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Flashcards in Contraceptive Methods Deck (39)
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1
Q

overview of contraception

A
  • 50% of pregnancies in the US are unintended
    • Almost 50% of these occur in women using a reversible contraceptive method
      • Nearly 50% of these end in elective termination
  • What are the factors that affect a woman’s choice or use of contraception?
2
Q

factors to consider

A
  • Efficacy
  • Convenience
  • Duration of action
  • Reversibility and time to return of fertility
  • Effect on uterine bleeding
  • Frequency of side effects and adverse events
  • Affordability
  • Protection against sexually transmitted diseases
3
Q

overview of contraception

A
  • Abstinence
  • Natural family planning / withdrawal
  • Lactation
  • Barrier methods / spermicide
  • Hormonal methods
  • Intrauterine devices
  • Permanent sterilization
  • Emergency Contraception
4
Q

natural family planning

A
  • Standard days method
  • Calendar rhythm methods
  • Basal body temperature method
  • Ovulation method
  • TwoDay method
  • Symptothermal methods
  • Nonhormonal, nonsurgical methods based on fertility awareness
5
Q

withdrawal method

A
  • The withdrawal method (coitus interruptus) requires men to withdraw from the vagina before ejaculation
  • Failure occurs if withdrawal is not timed accurately or if the pre-ejaculatory fluid contains sperm
  • Failure rates as high as 18-20% have been reported
  • Can offer emergency contraception options as long as they are not breastfeeding
6
Q

lactation amenorrhea method

A
  • Breastfeeding causes delay in resumption of ovulation postpartum
  • Only reliable if
    • The woman is less than six months postpartum
    • She is breastfeeding exclusively (ie: not providing food or other liquid to the infant)
    • She is amenorrheic
  • There are other methods of contraception available during the postpartum period
7
Q

barrier methods

A
  • Nonhormonal, few side effects
  • No prescription required for condoms, sponge
  • Increased effectiveness if used with spermicide
  • Condoms should be used once and discarded
  • Cervical cap, diaphragm, sponge may be cleaned and reused
    • Cervical cap, diaphragm need to be fitted
8
Q

barrier contraception: condoms

A
  • Male condom
    • Pregnancy rate 15% with typical use
    • Best protection against STD
    • Latex, polyurethane, natural membrane
    • Do not use oil-based lubricants with latex condom
  • Female condom
    • Pregnancy rate 21% with typical use
    • Polyurethane, prelubricated
9
Q

barrier contraception: diaphragm

A
  • Diaphragm + spermicide
    • Pregnancy rate 16% with typical use – even higher for women who have had babies
    • Requires fitting by a clinician
    • Not for preventing STD
    • Leave in 6-8 hrs after intercourse then remove and wash
    • May increase risk of UTI
    • Not recommended for HIV positive pts
  • Only effective when used with spermicide
  • Not a very popular method in the US
10
Q

barrier contraception: cervical cap

A
  • Cervical cap
    • Pregnancy rate 16%; 32% if previous births
    • Must be fitted by trained professional
    • Latex or silicone rubber; 3 sizes
    • Not for STD prevention
    • Leave in vagina 6-8 hrs (up to 48 hrs), then remove and wash
  • Less effective after previous births due to change in size/shape of cervix
  • Not as effective as the diaphragm
11
Q

barrier contraception: sponge

A
  • Vaginal sponge
    • Pregnancy rate 16% for typical use; 32% if previous births
    • Moisten with tap water before insertion deep in the vagina
    • May be left in place, used repeatedly up to 24 hrs
    • Nonprescription, no fitting required
    • 2 inch wide circular disk, ¾ inch thick, containing 1000 mg of nonoxynol-9 and attached to a loop for removal
12
Q

barrier method: spermicide

A
  • Spermicides (Nonoxynol-9)
    • Available without a prescription
    • Variety of forms including gel, foam, cream, film, suppository, and tablet
    • Not a highly effective method of contraception when used alone (without a barrier method)
    • Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration, or if a repeat dose is not applied before each additional act of intercourse
    • May cause local irritation, some increase in bacterial vaginosis infections, and may be messy
13
Q

hormonal methds

A
  • Oral contraceptive pills
    • Combined (estrogen-progestin) pills
      • Monophasic / continuous
      • Triphasic
    • Progestin only pills
  • Vaginal estrogen ring
  • Transdermal estrogen patch
  • Injectable progestin
  • Subdermal implants
  • Mirena IUD
  • The progesterone levels are the same throughout the pack. With the phasic ones, the estrogen is the only thing that is changed
14
Q

oral contraceptives

A
  • Several mechanisms of action
  • Estrogen/progestin-induced inhibition of the midcycle surge of gonadotropin secretion so that ovulation does not occur
  • Reliable form of contraception
    • Pregnancy rates 8% with typical use, < 1% with perfect use
  • Other benefits include reductions in dysmenorrhea, menorrhagia, acne, risk of ovarian cancer, endometrial cancer
15
Q

