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Résidence - FM Learner > 17. Contraception (28%) > Flashcards

17. Contraception (28%) Flashcards

1
Q

What populations should be advised about adequate contraception?

A

All patients, especially adolescents, young men, postpartum women, and perimenopausal women

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2
Q

What factors may reduce the efficacy of specific contraceptive methods? (4)

A
  • Delayed initiation of method
  • Illness
  • Medications
  • Specific lubricants
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3
Q

What should be assessed to ensure adequate contraception? (4)

A
  • Risks (relative and absolute contraindications)
  • Sexually transmitted disease exposure
  • Barriers to specific methods (e.g., cost, cultural concerns)
  • Efficacy and side effects
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4
Q

What should be advised for patients using hormonal contraceptives? (3)

A
  • Manage side effects appropriately
  • Recommend an appropriate length of trial
  • Discuss estrogens in medroxyprogesterone acetate
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5
Q

What are the typical use failure rates for barrier methods?

A

Barrier (Condom) - 18% failure rate

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6
Q

What is the failure rate for the combined oral contraceptive pill?

A

9%

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7
Q

What is the failure rate of Progestin-only pill (Micronor) ?

A

9%

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8
Q

Name side effect of Progestin-only pill (Micronor)

A

Irregular bleeding

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9
Q

What is the failure rate of combined transdermal patch ?

A

9%

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10
Q

Describe : Combined transdermal patch (3)

A
  • Evra 1 patch per week x 3 weeks, one week off)
    Stays on even in water, apply to dry clean area excluding breast
  • 17% skin reaction
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11
Q

What’s the failure rate of Combined vaginal ring ?

A

9%

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12
Q

Describe : Combined vaginal ring

A
  • NuvaRing x 3 weeks, one week off
  • May remove for 3h (eg. during coitus)
  • 5% vaginitis, leukorrhea
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13
Q

What is the failure rate for the injectable progestins (DMPA, DMPA- Depo–Provera)?

A

6%

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14
Q

Describe : DMPA- Depo–Provera (3)

A
  • 150mg IM q12w
  • Side effects: Irregular bleeding, weight gain, decrease bone density
  • Consider supplemental low-dose estrogen to reduce irregular bleeding if persists past 3 cycles
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15
Q

What are the failure rates for intrauterine devices?

A

<0.1%

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16
Q

Describe : Intrauterine devices (3)

A
  • LNG-IUD Mirena q7y, CU-IUD q10y
  • 44% amenorrhea at 6 months
  • Risk of expulsion/perforation postpartum until 6 weeks
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17
Q

What’s the failure rates of Subdermal implant (Nexplanon - Etonogestrel)

A

very effective likely <0.1%

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18
Q

Describe : Nexplanon - Etonogestrel

A
  • Very rare risk of implant migration
  • 15% bleeding irregularities
  • Not studied in overweight >130% IBW
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19
Q

What’s the failure rates of tubal ligation and vasectomy?

A

0.15%

20
Q

What should be done before starting contraception?

A

Start contraception if reasonably certain not pregnant

  • Pregnancy test >2w after last episode of unprotected intercourse
  • ≤7d after start of normal menses or spontaneous/induced abortion
  • No sex since start of last normal menses
  • Correctly, consistently using reliable contraception
  • 4w postpartum
  • Fully breastfeeding and <6 months postpartum
  • Back-up contraception for 7d if >7d after menses started
21
Q

What contraceptive method is recommended for
* postpartum ?
* breastfeeding women ?
* smokers >35 years old ?

A

Consider progestin-only

22
Q

What contraceptions to consider for patients with multiple medical comorbidities ?

A

Long-acting reversible contraception (LARC)
* IUDs
* Implants

23
Q

What contraceptions to consider for patients > 50? (3)

A
  • Consider progestin-only or non-hormonal method (consider avoiding estrogen)
  • After amenorrhea x 12 months -> No need for contraception if using non-hormonal method and >50yo (if <50yo advised to wait 2 years)
  • Consider FSH x 2 (>6 weeks apart) if >30IU/L then contraception required for another 12 months
24
Q

What contraceptions to consider for patients > 55?

A

> 55 years old can discontinue contraception (even if menstrual cycles continue, spontaneous conception very unlikely)

25
Q

Name emergency contraceptions (4)

A
  • Copper IUD
    Hormonal/oral :
  • Ulipristal acetate
  • Levonorgestrel
  • Combined OCP (Yuzpe) + Levonorgestrel (5 pills of Alesse)
26
Q

Describe : Copper IUD (2)

A
  • failure rate of <1% (>95% effective)
  • Effective up to 5 days (limited evidence up to 7 days) after unprotected intercourse, provided pregnancy ruled out
27
Q

Name populations that Hormonal/oral emergency contrapception are less effective in (2)

A

less effective if BMI>30 or weight ≥80kg

28
Q

Describe : Ulipristal acetate (Emergency contraception)

