22. Contraception Flashcards
Types of contraception
condom
combined oral contraceptives COC: E+P die
Progestin only pill POP die
Combined transdermal patch q 3sem
vaginal ring q3sem
Injectable progestin Depoprovera q3 mois
Implant: nexplanon 3 ans
IUD: 10 (copper) 8 ans (mirena)
permanent: tubal ligation or vasectomie
Progestin only pill (POP) side effects
irregular bleeding
Progestin only pill example
Slynd (drospirenone)
Micronor - Norethisterone D/C
Combined transdermal patch changement q cmb de sem
q 3 sem, 1 sem off
Combined transdermal patch example
EVRA
Combined transdermal patch effet sec principal
skin irritation
Combined vaginal ring exmaple and posologie
Nuvaring q3sem, 1 sem off
ok pour enlver ad 3h pour coitus
vaginal ring E2
viginite, leukorrhée ad 5%
Injectable progestins (depo provera) posology
Depo–Provera 150mg IM q12w
Injectable progestins (depo provera) E2
Irregular bleeding,
weight gain,
decrease bone density
Consider supplemental low-dose estrogen to reduce irregular bleeding if persists past 3 cycles
IUD mirena inséré à quel moment PP
6 sem
bc Risk of expulsion/perforation postpartum until 6 weeks
Ok with breasfeeding
nexplanon risks and E2
Very rare risk of implant migration
15% bleeding irregularities
Not studied in overweight >130% IBW
CONTRA INDICATIONS to estrogen (10) **
Current pregnancy
Migraines
Smoking and >35 yo
Liver disease
Thromboembolic disease or past VTE
Cardiovascular risk factors
Hypertension
Cancer
Unexplained vag bleeding
PP or immobilization eg 2/2 surgery
DETAILS:
Migraine with aura
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)
Cardiovascular risk factors: 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
Contre indications to progestin
Known or suspected pregnancy
●Known or suspected breast cancer.
●Undiagnosed abnormal uterine bleeding.
●Benign or malignant liver tumors, severe cirrhosis, or acute liver disease.
Interactions with other medications
Decreased effectiveness with
anticonvulsants (phenytoin, phenobarbitol),
antiretrovirals,
rifampin (not other antibiotics)
COC Side effects
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
Non-Contraceptive Benefits
Benefits
Cycle regulation, predictable bleeds
Decreased menstrual flow, anemia
Decreased acne, hirsutism
Decreased dysmenorrhea, premenstrual symptoms
Decreased perimenopausal symptoms
Decreased risk of fibroids, ovarian cyst
Risks w Estrogen
VTE RR 2-3 (compared to pregnancy RR 6 and postpartum RR 115)
10 / 10,000 woman-years (COC users) vs. 4-5 / 10,000 woman-years (non-users)
Venous thromboembolism (VTE) = blood clot forms in a vein.
VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE).
COC and cancer
Decreased ovarian, endometrial, colorectal cancer
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
Emergency contraception méthodes 4
Plan b - Levonorgestrel 1.5 mg PO x1 ad 72h
Ella - Ulipristal acetate 30mg PO x1 - failure rate of 1.4% (~75% effective) ad 5d
Cooper iud ad 5 days (limited evidence ad 7d)
Yuptze method ad 72h
Combined OCP (Yuzpe) 100-120mcg ethinyl estradiol plus 500-600 mcg levonorgestrel (5 pills of Alesse) q12h x2 - least effective
Missed pill wht to do
1) If missed pill <24h in any week
Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack
2) If missed pills in first week
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*
3) If missed pills during second or third week
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
*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
Consider progestin only pill for pt
Postpartum, breastfeeding, smokers >35 years old
high TVE risk
contre indications to Estrogen
Pour la prise de décision de la bonne contraception, prendre en considération 4
- Risques relatif vs contre indication absolues
- demander exposition aux ITSS
- identifier les barrières d’utilisation, eg. coût, préoccupations culturelles
- Explication de l’efficacité, effets secondaires court terme
facteurs qui peuvent réduire l’efficacité de la contraception
prise inadéquate
certain Rx (anticonvulsants, anti-rétroviraux, antibio rifampin, st johns worth)
certains lubrifiants ou huiles avec condoms en latex