Combined oral contraceptives

A
  • May be given cyclically (21 or 24 active followed by 7 or 4 inactive pills) or by an extended cycle regimen (84 active followed by 7 inactive pills) or active pills taken indefinitely
  • Ortho tricyclen, Seasonale, Loestrin shown
  • If you only want to have your period 3 times a year, YOU HAVE TO BE ON MONOPHASIC PILLS!!! You cant do this with triphasic etc. pills.
  • Monophasic pills must be used when prescribing longer cycles to avoid breakthrough bleeding
  • Most current OCs contain 20 to 35 mcg of ethinyl estradiol and various types of progestin
    • Norethindrone, levonorgestrel, norgestimate, desogestrel, drospirenone
    • Different progestins may have different side effects
  • Very low dose (20 mcg) pills may cause more breakthrough bleeding than higher doses
16
Q

progestins oral contraceptive

A
  • Synthetic progestins bind to progesterone and androgen receptors
  • Androgen binding affinity can cause unwanted side effects (weight gain, acne)
  • Norgestimate has a low androgen binding affinity
    • Indicated for pts with PCOS, acne
  • Drospirenone has anti-mineralocorticoid and anti-androgen properties
    • Marketed for pts with acne
17
Q

adverse effects of combined oral contraceptives

A
  • Adverse effects
    • Irregular menstrual bleeding – 32%
      • Menses often get lighter and less painful with time
    • Nausea – 19%
      • Usually resolves within 3 months
    • Weight gain – 14%
    • Mood swings – 14%
    • Breast tenderness – 11%
    • Headache – 11%
    • CV or thromboembolic events
  • Most of these sxs usually resolve in a few months
18
Q

Contraindications of combined oral contraceptives

A
  • Previous thromboembolic event or stroke
  • History of an estrogen-dependent tumor
  • Liver disease
  • Pregnancy
  • Undiagnosed abnormal uterine bleeding
  • Cerebral vascular or coronary artery disease (past or current history)
  • Complicated valvular heart disease
  • Women over age 35 years who smoke
  • Migraine with an aura
19
Q

indications for progestin only pills (minipills)

A
  • Progestin only pills (minipills)
  • Indicated in breastfeeding and women who need to avoid estrogen
  • More breakthrough bleeding
  • Slightly higher failure rate
  • Must be taken at the same time (within 3 hours) every day; no placebo period
  • Must have back-up or emergency contraception available
  • Migraine headaches with aura
  • Age over 35 years and smoker or obese
  • History of thromboembolic disease
  • Cardiac disease, especially coronary artery disease or congestive heart failure
  • Cerebrovascular disease
  • Early postpartum period
  • Hypertension with vascular disease or older than 35 years of age
  • Systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies
  • Hypertriglyceridemia
20
Q

initiating oral contraceptives

A
  • Thorough history for contraindications, risks
  • BP measurement
  • Recommended but not required: breast exam, cervical cancer screening, and screening for sexually transmitted diseases
  • May begin at any time in the cycle – neg UPT and back-up method for 7 days
    • First day start – start on 1st day of menses
    • Quick start – start on day Rx is given (neg UPT)
    • Sunday start – start on 1st Sunday after menses
21
Q

oral contraceptives: missed pills

A
  • Adolescents are especially inconsistent
  • Reduces suppression of ovulation, leading to breakthrough bleeding and possibly pregnancy
  • Minipill – if >3 hrs late, use a back-up method
  • Combined oral contraceptives – if >2 pills in a month are missed, use a back-up method
  • Offer emergency contraception
  • Consider switching to another method if a patient regularly misses pills
22
Q

vaginal estrogen ring

A
  • NuvaRing
  • Intravaginal ring worn for 3 weeks then removed for placebo/withdrawal bleed
  • Advantages include:
    • rapid return to ovulation after discontinuation
    • lower doses of hormones
    • ease and convenience
    • improved cycle control
23
Q

