Women's Health, Contraceptive Counseling- Schoenwald Flashcards
(91 cards)
1
Q
Decision Making
A
-For many people, personal and sensitive issue–> Religious or philosophical
- High rate of unintended or unplanned pregnancy, 2009 ~49.2%
- Oral contraceptives: Side effects, access, methods difficult to use correctly
2
Q
Approximately __% of unintended pregnancies occur in women who do not desire pregnancy yet do not use a method of contraception
A
40%
3
Q
Approximately ___% of unintended pregnancies occur in women using some form of birth control
A
60%
4
Q
Teenage pregnancy has dropped, 2009 study found rate dropped ___% from 1990 to 2005
A
40%
5
Q
Why use birth control?
A
- Family Planning – limit family size, space children
- Avoid child bearing – personal, medical condition
- Provider to discuss information on both benefits and risks of both contraception and pregnancy – so the patient can make an informed choice
- Most states have laws that permit access to contraception for minors (under 18yo)- confidential visits
- Signed consent forms (IUD, injections, Nexplanon, sterilization)
- Pregnancy test – documented negative
6
Q
Methods of contraception:
A
- Folk methods – coitus interruptus, postcoital douche, lactational amenorrhea, and periodic abstinence (rhythm or natural family planning)
- Barrier methods
- Hormonal methods
- LARC – Long acting reversible contraception (IUDs and implantable progestin)
- Sterilization
7
Q
List Ex’s of barrier methods
A
condoms (male and female), diaphragm, cervical cap, vaginal sponge, and spermicides
8
Q
List Ex’s of Hormonal methods
A
oral contraceptives, patches, ring, and injectable
9
Q
Describe Sterilization Procedures
A
tubal ligation or vasectomy
(BOTH are reversible, tubal ligation is more difficult to reverse due to scarring. Vasectomy is 1 procedure, and if it was decided to be reversed later on–> then you can do a reversible but it’s another procedure)
10
Q
Comparing Effectiveness of Family Planning Methods:
A
Least effective: withdrawal methods, spermicide usage,
Next: condoms
Next: Injectables, Pills (OCPs), Patch, ring
Most effective: implants, IUD, sterilization
11
Q
CDC Medical Eligibility criteria (for initiating contraception)
A
1- method can be used without restriction
2- Advantages of use generally outweigh theoretical or proved risk
3- Method usually not recommended unless other, more appropriate methods are NOT available or acceptable
4-Absolute contraindication, method NOT to be used
12
Q
Coitus Interruptus
A
- One of the oldest contraceptive methods= pullout method
- Withdrawal of penis before ejaculation
- **Failure rate higher than most methods
13
Q
Postcoital Douche=
A
- Plain water, vinegar, and a number of feminine hygiene products used
- Theoretically, douche flushes semen out of vagina
- Ineffective and unreliable
- Contributes to lack of normal vaginal flora>increased risk of infection
14
Q
CDC chart on Contraceptive use:
know for exam
A
takeaways:
- Pts on OCPs are at a HIGHER risk for DVTs, OCPs in the setting of clotting history= 3,4 (if you can use something else you should, (ie a woman with Factor 5 may opt for an IUD in place of OCPs)
- -add in smoking in a Pt with clotting risk–> BAD
-any Pt with a clotting history SHOULD NOT be prescribed an OCP. safest to have another method
15
Q
Lactational Amenorrhea=
A
Efficient method for breastfeeding women
16
Q
Lactational Amenorrhea:
-suckling results in decreased ____
A
GnRH, LH, and FSH
17
Q
Lactational Amenorrhea: results in ________ and anovulation
A
amenorrhea
anovulation (dont ovulate)
18
Q
Lactational Amenorrhea:
During first 6 months, if breast feeding exclusively, menses are mostly anovulatory and fertility remains ____
A
low (0.9 – 1.2%)
19
Q
Lactational amenorrhea:
-after 12 months, pregnancy rates ____
A
rose (7.4%)
20
Q
Lactational Amenorrhea:
Must use breastfeeding as the ____ ____ of infant nutrition
A
only form
21
Q
Periodic Abstinence=
A
-Women fertile for only a few days of menstrual cycle (so menstrual cycles are then mapped out)
- Rhythm or natural family planning method
- -Avoid coitus during the time of the cycle when woman most fertile
- -Fertile period=ovulation to 2-3 days after
22
Q
What is the pregnancy rate for Pts using the periodic abstinence method?
