Ex. 5 L1: Preventative Health/Nonhormonal Contraception (43)

Question 1

Menstrual cycle

Answer 1

Two Phases:
Follicular
-Onset of menses through ovulation
Luteal
-Ovulation through onset of next menses

Drop in estrogen -> LH surge -> release of matured follicle (ovulation)

Question 2

Preventative health: annual exam

Answer 2

Vital signs
Breast exam
Pelvic exam and or screening

Question 3

Breast exam

Answer 3

Average risk women:
-Self exam or clinical breast exam (varying recommendations)
-Mammogram
Recommended to start by age 40-50
Complete every 1-2 years
Continue until age 75 or when life expectancy is less than 10 years

High risk women:
-I.e. BRCA1 or BRCA2 gene mutations and first-degree relatives
Recommended to receive breast MRI and a mammogram annually starting at age 30

Question 4

Pelvic exam

Answer 4

Utility
-Screening tool for STIs, gynecologic cancers, pelvic inflammatory disease, ovarian cysts, polyps or fibroids
Components
-Assessments of external genitalia, internal speculum exam or rectovaginal exam
Recommendation
-Not routine in asymptomatic patients
-Performed when indicated by medical hx or symptoms

Question 5

Cervical screening (PAP) recommendations:

Answer 5

21-29: Pap every 3 years

30-65: Anyone:
-Pap smear every 3 years
-HPV testing every 3 years
-Co-testing (Pap + HPV testing) every 5 years

> 65 years (no prior screenings were normal)
-No screening

Hysterectomy with cervix removal
(no screening)

Question 6

Additional screening and counseling (PAP)

Answer 6

Cancer
-Endometrial, ovarian, colorectal
Substance use
Domestic violence
Hyperlipidemia
HTN
Diabetes
STIs
Thyroid function
Infertility
Osteoporosis
Obseity
Eating disorders
Sexual dysfunction
Depression
Anxiety
Contraception
Immunizations

Question 7

HPV

Answer 7

-Most common STI in the US, containing >150 viruses
-14 million new infections every year
-Genital HPV affects 42.5% of adults aged 18-59
-Commonly causes warts (papilloma)
-Genital warts may lead to an increased risk of multiple cancers

Question 8

HPV transmission

Question 9

HPV associated cancer cases per year - female

Answer 9

Cervix
11,869
11%
Vagina
875
75%
Vulva
4238
69%
Anus
5150
93%
Oropharynx
3557
63%

Question 10

HPV associated cancer cases per year - male

Answer 10

Penis:
1,364
63%
Anus:
2,410
89%
Oropharynx
17,248
72%

Question 11

HPV prevention

Answer 11

Barrier protection (condoms, dental dams)
Mutually monogamous
Male circumcision
HPV screening
HPV vaccination

Question 12

HPV screening

Answer 12

Patients w/a cervix
-Follow recommended cervical screening guidelines
Patients w/a penis
-Routine screening not currently recommended
Patients at higher risk include men who have sex w/men and or HIV+
May benefit from anal PAP smears

Question 13

HPV Vaccines

Answer 13

Cervarix (2vHPV)
Serotypes: 16, 18
Admin - no longer available in the US
Gardasil (4vHPV) - no longer available in the US
Gardasil 9 (9vHPV)
Serotypes:
6,11,16,18,31,33,45,52,58
Admin schedule:
Start <15y/o: 2 dose series
-0,6-12 months
Staer >15y/o: 3 dose series
0,2,and 6 months
Females 9-45
Males 9-45

Question 14

HPV vaccines ages

Answer 14

Ages 19-26:
-Administer 2 or 3 doses series in those who did not start or finish the vaccine series
Ages 27-45:
Vaccination provides less benefit after exposure
Risk vs benefit discussion

Question 15

HPV vaccine - efficacy

Answer 15

Aged 16-26:
F: 98% cervical cancer
100% vulvar cancer
100% vaginal cancer
M: ~75%
Aged 27-45:
~88-95% effective genital warts, vulvar cancer, vaginal cancer, and cervical cancer in Females
Efficacy in men aged 27-45 is inferred based on this data

Question 16

HPV Vaccine safety

Answer 16

Injection site reactions
Dizziness/Fatigue
HA
Syncope (fainting)
Vomiting
Myalgia

