
- improvement of acne
- control of hirsutism
- management of uterine leiomyomata (fibroids)
- suppression of endometriosis
- decreased endometrium, ovary, and colon ca risk
53
Differences in combines OCs:
- amount of estrogen (10-50 mcg)
- type and amount of progestin
- pattern of delivery (monophonic, triphasic)
- Cost
54
2 biggest things when prescribing OCs:
-reviewing medical hx
-Measure BP
No longer recommended for pelvic exam, Pap smear, std screen
55
Starting OCs:¸
- Sunday start avoids menses on weekends
- Or quick start take pill day Rx is given, r/o existing pregnancy, 2nd is when efficacy starts
- or first day of menses start, gives maximum contraceptive effect starting with first cycle
56
Increased cycle length can...
increase BTB but are you treating symptoms such as HA, PMS and dysmenorrhea with the menstrual cycle.
57
What is the most common reason women stop using OCs?
unscheduled bleeding
58
As estrogen levels go down, HA, nausea, breast tenderness go ______ and rates of irregular bleeding go ____
down, up
59
OC drug interactions:
- Anticonvulsants: Phenytoin, phenobarbital, carbamazepine, topiramate decrease OCP effectiveness
- Antibiotics- Rifampin only one proven to reduce estradiol and progestin levels
- St. Johns Wort
60
can healthy women who don't smoke continue taking OCs through menopause?
yep
61
Info about the patch:
- change weekly
- 21 days on, 7 off
- better steady-state hormone levels
- highest average serum estrogen levels of all methods
- increased dvt?
- less discrete
- cost more
- no generi available
62
vaginal ring info:
- ring changed monthly
- 21 on, 7 off
- learning curve
- increased vaginal discharge?
- cost more
- no generic
63
Progestin-only options:
- Progestin-only pills
- DMPA
- Implant
- IUD
- Plan B
64
Progestin only pills mode of action:
- thickens cervical mucus
- Thins endometrium
- Variable suppression of ovulation
65
Taking progestin only pills:
- take continuously, no placebos
| - short half-life so take on consistent schedule
66
progestin-only pregnancy rate:
- correct use- <1%
| - typical use- 9%
67
progestin only pills contraindications:
- breast ca
- undiagnosed abnormal uterine bleeding
- active liver disease
68
what are not contraindications of progestin only pills that are of combination pills?
- stroke
- MI
- DVT
69
progestin only pills side effects:
- irregular bleeding
| - amenorrhea- no cycling with this pill
70
what type of contraception should you use in lactating women?
-progestin only OCs
71
how do you administer DMPA (Depo)
-3 month injection: 150 mg IM
72
DMPA modes of action:
- suppress ovulation
- thicken cervical mucus
- thins endometrium
- decrease tubal motility
73
DMPA pregnancy rate:
- correct use- 1%
| - typical use 6%
74
DMPA contraindications:
- breast Ca
- undiagnosed uterine bleeding
- active liver dz
- osteoporosis or risk factors of
75
DMPA black box:
-loss of bone density
76
DMPA risks:
-decrease bone density in long term use
77
DMPA side effects:
- change in bleeding pattern: frequent irregular bleeding x6 mo. subsequent amenorrhea
- weight gain
- HA
- Mood changes esp with preexisting depression
- UNPREDICTABLE RETURN TO fertility (6 mom - 2 yr)
78
Top tier contraception:
- LARCs
| - Sterilization
79
common feature of high-effective contraception:
-eliminate user failure
80
LARCs:
Implant: Nexplanon
Intrauterine: Mirena, Skyla, ParaGard
-most effective non-permanent methods
-underutilized in us
81
Nexplanon (progestin only implant) info:
-insertion and removal by trained providers
82
Nexplanon MOA:
- thicken cervical mucus
- decreases tubal motility
- Some inhibition of ovulation in early stages
- endometrial thinning
83
Nexplanon pregnancy rate:
-correct use and typical use <1%
84
Nexplanon contraindications:
- Breast Ca
- undiagnosed abnormal uterine bleeding
- active liver dz
- no association with MI, Stroke, or VTE
85
Nexplanon Side effects:
- unschedule bleeding: 15% d/c use for this reason, may have 5 days of bleeding/month, not predictable
- HA
- weight gain
- acne
- breast tenderness
- mood changes
86
Nexplanon cost:
- 400-800
- variable coverage by 3rd party payers
- possible buyers regret
87
intrauterine device uses by country:
Most in asia