A
  • Effective up to 5 days
  • Hormonal contraception can be initiated up to 5 days after unprotected sex with backup for first 14d
29
Q

Describe : Levonorgestrel (Emergency contraception)

A
  • Effective up to 72h (proven efficacy up to 96h, limited efficacy up to 120h)
  • Hormonal contraception can be initiated the day of (or after) with backup for first 7d
30
Q

Name C-I Emergency contraception (2)

A
  • Pregnancy
  • and active pelvic infection/cervicitis for IUD
31
Q

Name examples of Estrogen OCP (6)

A
  • Monophasie : Alesse, Marvelon, Yasmin, Yaz
  • Biphasique : Lolo, Synphasic
  • Triphasic
  • Longue durée
  • IUD : NuvaRing
  • Timbre transdermique : Evra
32
Q

Name examples of Progestin-only OCP (3)

A
  • PO : Micronoc, Slynd
  • IM : Depo-Provera
  • Implant S/C : Nexplanon
  • IUD : Kyleena, Mirena
33
Q

Name Contraindications to Estrogen

A
  • Migraine with aura (≥5 min reversible visual/sensory/speech/motor symptom that is accompanied within 60 mins by a headache)
  • Smoker age ≥35 years and smoking ≥15 cigarettes per day
  • Uncontrolled hypertension (>160/100)
  • Acute DVT/PE
  • History of DVT/PE, not on anticogulation, with risk factor (history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including antiphospholipid syndrome/SLE, active cancer with the exception of non-melanoma skin cancer, history of recurrent DVT/PE)
  • Current or history of vascular disease, ischemic heart disease, stroke, complicated valvular disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)
  • Liver disease (severe cirrhosis, hepatocellular adenoma, malignant hepatoma)
  • <4 weeks postpartum or peripartum cardiomyopathy
  • Major surgery with prolonged immobilization
  • Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy)
  • Active breast cancer
34
Q

Name C-I : Progestin-only pills (2)

A
  • current breast cancer
  • relative contraindications include liver disease
35
Q

Combined-COC has less effectiveness with what other medications? (3)

A
  • anticonvulsants (phenytoin, phenobarbitol)
  • antiretrovirals
  • rifampin (not other antibiotics)
36
Q

Name side-effects of Combined COC ()

A

Common in first three months, tend to improve with time
* Nausea - Take pill at bedtime or with meal (consider lower estrogen)
* Breast tenderness (consider lower estrogen)
* Headache
* Breakthrough bleeding (r/o smoking, noncompliance, cervical/uterine disease, pregnancy, consider increase estrogen)
* No evidence of weight gain

37
Q

Name Non-Contraceptive Benefits of Combined COC (6)

A
  • Cycle regulation, predictable bleeds
  • Decreased menstrual flow, anemia
  • Decreased acne, hirsutism
  • Decreased dysmenorrhea, premenstrual symptoms
  • Decreased perimenopausal symptoms
  • Decreased risk of fibroids, ovarian cyst
38
Q

Name Non-Contraceptive Risks of Combined COC (6)

A
  • TVP (10 / 10,000 woman-years (COC users) vs. 4-5 / 10,000 woman-years (non-users)
  • UNCLEAR risk of gallbladder disease, possible increase in symptomatic gallstones when used for 15 years
39
Q

Describe risk of Combined-COC and cancer (4)

A
  • Decreased ovarian, endometrial, colorectal cancer
  • Possible association with cervical cancer (causation not demonstrated)
  • Decreased risk of benign breast disease
  • Possible increase in breast cancer in current/recent COC users (5 / 1000 COC-users vs. 4 / 1000 non-users will be diagnosed with breast cancer before 39 years-old)
40
Q

Describe follow-up in COC (4)

A
  • Weight (BMI), BP
  • Contraindications (Smoking, Migraines, Liver disease, Thromboembolic disease, Cardiovascular risk factors, Cancer).
  • Stop OCP at age 50yo, consider taper or switch to HRT if vasomotor symptoms
  • STI screen
41
Q

What to do if missed combined OCP : If missed pill <24h in any week

A

Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack

42
Q

What to do if missed combined OCP :If missed pills in first week

A
  • Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack
  • Back up x 7d*
43
Q

What to do if missed combined OCP : If missed pills during second or third week

A
  • Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack and start new cycle of OCP without a hormone-free interval
  • Back-up contraception if 3 or more consecutive doses/days of OCP missed
44
Q

If unprotected intercourse in last ____ days and not on active hormone x ____ days, there is a risk of ovulation and unintended pregnancy consider emergency contraception

A

if unprotected intercourse in last 5 days and not on active hormone x 7 consecutive days, there is a risk of ovulation and unintended pregnancy consider emergency contraception

45
Q

What to do with Missed Progestin only pills (3)

A

> 3h delay

  • Take most recent pill ASAP and continue taking remaining pills until end of pack
  • Back-up x 48h
  • If unprotected intercourse in last 5 days, EC recommended

Résidence - FM Learner (39 decks)

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