A
Pregnancy rate 10-25%
23
Q
Periodic Abstinence:
-Methods?
A
- Calendar method - failure rate up to 35%
- Temperature method – record upon wakening basal body temperature – temperature has slight drop 24-36 hours after ovulation. The temperature then rises abruptly (0.5-0.7 degrees F)for remainder of cycle.
- Cervical mucus method (Billings) – uses changes in cervical mucus to predict ovulation – starting several days before until just after ovulation, mucus becomes thin and watery, at other times mucus thick and opaque
24
Q
Male Condom:
A
- Cover for the penis during coitus–> prevents deposition of semen into vagina
- Reduce transmission of infectious agents
Material: -Latex (most common) -Polyurethane (vinyl) -lamb intestine (lamb skin) effective and inexpensive contraception protection from STIs including HIV - no prescription needed -Some condoms contain spermicide
- Failure rate 10-30% in first year of use-technique?
- More effective if used in conjunction with other birth control method
- Still may have skin contact of scrotal-labial
25
Female Condom:
- material?
- describe this method
- disadvantages?
- Failure rate?
- Made of thin polyurethane material with 2 flexible rings on either end
- One ring fits inside vagina and other ring sits outside near the introitus
- Under control of female and offer some protection against STIs
- Disadvantages – cost and bulkiness
- 6 month failure rate with perfect use 2.6%
- Reduces annual risk of HIV by more than 90%
26
Can you use a female condom with a male condom?
NO -Do not use with male condom
27
Vaginal Diaphragm
=Mechanical barrier between vagina and cervical canal
- Designed to fit in vaginal canal and cover cervix
- Contraceptive jelly or cream should be placed on the cervical side of the diaphragm(insert with dome facing down)
- Can be inserted up to 6 hours before intercourse
- Should be left in place for at least 6-24 hours after intercourse
- Perfect use failure rate 6%,
- Normal use 15-20%
- Must be fitted by a healthcare provider, prescription needed
- May need size adjustment
- May protect against STIs-(minimal to none)
- May cause vaginal wall irritation or increased risk of UTIs
28
Cervical Cap
=Small cuplike diaphragms placed on cervix and held in place by suction
- Most be fitted tightly over cervix to provide barrier for sperm
- Must be measured by healthcare provider
- Difficulty placing cap
- May remain in place for 1-2 days at a time
- Cap should be left in place for 8-48 hours after intercourse
- Foul discharge may develop after this
- Proper placement over cervix confirmed by digital self exam after each sexual act
- Failure rate similar to that of diaphragm
29
Spermicides: list Ex's
Spermicidal vaginal jellies, creams, gels, suppositories, vaginal sponge, and foams
30
Spermicides: effect?
- Toxic effect on sperm also act as mechanical barrier
| - Can be used alone or in conjunction with diaphragm or condom
31
Spermicides: Failure rate?
15% per year with perfect use but double with typical use
32
Spermicides: irritation S/E
Chemicals may irritate vaginal mucosa/genitalia
33
T/F: spermicides are not effective in preventing gonorrhea, chlamydia, or HIV
true
34
Genital lesions from frequent use of spermicides may be linked to increased risk _____
HIV infection
35
Oral Hormonal Contraceptives
- General use started in 1960s
- MC used method is combined method – pills containing both estrogen and progestin are taken for 21 days followed by 7 days of placebo during which time most women have withdrawal bleeding
- Estrogen dose has been reduced over past decades, usually 15-35 micrograms
- Progestin dose has also been reduced
- Studies show reduced risk of endometrial and ovarian cancers, ectopic pregnancy, PID, menstrual disorders, benign breast disease, and acne
36
OCP:
| -timing?