transdermal estrogen patch

A
  • Ortho Evra
  • Provides continuous sustained release of hormonal contraception over several days
  • A new patch is applied weekly
  • Similar side effect and efficacy data to NuvaRing and oral contraceptive pills
24
Q

injectable contraceptives

A
  • Depot medroxyprogesterone acetate (DMPA)
  • Brand name Depo-Provera
  • 150mg IM or 104mg SQ
  • Injection given every 12 weeks
  • 99.7% effectiveness
  • Amenorrhea and weight gain may occur
  • Cannot use > 2 years due to risk of osteoporosis
  • Recommend giving first injection while on menses
  • Document negative pregnancy test
25
Q

subdermal implants

A
  • A single-rod progestin implant, Implanon or Nexplanon, available in the US and elsewhere
  • Contraception is provided for three years
  • Fertility returns rapidly after removal of the rod
  • No pregnancies occurred in premarketing studies
  • Irregular bleeding was the primary reason for discontinuation in premarketing studies
26
Q

emergency contraception indications and access

A
  • Indications
    • Unprotected sex including sexual assault
    • Failure of barrier or other contraceptive method
    • Not intended as primary method of contraception
  • Access
    • Plan B One-Step available OTC for anyone
    • Other brands are available by prescription for patients age 16 years and younger
27
Q

Emergency contraception

A
  • “Morning-after pill”
    • Plan B, Next Choice, Ella
    • Effective up to 120 hours post intercourse
    • Does not interrupt pregnancy and is ineffective after pregnancy has occurred
  • Combined oral contraceptive pills may be given at high doses
  • Copper IUD insertion
    • Provides continuing contraception
    • More effective than hormonal agents
  • Plan B contains two 0.75mg tabs levonorgestrel to be taken 12 hrs apart
  • Plan B One-Step contains one higher dose tab of levonorgestrel
  • Next Choice One-Step is another brand of levonorgestrel (one pill)
    Ella is brand name of another hormonal method, ulipristal acetate
  • Most effective within 72 hrs of intercourse
  • Inhibiting or delaying ovulation
  • Interfering with fertilization or tubal transport
  • Preventing implantation by altering endometrial receptivity
  • Causing regression of the corpus luteum
  • Most common side effects are nausea and vomiting; more common with combined pills that Plan B
    • Antiemetics can be given concomitantly
    • If vomiting occurs within one hour of dosing, the dose needs to be repeated
  • Additional (back-up) contraception should be used until the next menses
    • Menstrual bleeding usually occurs within 1 week
    • If no bleeding within 3 weeks, do a pregnancy test
28
Q

Intrauterine devices

A
  • IUDs to prevent pregnancy have been in use for centuries
  • Most modern IUDs are medicated, containing either copper or a progestin to enhance the contraceptive action of the device
  • Used commonly worldwide
  • Highly effective, safe, cost-effective, long-acting, and rapidly reversible method of contraception with few side effects
  • Private and convenient method of contraception, does not interfere with the spontaneity of sex, offers several noncontraceptive health benefits, and can be used by lactating mothers
  • User satisfaction is high
  • Absolute contraindications to IUD use are rare
  • Lower rates of endometrial cancer, ectopic pregnancy, PID, dysmenorrhea, and symptomatic endometriosis
  • Highly effective
    • 10 year pregnancy rates
      • 1.1% levonorgesterol
      • 2.2% copper
      • 1.9% tubal ligation
    • Safe
    • Cost effective ($3-5/mo)
    • Long acting (5 & 10 yrs)
    • Easily reversible
  • Ideal candidates for intrauterine contraception are women who:
    • Are at low risk of acquiring sexually transmitted infections
    • Are not planning a pregnancy for at least one year
    • Want to use a reversible contraceptive
    • Want or need to avoid estrogen-based methods
  • Nulliparous women, women in nonmonogamous relationships, adolescents, breastfeeding women, and women with a history of PID or ectopic pregnancy can all safely use the IUD with appropriate counseling about side effects and prevention of STDs
29
Q

Ideal candidates for intrauterine contraception

A
  • Women at high risk for STDs
    • Nonmonogamous relationships / multiple partners
    • History of STD
  • Women with a history of problems with intrauterine contraception
    • Expulsion, perforation, pain, pregnancy, bleeding
  • Dysmenorrhea or menorrhagia (copper IUD)
  • Hormonal sensitivities (Mirena IUD)
30
Q

