Contraception Options

Question 1

When you think of risks vs benefits on contraception. What is the big complication to consider?

Answer 1

The woman’s risk for cardioembolic events.

They are: HTN, age>35, and smoker

Question 2

What are some excessive estrogenic effects that may result from taking contraception?

Answer 2

Dysmenorrhea
Nausea
Cholasma
CVA
DVTR
Thromboembolic disease
PE
Telangiectasias
Hepatic adenoma/adenocarcinoma
Cervical changes
Breast tenderness (secondary to increased size)

Question 3

What are some excessive progestational effects?

Answer 3

Breast tenderness
Transient HTN
Depression
Fatigue
Decreased libido
Decreased duration in menstrual bleeding
Increased appetite

Question 4

What are some excessive androgenic effects?

Answer 4

Hirsutism
Acne
Oily skin
Edema
Increased libido

Question 5

If you had a patient deficient in estrogen, when would you expect them to have?

What about if she was deficient in progesterone?

Answer 5

Deficient ESTROGEN: continuous spotting/bleeding, atrophic vaginitis, no withdrawal bleeding, decreased duration in menstrual bleeding, breakthrough bleeding on days 1-9 of cycle
vs.
Deficient PROGESTERONE: Breakthrough bleeding on days 10-21 of cycle and delayed menses

Question 6

You have a patient who is on a combination pill and she comes to see you complaining of menorrhagia, N/V, headache, bloating, and irritability. What do you do?

Answer 6

You know these symptoms indicate she is getting too much estrogen and too little progesterone so you lower her dose of estrogen and increase her dose of progesterone.

Question 7

Who are the best candidates for progestine-only OCPs?

Answer 7

Those with migraine headaches and who are breastfeeding… or who have some contraindication for combined OCPs

Question 8

True or False. It is okay for women with a family history of breast CA to take a combination OCP?

Answer 8

FALSE!

Question 9

What should you know about OCPs and antibiotics, anticonvulsants, warfarin, and certain oral hypoglycemic agents?

Answer 9

Antibiotics and anticonvulsants decrease the efficacy of OCPs

OCPs decrease the efficacy of warfarin and hypoglycemic agents (oral and insulin)

Question 10

True or False. OrthoEvra releases 60% more estrogren than OCPs?

Answer 10

True.

**Increased risk of serious cardioembolic events

Question 11

Ortho Evra Patch
Typical failure rate?
MOA?
Advantages?
Disadvantages? 
Management/Prescriptive guidelines?

Answer 11

**<1-2%
**Prevents ovulation, similar to OCPs
**Once per week for 3 weeks, easily reversible
**Site reactions, prog/estrog S/Ss, no STI protection
**Reduced effectiveness in women >198 lbs/90 kg
**Same contraindications as OCPs
**If off for >24 hrs, need to restart 4-week cycle and use
back up method

Question 12

When would you instruct your patient to start/place the OrthoEvra patch?

Answer 12

On the first day of her menstrual cycle or the Sunday after the first day of her menstrual cycle

Question 13

What do you tell the patient if she patch falls off/or is off for more than 24 hours?

Answer 13

Put on a new patch (start the 4 week calendar over again) and use a backup method

Question 14

Which contraceptive method decreases HDL, has the potential to reduce bone density with long-term use, when discontinued may have a delayed return of fertility of up to 1 year, and may be helpful in reducing pain from endometriosis?

Answer 14

Depo-Provera (long-acting reversible contraceptive/LARC)

If pregnancy planned within a year, should not be given
There is a 2 week grace period for injections. If longer than 2 weeks, pregnancy test needs to be done.

Question 15

Which contraceptive methods require informed consent?

Answer 15

Implanon and IUDs

Question 16

Which IUD can remain in the uterus for 10 years?

Answer 16

ParaGard/Copper IUD

Question 17

Which IUD can remain in the uterus for 5 years?