- In general start with onset of menstrual cycle
- -First Sunday after menses began
- -Quick start – start immediately regardless of menses
- -Recommend backup contraception for at least *7 days after
-Administer pills for prolonged period of time to cause extended periods of amenorrhea (reduce number of periods) significant amount of women experience irregular bleeding
37
OCP:
| -failure rate?
1.26 – 8% in first year
38
OCP:
| return of fertility rate?
Return of fertility soon after discontinuation
39
How OCPs work
- Alter pituitary gonadotropin release (LH and FSH)
- No rise in first half of cycle, thus growth of dominant follicle and ovulation do not occur
- Change in consistency of cervical mucus, resulting in less sperm penetration
- Endometrial lining less receptive to implantation
- Alter tubal transport of both sperm and oocytes
- Monophasic (constant dose of hormones) or Multiphasic (varying doses of hormones)
- Advise to use alternate form of contraception if OCP use interrupted because of forgotten pills or side effects
Antibiotic usage can alter effectiveness of OCP- How???
40
Antibiotic usage can alter effectiveness of OCP- How???
-if you're on ABX and you kill off all the good bacteria in the gut (GIT), this can interfere with the metabolism of the OCP--> decreased absorption of the OCP
41
OCPs:
| -risks?
- Lower dose estrogen in birth controls - safe for most women
- Cervical cancer risk - increased after 5 years of use, but some studies show risk declined after stopping for 10 years
- Breast cancer risk – large study in 1996 showed increased risk 1.24% compared with non-users, risk disappears after 10 years discontinuation
- **VTE/blood clot – triples a users risk from 3 to 9 events per 100,000 (overall risk is still low)
- Pregnancy, childbirth, and puerperium are associated with risk of VTE higher than that associated with the use of OCs
- Think about other risk factors such as age, SMOKING, diabetes, HTN, migraines, clotting disorders (Factor V Leiden)
- Smoking + OC's act synergistically to increase risk + age >35yo
- -Stroke
- -MI
- -Increased triglycerides
42
OCP's:
| Contraindications/Caution
- Pregnancy
- Undiagnosed vaginal bleeding
- Prior history VTE, MI, or stroke
- Increased risk for CV event – SLE, uncontrolled diabetes, or HTN
- Cigarette smoking + age >35yo
- Current or prior breast cancer
- Active liver disease
43
What do to if missed Pill?
OCs need to be taken consistently for contraceptive efficacy and reduced side effects
44
Patch:
| -describe this method
- 1 patch applied weekly x 3 weeks, then removed for 1 week
- Patch is roughly size of small post- it note
- Apply to buttocks, lower abdomen, upper outer arm, torso
- Used on 28 day cycle
- Time needed to achieve steady hormone level
- Use back-up contraception
- Risks similar to that of OCPs, risk of VTE, headache, nausea
- **Site reaction, more breast symptoms, and more dysmenorrhea
- Detachment of patch – reattach within 24 hours, if longer, need new patch
- Failure rate similar to OCPs, increased in women weighing over 198lbs
45
Patch:
| -brand name Ex's
Ortho Evra and Xulane (newest)
46
Vaginal ring:
| -describe this method
- Vaginal ring approximately 5cm in diameter, flexible
- Releases hormones at fairly constant rate
- Maintains efficacy even if removed for 3 hours
- Designed to be left in place during intercourse
- 1 ring inserted and left for 3 weeks, then removed for one ring-free week
47
Vaginal Ring:
| 10-15% of users report _____
vaginal related symptoms – discomfort, leukorrhea, vaginitis, sensation of foreign body, or problems with intercourse
48
```
Progestin only (Minipill):
-describe this method
```
- Small dose of progestin alone taken every day– Norethindrone 0.35mg
- Provides reasonably good protection against pregnancy without suppressing ovulation
- Mechanism of action not known – possible cervical mucus less permeable to sperm and endometrial activity goes out of phase
49
```
Progestin only (Minipill):
-Failure rate?