Question 17

Role of provider in HPV assessment

Answer 17

Educate about HPV related risks
Give strong and clear recommendations
Utilize standing orders
Process or monitoring and follow up
-Protecting your patients from preventable cancers

Question 18

_% of women aged 15-49 are currently using contraception

Answer 18

65

Question 19

Ideal contraception

Answer 19

100% safe and effective
Easy to use
Independent of timing of intercourse
Affordable
Reversible
HIV/STI protection

Question 20

Reasons for Non-Hormonal Contraception

Answer 20

Back-up hormonal method
SE or contradictions to hormones
No need for ongoing contraception
No alteration to body’s natural menstrual cycle

Question 21

Behavioral Methods

Answer 21

Coitus Interruptus
Lactation Amenorrhea Method (LAM)
Fertility Awareness Methods (FAM)
Natural Family Planning (NFP)

Question 22

FAM + NFP

Answer 22

Basal Body Temp (BBT)
-Predict Ovulation
-Regular cycles
-Initial drop in temp followed by a significant rise indicates ovulation
Billings Ovulation Method
-Cervical Mucus
-Irregular Cycles
Calendar/Rhythm Method
-based on past cycles
Standard Days Method
-26-32 day cycles
Two-Day method
-Cervical secretions

Question 23

FAM + NFP Other methods

Answer 23

Sympothermal method
-Uses a minimal of 2 indicators at the same time
-May include other symptoms of ovulation
Electronic Monitoring
-Detect luteinizing hormone (LH) in urine
ClearBlue Fertility Monitor
OvuSense Fertility and Ovulation Monitor
Marquette Method
-Combination of ClearBlue Fertility Monitor and Other NFP methods

Question 24

FAM + NFP App

Answer 24

Natural cycles
-First app approved by FDA to be marketed as a contraception method
Based on BBT and cycle data
App will prompt user to use protection on likely fertile days
Typical use failure rate: 7%
Perfect use fail: 1%
Monthly Subscription costs: $14.99
Partnership w/Oura Ring - Allows patient to skip manual temperature checks

Question 25

FAM + NFP Summary

Answer 25

**Advantages:** -No effect on hormones or menstrual cycle -No SE -Inexpensive or free -Acceptable in many cultures and religions **Disadvantages** -No protection against STI -Difficulty predicting ovulation in those w/irregular cycles -Requires consistent and accurate record keeping -Requires extended periods of abstinence or backup contraception **Effectiveness: 1-34% failure rate**

Question 26

Barrier Methods

Answer 26

Physically prevents sperm from entering the uterus Used each time a person has intercourse Used CORRECTLY each time Many different options Fewer SE and less efficacy compared to hormonal Contraception

Question 27

Barrier method types

Answer 27

Male condom Female condom Vaginal sponge Diaphragm Cervical cap Contraceptive Gel Spermicide

Question 28

Barrier Methods Summary:

Answer 28

**Male Condom** Adv: Low $$ HIV/STI protection Easy to obtain Disadv: User dependent Slippage/breakage **Female Condom** Adv: -Insert up to 8 hrs before -HIV/STI protection Disadv: -user dependent **Vaginal Sponge:** Adv: Protects for 24hrs from insertion Disadv: User dependent No HIV/STI protection **Diaphragm** -Insert 6-8 hrs before -No systemic SE Disadv: -No HIV/STI protection -Need proper fitting -UTI/TSS risk **Cervical cap** Protects for up to 28 hrs No systemic SE Disadv: -No HIV/STI protection -Need proper fitting UTI/TSS risk **Contraceptive Gel** -Insert immediately before or up to 1 hour Disadvantage: -1 dose for each act of interocourse Vaginal infections -No HIV/STI protection **Spermicide** -Low $$ -Easy to obtain Disadvantage: No HIV/STI protection Irritation

Question 29

Long Term Method

Answer 29

Copper IUD -Prevents pregnancy up to 10 years Can also be used for emergency contraception Inserted and removed by HCP Extremely effective - typical fail rate 0.8% Non-hormonal - copper acts as a spermicide and prevents sperm from fertilizing eggs $$$ No STI prevention SE -Heavy/painful bleeding -Spotting

Question 30

Permanent Methods

Answer 30

Surgery Sterilization

Question 31

Effectiveness ranking

Answer 31

**MOST**: Implant IUD Sterilization Injection Pill Patch Vaginal Ring Diaphragm Male Condom Female Condom Cervical cap Sponge FAM Spermicide