Answer 17

Mirena/Progestin-only IUD

Question 18

What are the two absolute contraindications to use of an IUD

Answer 18

Pregnancy
Active, recurrent, or recent PID including gonorrhea and
chlamydia

*An IUD can be inserted 4-8 weeks postpartum

Question 19

What do you do if a patient tells you she can’t find her string?

Answer 19

Abdominal US to ensure IUD is still in place

Question 20

How long must a diaphragm/cervical cap be left in place after intercourse?

Answer 20

6 hours

Question 21

After how much weight loss or weight gain must a cervical cap/diaphragm be refitted?

Answer 21

20 lbs

Question 22

What are the top 3 least effective contraceptive methods (with the greatest failure rate)?

Answer 22

Spermicides (21%)
Diaphragm (18%)
Male condoms (12%) vs female condoms (21%)

Question 23

If using an IUD as emergency contraception, when should it be inserted?

Answer 23

Within 5-6 days of having intercourse

*It is 99% effective vs Plan B which is 85% effective

Question 24

What is the most common side effect of Plan B?

Answer 24

N/V… so prescribe or advise anti-emetic use

Question 25

If using the basal body temperature method for contraception, when should you avoid intercourse?

Answer 25

2-3 days before the expected drop in temperature (indicates ovulation) to approximately 3 days following the rise (rises after ovulation d/t progestin)

Question 26

What are combined pills?

Answer 26

Alter the dosage of estrogen and progestin throughout the cycle and contain: Estradiol - Most common estrogen preparation

Question 27

What is a mini pill?

Answer 27

Progestin only, not as effective as combination pills

Question 28

What is effectiveness of the pill?

Answer 28

Typical 1st year failure rate is 3% Typical 1st year failure rate in age <22 yrs is 4.7%

Question 29

MOA of the pill

Answer 29

Estrogenic effects: *Ovulation inhibited by suppression of FSH/LH *Implantation inhibited by alteration of endometrium *Ovum transport is accelerated *Luteolysis may occur as estrogen causes progesterone levels to fall Progestational effects: *Thick cervical mucus interfers with sperm transport *Capacitation may be inhibited *Ovum transport may be slowed *Implantation is hampered by suppression of endometrium *Ovulation inhibited by hypothalmic-pituitary-ovarian disturbances

Question 30

Advantages of the pill include...

Answer 30

``` Excellent protection against unwanted pregnancy Safe for most women Decreased menstrual cramps and pain Less menstrual blood flow Improvement in facial acne Woman controls own fertility Excellent reversibility and easy to use ```

Question 31

Non-contraceptive benefits of the pill include...

Answer 31

* Decreased menstrual cramps and pain * Less menstrual blood flow * Improvement in facial acne

Question 32

S/S of combination of estrogen excess and progesterone deficient

Answer 32

``` Dysmenorrhea Menorrhagia N/V Headache Irritability Bloating/edema Syncope ```

Question 33

Absolute contraindications for OCP use.

Answer 33

``` Hx of thromboembolic disorders Hx of CVA CAD Known or suspected breast CA Pregnancy Liver tumor or impaired LFTs Previous cholelithiasis during pregnancy Undiagnosed, abnormal uterine bleeding ```

Question 34

``` NuvaRing Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines? ```

Answer 34

**<1-2% **Releases synthetic estrogen and progestin, prevents ovulation, convenient, once a month, fewer mood swings compated to OCP, possible shorter/lighter periods **Increased vaginal discharge/infection, may worsen depression, no STI protection **Age >35, smoker, uncontrolled HTN, hx of MI, CVA, DVT, PE, etc. **Inserted once a month, left for 21 days **If it slides out, needs to be put back in within 3 hrs, back up method needed if left out for more than 3 hrs

Question 35

``` Depo-Provera Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines? ```

Answer 35

PROGESTIN ONLY **<1% **Suppresses FSH and LH, thickens cervical mucosa, alters endometrium **Highly effective, long acting, convenient, prolonged amenorrhea possible, decreased anemia, decreased cramps and ovulation pain/endometrial pain **No estrogen related side effects **Possible reduction in risk of PID and CA **Delayed return of fertility (up to 1 year) **Injection Q3 months -2 week grace period- **Decrease in HDL **Possible reduction in bone density with long-term use

Question 36