```
2-7%
50
Progestin only (Minipill):
- describe how this pill must be taken?
- who is this option ideal for?
- Minipill must be taken each day promptly, delay of even 2-3 hours diminishes contraceptive effectiveness of coming 48hours
- EC recommended if more than 1 pill missed
- Ideal for women for whom estrogen is contraindicated - >35yo who smoke, migraine headache, HTN, SLE, or breastfeeding
51
Depo:
-describe this method
-how does it work?
=Injection of Depo medroxyprogesterone acetate (DMPA) given every 3 months
-Works by suppressing surge of gonadotropins thus suppressing ovulation, thickening cervical mucus, and thinning endometrium so implantation less likely
52
Depo:
| -where is the injection usually given?
Usual dosage is 150mg IM administered into gluteus or deltoid
53
Depo:
| -is labeled as effective for up to ___ weeks
- *13 weeks but contraceptive activity persists for up to 4 months
- Irregular bleeding and prolonged menses common in first 6 months, then amenorrhea with continued use - 70%
54
Depo:
| -failure rate?
0.3 - 3% per year
55
Depo:
| -when do menses and fertility return after d/c?
Menses and fertility may take a while to return after discontinuation – average of 10 months
56
Depo:
| MOST Significant S/E?
- **reduction in bone mineral density (1.5 - 2.3%)with current use, but shown to return to normal after discontinuation. Not linked to increase in fracture risk.
- -Encourage adequate calcium intake and weight bearing exercise
- -Mood change and depression have been reported
-Weight gain 5lbs after 1 year use in earlier studies, recent studies suggest depo not associated with weight gain/changes
57
Depo:
| -significantly reduces risk of ______ CA
- endometrial CA
| - & Risk of ectopic pregnancy reduced
58
Depo:
| -may improve ______
endometriosis
59
Emergency Contraception:
| -methods?
Plan B
| EllaOne
60
Emergency Contraception:
| -methods?
- Plan B
| - EllaOne
61
Plan B not likely to be effective in BMI >___
>26
62
Ella not likely to be effective in BMI >___
35
63
```
Emergency Contraception (EC):
-used to?
```
- Used to prevent unwanted pregnancy after unprotected intercourse or after failure of contraceptive method
- Hormonal methods prevent pregnancy by delaying or inhibiting ovulation or by disrupting functioning of corpus luteum
64
Plan B:
- Levonorgestrel 1.5 mg - Single dose, 1 tablet po x 1 dose within 72 hours.
- Need back-up method of contraception x 7 days. May resume OCPs ASAP
65
Ella:
- Ulipristal 30 mg x 1 dose. Need back-up method of contraception x 14 days or next period.
- Wait 5 days to resume OCPs because combination may reduce effectiveness
66
IUD for EC
- Copper IUD is another EC option (off label use)
- May inhibit implantation or possibly interfere with sperm function
- Must be inserted within 5 days of unprotected intercourse
- 1% failure rate
- Offers continued contraceptive benefit
67
LARC=
long acting reversible contraception
68
LARC:
- how safe is this method?
- 3 types:
- Safe for most women
- Can be used by adolescents and nulliparous women
3 Types:
- Levonorgestrel IUD
- Copper IUD
- Etonogestrel (Nexplanon)single implantable rod
69
IUD-Intra uterine Device:
- how effective?
- Satisfaction rate?
- Complications?