Contraindications for intrauterine devices

A
  • Severe uterine distortion
    • Bicornuate uterus, cervical stenosis, or leiomyomata distorting the uterine cavity
  • Active pelvic infection
  • Known or suspected pregnancy
  • Wilson’s disease or copper allergy (copper IUD)
  • Unexplained abnormal uterine bleeding
  • Current breast cancer (Mirena IUD)
31
Q

copper IUD (paragard)

A
  • T-shaped polyethylene frame with 380 mm² of exposed surface consisting of fine copper wire wound around the vertical stem and copper collars on each of the horizontal arms
  • There is a 3 mm ball at the base of the stem to decrease the risk of cervical perforation
  • The contraceptive effect of copper may be related to in utero oxidation with release of copper ions. Copper ions may inhibit sperm migration through the fallopian tube, thus preventing zygote formation
  • Pregnancy rates < 1%
  • May stay in place for 10 years (12 yrs)
  • May cause heavy menses, dysmenorrhea
  • Does not protect against STDs
  • Effective immediately
  • $450
32
Q

components of paragard

A
  • IUD Device
  • Insertion tube
  • Solid rod/trocar
33
Q

Levonorgesterl IUD (mirena, skyla)

A
  • Progestin-releasing T-shaped polyethylene frame with a collar containing levonorgestrel
    • 200mcg progesterone released daily (Mirena)
  • Like the copper IUD, the stem contains barium sulfate so it can be detected by x-ray
  • Does not contain latex
  • Progestin effect is primarily local
  • Immediately effective only if inserted right after menses
  • Pregnancy rates < 1%
  • May stay in place for 3-5 years (7 yrs?)
  • Reduction in dysmenorrhea and menstrual bleeding
  • Hormonal side effects, such as breast tenderness, mood changes, and acne may occur
  • High continuation rates
    • 93% at 1 year; 65% at 5 yrs
34
Q

Levonorgestrel IUD (mirena) advantages and disadvantages

A
  • Disadvantages
    • Changes in bleeding patterns
      • Amenorrhea
      • Unscheduled bleeding
    • Breast tenderness
    • Mood changes
    • Acne
  • advantages
    • Reduction in menses & dysmenorrhea
    • Treatment of endometrial hyperplasia
    • Endometrial protection at perimenopause
    • Treatment of endometriosis
35
Q

insertion of IUD

A
  • Cycle day 5-10 ideal
  • Patient has been abstinent since LMP
  • Documented negative pregnancy test
  • Screening for STDs
  • NSAIDs 30-60 minutes prior to procedure
  • Insert IUD
  • RTC in 4 weeks to check strings, side effects
    • Teach patient how to check her strings
    • Avoid STD exposure for > 20 days
36
Q

risks/adverse events at insertion

A
  • Uterine perforation
  • Syncope
  • Diaphoresis
  • Vomiting
  • Unable to insert
  • Cramping/bleeding
  • Expulsion
  • Embedment in myometrium
37
Q

Adverse events and problems with IUD insertion

A
  • Abnormal bleeding
    • Intermenstrual bleeding or spotting
    • Common in first 3 months
    • Heavy bleeding (decreased with NSAIDs)
  • Pregnancy complications / ectopic pregnancy
  • Pain or partner feels strings
  • Expulsion
    • 3-10% copper; 6% Mirena
  • Infection within first 20 days: 1/1,000
  • Perforation: 1/1,000
    • Risk with inexperience, immobile/retroverted uterus
  • If no strings are visualized, do a UPT to r/o pregnancy; see if you can find the strings in the cervical canal; if not, send the pt for pelvic US. If no IUD is visualized on US you must do a pelvic X-Ray to r/o expulsion; IUDs are radiopaque
38
Q

Permanent sterilization

A
  • Tubal ligation (BTL)
    • Mechanical blockade using clips, rings, coils, or plugs
    • Coagulation-induced blockage using electrical current or chemical agents
  • Hysterectomy
    • Done for another medical indication
  • Vasectomy
39
Q

hysteroscopic sterilization

A
  • Essure
  • 2 part procedure
  • Fibrotic reaction causing stenosis of tubes
  • 3 mo after fiber placed need to do HSG

Only method that gives confirmation of sterilization