1- Contraceptives Flashcards
Women 18-24 yrs, black or hispanic, low education/SES, and cohabitating but never married are at higher risk for what?
Higher risk for unintended pregnancy
Delay in prenatal care, reduced likelihood of breastfeeding, depression, and risk of physical violence during pregnancy are consequences of what?
Consequences of unintended pregnancy affecting the mother
Birth defects/ low weight, more likely to experience poor mental/ physical health during childhood, lower educational attainment, and more behavioral issues in teen years are consequences of what?
Consequences of unintended pregnancy affecting the child
What are the barriers to contraception use?
Unnecessary medical tests, cost, inability to receive contriception on same days as office visit, objection to contraception (religious beliefs), difficulty obtainined continued contraception, lack of understanding of confidentiality law by adolescents
In order to start contraception, a patient only needs to meet what?
Reasonable certainty that she is not pregnant
What are the requirements, that if any are met, there is > 99% positive predictive value the Pt is not pregnant?
≤ 7 days after start of menses, no sex since start of last menses, correctly/ consistently using reliable contraception, ≤ 7 days after spontaneous/ induced abortion, w/in 4 weeks postpartum, fully/ nearly fully breast feeding + amenorrheic + < 6 mos postpartum
What are the most effective methods of birth control?
LARC (impant, IUD), surgical sterilization
What are the least effective methods of birth control?
Fertility-awareness based methods, spermicide
What should always be used to reduce the risk of STIs?
condoms
The standard days method of natural planning (although high failure rates) may be used by who?
Women with menstrual cycles from 26-32 days long
A pt using the standard days method of natural planning should abstain from intercourse on which days?
8 to 19
When would a pt use the calendar method of natural family planning?
If cycle is outside of 26-32 day range
What is required to “effectively” use the calendar method of natural family planning?
Monitor cycle X 6 months, avoid sex during fertile peroid
How do you calculate your fertile peroid if using the calendar method?
First day of fertile period = length of shortest menstrual cycles - 18 days, last day of fertile peroid = length of longest menstrual cycle - 11 days
In the cervical mucus method of natural family planning, you should check cervical mucus daily and your peak day is when?
Last day of “stretchy” clear mucus
How can the fertile period be identified when using the cervical mucus method of natural family planning?
Occurs with 1st signs of mucus and continues until 4 days after peak day
When should you abstain from sex if using the cervical mucous method?
From time of ANY cervical sercretion until 4 days after peak day
What is the two day method?
If no secretions for 2 consecuative days, okay to have intercourse
How do you use the basal body temp method of natural family planning?
Check basal body tempe each a.m. before getting out of bed, rise in tempe of 0.5-1deg F = ovulation
When should you abstain from sex if using the basal body temp method of natural family planning?
From end of menstrual period until 3 days after temp increase
Which natural family method is a combination of mucus and basal body temp methods?
Symptothermal methods
How do you idenitify the fertile peroid if using the symptothermal method?
Monitor for 1st sign of ovulation (temp change, last day stretchy cervical mucus) until 3 days after temp rise or 4 days after peak mucus
What are the barrier methods of contraception?
Diaphragm, condoms, cervical caps, cervical sponge
What male condom is more likely to slip or break?
polyurethane base
What type of condoms for men have lower level of STI protection than latex?
Natural membranes
Use of what should be avoided if using condoms?
Petroleum-based vaginal products (includes vaginal yeast infection tx)
What is the typical use failure rate and perfect use failure rate of condoms for men?
18% vs 2% (often incorrectly used)
What are the advantages of male condom use?
reduces transmission of STIs, readily available, inexpensive
What is a disadvantage of male condom use?
May break or fall off
What types of female contraceptives can be left in place x 48 hours and must be left in for a minimum of 6 hours after sex?
Cervical caps and diaphragm
What type of female contraceptive can be inserted up to 8 hours in advance?
Condoms for women
What are the advantages of female controlled barriers?
immediately active (spermicide requires 15 minutes for activation), no effect on menses or hormones
What are the disadvantages of female controlled barriers?
UTI risk w/ diaphragm, no HIV protection
What type of female contraceptive releases continual spermacide and must be left in for a minimum of 6 hours after sex?