```
IUDs highly effective
Rapidly reversible
High satisfaction and continuation rates
Cost effective
Complications are rare
```
70
Two types of IUDs available:
- Copper IUD
| - Levonorgestrel IUD
71
Copper IUD:
| -approved for up to __ years use
10 years!
- No hormones!!!
- Exact mechanism of action unknown, possible spermicidal activity, interference with either normal development of ova or fertilization of ova, activity on endometrium that may promote phagocytosis of sperm
- Highly effective, failure rate 0.6 - 0.8%
-Side effects – abnormal bleeding and cramping can treat with NSAIDs
72
Mirena IUD:
- Describe
- Approved for how many years of use?
- Releases 52mg levonorgestrel, initially released 20 mcg/day reduced by 50% after 5 years
- Approved for use up to 5 years
73
Mirena IUD:
| -MOA?
Mechanisms of action:
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
74
Mirena IUD:
- Failure rate?
- best for which Pt population?
Highly effective , failure rate 0.1 - 0.7%
- Larger - best for women who have given birth but not required
- Good for heavy periods – some irregular bleeding in initial 3-4 months and then decrease in menstrual flow by as much as 70%
- Reported side effects – headache, acne, mastalgia
75
Liletta IUD:
- Releases?
- Approved for use up to ___ years
- Releases 52 mg levonorgestrel, avg. 15.6 mcg/day over 3 years
- Approved for use up to 3 years
76
Liletta IUD:
| -MOA?
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
77
Liletta IUD:
| -advantages
- Highly effective
| * Cheaper than the Mirena IUD
78
Skyla IUD:
- releases?
- Approved for use up to __ years
- Releases 13.5 mg levonorgestrel, avg. 6 mcg/day
| - Approved for use up to 3 years
79
Skyla IUD:
| -MOA?
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
80
Skyla IUD:
- effectiveness?
- size?
Highly effective
Low hormone dose
One of smallest IUDs
81
Kyleena IUD:
- releases?
- approved for use up to __ years
Releases 19.5 mg levonorgestrel, avg. 9 mcg/day
| -Approved for use up to 5 years
82
Kyleena IUD:
| -MOA?
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
83
Kyleena IUD:
- effectiveness?
- best for women who?
- Highly effective
| - Best for women who have not given birth yet b/c very small
84
IUD Complications (there's a lot)
- Ectopic pregnancy – increased risk, but still lower than non-IUD users because high effectiveness
- Spontaneous abortion – 50% if pregnant with device in place, recommend removal of IUD if possible
- Expulsion – More common in first few weeks of use, ~5%
- Uterine Perforation – 1-2 events per 1,000 insertions
- Infection – Risk PID remains low, screen for STIs
- Irregular bleeding
85
IUD:
| -check Pt ____ weeks after IUD inserted and _____ after
Check patient 4-6 weeks after IUD inserted and yearly after, ask patient to check for strings
86
IUD:
| -management of missing strings
- First encourage patient to use back-up method of BC
- Do pregnancy test
- Order transvaginal ultrasound to determine where IUD is located
- Refer to GYN for removal
87
Implant
- Etonogesterel (68 mg ) – Nexplanon
- Discreet
- Highly effective
- Similar mechanism of action to Depo
- Rapidly reversible
- Approved for up to 3 years
- May be inserted at anytime during menstrual cycle
- MC side effect is irregular bleeding/spotting
- Weight gain also reported
- Providers must be trained by manufacturer for insertion/removal
- No reported pregnancies in more than 70,000 cycles of use
88
Sterilization: list 4 procedure ex's
- tubal ligation
- Essure
- Vasectomy
- Hysterectomy
89
Tubal ligation
- Surgical procedure
- “tie off” fallopian tubes
- Prevent eggs from traveling from ovaries to uterus
90
Essure=
=Implant into fallopian tubes that encourages scar buildup
| -*Takes 3 months to be effective
91
Vasectomy=
- Surgical procedure
| - Blocks or cuts vas deferens