``` Nexplanon Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines? ```

Answer 36

PROGESTIN ONLY * *<0.01% * *Same as other progestins * *Good for 3 yrs * *Same as other progestins * *Requires informed consent * *Implant may be slightly visible * *Expensive

Question 37

``` IUD Types? Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines? ```

Answer 37

**Copper-releasing (ParaGard) - 10 yrs **Progestin-releasing (Mirena) - 5 yrs **1-3% **Immobilizes sperm and interferes with migration **Local foreign body inflammatory response **Same as other progestins **Can prevent Asherman's Syndrome **Pain/cramping, up to 45% removals due to pain **Increased menstrual bleeding **Pregnancy - spontaneous abortion up to 50% if IUD left in uterus and ectopic pregnancies occur in 5% **Spotting/bleeding/hemorrhage/anemia **Expulsion, up to 10% in first year **Lost IUD string **PID - highest risk in first 6 weeks after insertion **Requires informed consent **Danger signs** late menses, abdominal pain/dysparunia, fever, chills

Question 38

``` Diaphragm/Cervical Cap Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines? ```

Answer 38

* *18% * *Barrier against sperm transport * *Use with spermIcide cream or gel * *May provide some STI protection when used with spermicide * *Possible increased risk of UTI, vulvovaginitis * *Allergy to rubber/latex/spermicide * *Check for holes periodically * *AVOID OIL-BASED LUBES * *Leave in for 6 hrs following sex, instill spermicide in vagina for repeated intercourse

Question 39

Spermicides Typical failure rate? Advantages? Disadvantages?

Answer 39

* *21% * *Purchased OTC * *May cause skin irritation

Question 40

Condoms Typical failure rate? Advantages? Disadvantages?

Answer 40

* *male 12% * *female 21% * *protection against STIs * *Allergy to rubber or spermicide * *They break * *Natural skin condoms have no protection against STIs * *NO OIL BASED LUBES

Question 41

Emergency Contraception Types? Effectiveness?

Answer 41

``` OTC levonorgestrel (Plan B) No prescription if over 17 yrs Should be taken within 72 hours NOT THE ABORTION PILL Only 85% effective ``` IUD - Copper releasing Inserted within 5-6 days, almost 99% effective

Question 42

Sterilization

Answer 42

``` Permanent Female 1:400 failure rate Male 1:600 failure rate Female tubal ligation Male vasectomy ```

Question 43

Natural family planning | Typical failure rate?

Answer 43

First year failure rate 20%

Question 44

Calendar Method

Answer 44

**Record serial cycles, identifying longest and shortest cycles **Determine fertile phase by subtracting 18 days from shortest cycle (earliest day of fertility) and 11 days from longest cycle (latest day of fertility) **Abstain from sex during this time frame

Question 45

Basal Body Temp Graph

Answer 45

BBT **Record daily BBT prior to rising in AM over 3-4 month period **Temp drops 12-24 hrs prior to ovulation and rises following ovulation due to production of progesterone **Avoid intercourse from 2-3 days prior to expected drop to approximately 3 days following the rise

Question 46

Cervical Mucus Test

Answer 46

Billings Testy **Record changes in cervical mucus (Spinnbarkeit) over 3- 4 month period **Notice when mucus changes from scant and thick amounts to thin, with increasing Spinnbarkeit **Abstain from time of mucus change until approx 4 days after change, mucus resumes thickness

Question 47

Symptothermal Method

Answer 47

Method that uses both the basal body temp and cervical mucus techniques

Question 48

Lactational/Amenorrhea Method

Answer 48

Pro-longed breast feeding **Pt relies on breastfeeding for natural family planning as breastfeeding often delays the onset of ovulation and menstruation for approx 6 months