Sponge
What is the MOA of female spermicides?
Attack sperm flagella and body, reducing motility (can be used alone or w/ additional barrier)
What is Plan B or Preven?
Emergency oral contriceptive. Two doses of contraceptive pills taken within 72 hrs of unprotected intercourse
How can an IUD be used as a form of emergency contriceptives?
IUD inserted w/i 5 days of unprotected intercourse
What form of emergency contriceptives is a selective protegesteron receptor modulator (SPRM)?
Ulipristal Acetate (Ella)
What is the advantage of a SPRM vs hormone emergency contriceptives?
SPRMs are effective for up to 120 hrs post unprotected intervourse vs hormones which are only effective for 72 hrs.
Oral contraceptive pills, NuvaRing, OrthoEvra Patch, and Depo Provera are all what types of contraception?
Short acting/ frequent use
Who are the best candidates for short acting/ frequent use contraceptives?
Those wanting a short interval prior to wanting a pregnancy (except DepoProvera), not looking for long term prevention, non-contraceptive benefits, uninsured/ financial concerns
What should be tested prior to starting a pt on combo oral contriceptives?
BP (looking for severe/uncontrolled HTN)
Combined (E + P) oral contraceptives (COCs) have differing levels of what in different pills?
Progestin
What is the role of estrogen in combined oral contraceptives?
Cycle regulation
What is the main MOA for COC?
Ovulation supression (also thickens cervical mucous and thins endometrial lining)
What type of combo pills have a single dose of E and P for 21-24 days + placebo pills for 4-7 days?
Monophasic pills
Why are 24/4 monophasic pills preferred over 21/7 (especially if BMI > 30)?
Increased efficacy and decreased hormone withdrawal SEs during hormone-free interval
What type of combo contriceptive pills offers differing doses of E & P throughout the course of the pack>?
Triphasic
What COC is usually monophasic and is packaged in 84/7 or 365 active pills?
Continuous
In addition to reversibility, safe for all ages, extended periods w/o hormone-free days, decreased blood loss/ cramps/ more predictable menses, and decreased acne/ hirsutism, what is another (long-term) advantage of COCs?
Prevention of ovarian cysts and certain cancers (ovarian, endometrial, colon)
What are the most common SEs of combo contriceptive pills?
Unscheduled bleeding, nausea, breast tenderness, HA, intentional amenorrhea
What are the risks of COC?
HTN, venous thromboembolism, MI and stroke, lipid changes and metabolic changes
For a pt on COC, what is the relative and absolute risk for thromboembolism (VTE)?
Relative risk = 3 to 5 fold increase, Absolute risk = 0.06 per 100 pill-years
What is the absolut risk of MI or stroke in pt taking COC?
Low, 5-10 per 100,000 women years
Risk of MI or stroke in pts taking COC doubles in women taking what?
Combined hormone contraceptives (CHC)
Is the risk of MI, stroke, or VTE higher w/ COC use or during pregnancy/postpartum?
During pregnancy
When is progestin only contraception typically used?
Nursing mothers or if E is c/i’d (can be initiated at any time, no back up needed if starting within first 5 days of bleed)
What is the MOA of progestin only contraception?
Thickens cervical mucus to prevent sperm entry (also thins endometrium, suppresses ovulation, slows sperm motility)
What effect does COC use have lipid and carb metabolism?
Negatively impacts (not clinically significant)
What are the advantages of progestin only contraceptives?
Reversible, safe for all ages, may be used if E c/i’d
What are the SEs of progestin only COC/ POP?
Increased break through bleeding, intermittent amenorrhea
What is the limitation to progestin only contraceptives?
Limited window for missed pills (>3 hours late taking dose will decrease effectiveness)
What are the absolute C/is to COC and transdermal contraceptive use?
≥ 35 yrs & smoking ≥ 15 cigs/day, uncontrolled HTN, migraine w/ aura, DM > 20 yr w/ complications, VTE, known ischemic heart disease, hx of stroke, compliction valvular heart disease, breast CA, severe cirrhosis, hepatocellular adenoma or malignant hepatoma or multiple RF for ACD
What is a 1 on the US medical eligibility criteria for contraception?
