OCP Counselling

Question 1

what to ask on sexual history for OCP

Answer 1

previous and present use of contraception, compliance and SEs experienced

sexual orientation and practices

present and past number of partners, concurrent partners

current relationship–> monogamous, health and age of partner

STIs now and in the past (consider screening for current symptoms)

possibility of current pregnancy

Question 2

what to ask on OB/GYN history when counselling about contraception

Answer 2

age of menarche

menstrual cycle length, regularity, total days, amount of bleeding

PMS, other menstrual sx

dysmenorrhea, pelvic pain, dysfunctional uterine bleeding

date of last pap and pelvic exam, past abnormal paps and gynecological procedures

GTPAL

current breastfeeding

childbearing goals and attitude towards accidental pregnancy

Question 3

what to ask specifically on PMHx for OCP counselling

Answer 3

HTN
liver disease
thromboembolic disease–> IHD, CVA, DVT/PE
cancer–breast, uterine, ovarian
migraines with aura or focal neuro findings

Question 4

what other meds might interact with the OCP

Answer 4

anticonvulsants

antibiotics

Question 5

what to ask about on family history when counselling contraception

Answer 5

clotting disorders/VTE/PE

breast, uterine, ovarian, liver cancer

Question 6

is a gyne exam necessary to prescribe contraception

Answer 6

no–only do if suspect STI or if gyne exam is due

pap test if due

Question 7

what investigations should be done if planning to prescribe contraception

Answer 7

beta hcg if suspect pregnancy or if planning IUD

STI testing if high suspicion, patient requests or planning IUD

Question 8

absolute contraindications to the IUD

Answer 8

pregnancy

unexplained abnormal vaginal bleeding

cervical, uterine or salpingeal infection, current or recurrent PID or STIs in last 3 months

immediately post septic abortion

malignant trophoblastic disease

copper allergy or wilsons disease (for copper IUD)

current breast cancer (for hormonal IUD)

severely distorted uterine cavity

Question 9

how effective is the IUD

Answer 9

99.9%

Question 10

what are the pros of the IUD

Answer 10

most effective reversible form of contraception

lasts 5 or more years

copper IUDs can be emergency contraception within 7 days

hormonal IUD improves menorrhagia and dysmenorrhea

Question 11

cons of IUD

Answer 11

small risk of uterine perforation (0.6-1.6/1000), pain or dysmenorrhea

irregular bleeding is common in first few months and decreases over time

possible risk of PID around month of insertion

small risk of expulsion (more during first year)

r/o ectopic pregnancy if becomes pregnant with IUD

Question 12

absolute contraindications of OCP, ring and patch

Answer 12

previous PE, DVT, CVA, CAD

smoker older than 35 (more than 5 cigs/day)

current breast, endometrial, cervical ca

unexplained abnormal vaginal bleeding

cirrhosis, other liver disease

pregnancy

less than 6 weeks post partum if breastfeeding

uncontrolled HTN about 160/100

migraines with aura

complicated valvular disease

DM with retinopathy, neuropathy, nephropathy

Question 13

how effective are the OCP, ring, patch

Answer 13

99.9% if used perfectly–user failure rates are 3-8%

Question 14

pros of OCP, ring, patch

Answer 14

improved cycle regulation, decreased menstrual flow, improved acne and hirsutism, improved dysmenorrhea and PMS

decreased risk of ovarian, endometrial and colon cancer

decreased risk of benign breast disease, fibroids and ovarian cysts

Question 15

cons of OCP, ring, patch

Answer 15

must take pill daily and at same time

irergular bleeding common for first few cycles and tends to improve with time

slight increase in VTE risk compared to non users, highest in first year of use

common SEs: nausea, breast tenderness, headache

increased risk of weight and mood changes–not supported by evidence but anecdotally

Question 16

absolute contraindications to progesterone only pill

Answer 16

pregnancy

current breast ca

relative are viral hep and liver tumours

Question 17

efficacy of progesterone only pill

Answer 17

99.5% with perfect use; 5-10% failure rate

Question 18

pro of progesterone only pill

Answer 18

can be used in breastfeeding women or in patients with contraindication to combined OCP

Question 19

what vital sign must be normal before starting OCP

Answer 19

blood pressure

Question 20

when should you follow up new OCP start

Answer 20

3 months

Question 21

when should you follow up new IUD insertion

Answer 21

4-6 weeks to check strings

Question 22

do minors need parental consent for contraception

Answer 22

no

Question 23

why do you have to confirm the purpose of contraception is to prevent pregnancy

Answer 23

may want it to treat acne

*must tell them it doesnt protect against STDs

Question 24

are any OCPs more effective than another

Answer 24

no

Question 25

how do cardiovascular risks compare between pregnant women and those on OCP

Answer 25

the cardiovascular risk of pregnancy is significantly higher than for OCP

Question 26

what increases risk of ischemic stroke in those on OCP

Answer 26

smoking and HTN

Question 27

how do VTE risks compare between pregnant women and those on OCP

Answer 27

much higher in pregnancy than in those on OCP (but those on OCP have higher risk than general population)

Question 28

what other patient consideration puts them at even higher risk of VTE while on the OCP

Answer 28

obesity

Question 29

how does OCP change breast cancer risk

Answer 29

only slightly higher in OCP use--3/1000 vs 2/1000 but the risk is significantly higher if there is family history of breast ca

Question 30

how long does it take normal ovulatory menstruation to occur again after stopping OCP

Answer 30

1-3 months but can be sooner or later

Question 31

what does the patient do if they missed: | 1 pill

Answer 31

take it as soon as you remember and take next pill at usual time

Question 32

what does the patient do if they missed: | 2 pills in a row

Answer 32

in the first two weeks--> take two pills on the day you remember and two pills the next day; finish rest of pack as usual. **use backup for 1 week in the third week--> keep taking one pill every day until Sunday; on Sunday, set aside rest of pack, including spacers, and start taking a new pack of pills. **use backup for one week

Question 33

what does the patient do if they missed: | 3 or more pills in a row at any time

Answer 33

keep taking one pill every day until Sunday. On sunday, set aside the rest of the pack and start taking a new pack of pills. **use backup for TWO weeks

Question 34

if the patient starts birth control pills right away (without waiting for menses) how long must they use backup

Answer 34

1 week

Question 35

what risk factors must be screened per the example LMCC case

Answer 35

``` DVT active liver disease undiagnosed vaginal bleeding HTN migraines pregnancy ```

Question 36

how to ask about the risk factors mentioned in the LMCC case

Answer 36

``` history of clots? history of abdominal pain? history of jaundice? history of abnormal periods? history of HTN? history of migraines? history of mood changes or depression? ```

Question 37

what does the LMCC case definitely want us to do for young people coming in?

Answer 37

HEEADSS

Question 38

what is HEEADSS

Answer 38

``` Home and environment Education Employment Activities Drugs Sexuality Suicide/depression ```