middle: Europe
least: USA
88
intrauterine device pregnancy rate:
-correct and typically: <1%
89
Intrauterine device MOA:
```
Prevention of fertilization:
-Device creates “hostile -intrauterine environment”
-Toxic to ova and sperm
-Impairs implantation
-Not an abortifacient
Hormonal IUDs also:
-Thicken cervical mucus
-Cause endometrial thinning
```
90
intrauterine + hormonal:
```
Mirena (52 mg levonorgestrel)
5 year method
Skyla (13.5 mg levonorgestrel)
3 year method
Cost ~$500-$1000
```
91
intrauterine + copper
```
ParaGard
10 year method
2nd only to sterilization
in cost-effectiveness
Cost ~$500-$1000
```
92
ParaGard vs Mirena/Skyla
ParaGard superior for hormone-intolerant women
ParaGard most economical
ParaGard longest duration
Mirena/Skyla decrease menstrual bleeding
Mirena/Skyla decrease dysmenorrhea
Mirena/Skyla may decrease pain from endometriosis
Mirena/Skyla may decrease sxs from leiomyomata
93
general intrauterine device contra:
Active pelvic infection
Known or suspected pregnancy
Undiagnosed abnormal uterine bleeding
Severely distorted uterus
94
paragard contra:
- wilsons dz
| - copper allergy
95
mirena, skyla contra:
-current breast ca
96
intrauterine device adverse effects:
Missing strings
Expulsion risk ~5%
Sxs: cramping, abnormal bleeding, changes in string
May be asymptomatic
Confirm with pelvic ultrasound
Uterine perforation
Usually at the time of insertion
Recognition may be delayed
Partner discomfort
“Buyer’s regret”
Pelvic infection
Risk limited to the insertion process (first 20 days after insertion
Associated with STI (chlamydia, gonorrhea)– consider testing prior to insertion
Long-term use of IUD is NOT associated with increased risk of pelvic infection
97
ParaGard side effects:
Increase in dysmenorrhea
| Increase in menstrual bleeding
98
Mirena/Skyla side effects:
-Irregular bleeding
-Amenorrhea
-Hormonal side-effects:
Acne, weight gain, nausea, headache, breast tenderness
mood changes
99
Permanent Sterilization:
- Male = Vasectomy
- Tubal sterilization
- Postpartum sterilization
- Laparoscopic sterilization
- Tubal cautery, rings, clips, etc.
- Hysteroscopic sterilization
- Essure
100
Vasectomy:
- safer, less costly, more effective than tubal ligation
- office procedure
- local anesthesia
- cost- 400-700
- Failure rate 1 in 500
- gold standard
- underutilized
101
Tubal sterilization:
-5x more common than vasectomy
102
Laparoscopic sterilization
Multiple techniques available
Tubal cautery and division, clips, bands, rings, etc.
1 in 300 failure rate for all methods
103
Hysteroscopic sterilization (Essure)
- Office-based procedure
- Usually does not require general anesthesia
- Less effective than conventional tubal ligation? (1% failure?
- Alternative device (Adiana) marketed in U.S. 2009-2012; now off the market (for business reasons according to mfr
104
Operative risks of female sterilization:
Bleeding
Infection
Damage to internal organs
Anesthesia complications
Less risk from local anesthesia vs. general anesthesia
Ectopic pregnancy risk if pregnancy does occur!
Cost varies widely depending on method and location of procedure ($1500-$6000)
105
Most common risk of sterilization?
-regret
Occurs in 3-25% of women
1-2% of women seek reversal
Usually associated with change in marital status
Increases with young age at time of procedure
106
Emergency contraception info:
12% of reproductive aged women used emergency contraception at least once between 2006-2010.
Intended for occasional or back-up use (no method used or method failure)
Plan B (levonorgestrel) – OTC
ella (ulipristal)-- Rx
ParaGard (copper) IUD– Office placement
107
Plan B info:
```
Use up to 72 hours post-coitus
Progestin; delays ovulation
OTC status
Generic products available
No harm to existing pregnancy
Cost ~$30-$65
```
108
Ella info:
```
Up to 120 hours post-coitus
More effective than Plan B
Anti-progestin
Delays ovulation
Requires Rx
Pregnancy must be excluded
(history or pregnancy test)
Cost ~$50-$60
```
109
ParaGard as emergency contraceptive:
```
Most effective postcoital method
Inhibits fertilization
Use up to 5 days post- coitus
Requires office procedure
Exclude existing pregnancy
(pregnancy test)
Provides ongoing contraception
Cost ~$500-$1000
```