No restriction
What is a 2 on the US medical eligibility criteria for contraception?
Advantages > theoretical/ proven risks
What is a 3 on the US medical eligibility criteria for contraception?
Theoretical/ proven risks > advantages (not recommended unless more appropriate methods not available/ acceptable)
What is a 4 on the US medical eligibility criteria for contraception?
Unacceptable
What is the MOA for Depo Provera?
Supress ovulation & thin endometrial line and thicken cervical mucous
Why is the continuation rate 50% for depro provera?
SEs (irregular bleeding, spotting, occasional heavy bleeding, weight gain). These will improve if the pt sticks w/ the medication
What are the advantages of Depo Provera?
Reversible, can be started at any time. No back up needed if starting w/in 1st 7 days of bleeding, safe for all ages
How often does pt need to get Depo provera injection?
Q13 wks
What effect does Depo Prover have on bone density?
Decreases bone mineral density ( esp. in adolescents, reversible when they d/c the med. Encourage Ca supplementation)
NuvaRing, OrthoEvra Patch, and Annovera are what type of contraceptive options?
Transdermal (E + P)
Although low, what are failure rates of transdermal contraceptives typically a result of?
User dependent
Implanon and Nexplanon (both P only so good if E c/i’d) are what types of contraceptive methods?
Sub-dermal implants (Etonogestrel)
What is the MOA for sub-dermal implants?
Thicken cervical mucus and inhibit tubal motility → inhibits follicular maturation and ovulation
How long is a sub-dermal implant effective for?
3 years
No back up is needed if a sub-dermal implant is inserted within what time period?
Within first 5 days of menses
What are the advantages of sub-dermal implant contraceptives?
Long acting, reversible, safe for all ages (including adolescents)
What are the SEs of sub-dermal implant contraceptives?
Unpredictable unscheduled bleeding, amenorrhea, weight gain
Although very low, are failure rates of sub-dermal implants user dependent or independent?
User independent
What is the duration of use for a Lovenorgestrel IUD?
3-6 yrs
Is back up needed if Levonorgestrel IUD is inserted w/in first 7 days of menses?
NO
What is the MOA of Lovenorgestrel IUD?
Changes cervical mucous to become thicker, alteration of endometrium prevents implantation of fertilized ovum (only 5-15% anovulatory effect)
What will increse the longer the pt is on a Levonorgestrel IUD?
Increased spotting leading to amenorrhea, ovarian cysts
What drug has FDA approval to tx menorrhagia?
Mirena
Is back up needed after insertion of a copper IUD?
No
What is the duration of action for a copper IUD?
10 yrs
What is the MOA for a copper IUD?
Copper ions inhibit sperm motility so sperm rarely reaches the fallopian tubes and are unable to fertilize the ovum (+ inflammatory reaction in the endometrium kills sperm)
What are the SEs of a copper IUD?
Increase menstrual blood loss & dysmenorrhea
Increased chance of ectopic pregnancy, spontaneous abortion and preterm delivery (if become pregnant) are all risk factors to what form of female contriceptives?
IUDs
Mirena (5 yr), Kyleena (5 yr), Skyla (3 yr), and Liletta (6 yr) are what type of contraceptive?
Progestin containing IUD
Paragard is what type of contraceptive?
Non-hormonal IUD (can use up to 10 yrs)
What are the options for female sterilization?
Laparoscopic/ abdominal tubal ligation, salpingectomy, hysteroscopic sterilization (Essure)
What is the MOA for laparoscopic/ abdominal tubal ligation?
Interrupts fallopian tube to prevent fertilization
What type of sterilization technique involves a metal and polyer microinsert into the fallopian tube and was removed from market in Dec 2018
Hysteroscopic sterilization (Essure)
What is the MOA for a vasectomy (male sterilization)?
Interrupts vas deferens preventing passage of sperm into seminal fluid
For what duration is alternative contraception needed s/p vastectomy?
Until 2 consecuative sperm samples show no motile sperm
What % of pts request a vastectomy reversal?
1%
What are the ethical issues associated w/ sterilization?
Age < 30, marital status, low parity, desire for children, cognitive ability, disability or minority status, insurance descrimination, misinformation about permanence or risks
