24: Contraception and sterilization Flashcards
Lactational amenorrhea
prolactin-induced suppression of GnRH and subsequent suppression of ovulation
-will begin to ovulate 6-12 months after delivery; use as contraception max 6 months
? act as mechanical barriers between sperm and egg. Their efficacy rate is ?
Condoms, diaphragms (place before, leave in 6-8 hrs after), and cervical caps (6 hrs before, 1-2 days after)
75% to 85% with practical use
Efficacy of spermicides is ? Do they protect against STIs
70% to 80% but variability in user technique can significantly lower efficacy
-Spermicides DO NOT protect against STIs and may, in fact, make the vaginal mucosa more susceptible to infections such as HIV
two IUDs in the US market:
ParaGard (copper-containing; 10 years of use) and Mirena (progestin-containing; 5 years of use)
primary mechanism of action for IUDs is a ? Other mechanisms include ?
sterile spermicidal inflammatory response.
-inhibition of implantation and alteration in tubal motility.
Potentially serious side effects of IUDs include ?
pain/bleeding, expulsion, insertion-related PID, uterine perforation, and spontaneous abortion
hormonal contraceptives forms ?
oral, injectable, transdermal, implantable, vaginal, and intrauterine forms.
Combined hormonal contraception methods (OCPs, Ortho Evra, and NuvaRing) prevent pregnancy by ?
suppressing ovulation, altering cervical mucus, and causing atrophic changes in the endometrium.
Benefits of combined hormonal contraception include ?
protection from ovarian and endometrial cancer, anemia, PID, osteoporosis, dysmenorrhea, acne, hirsutism, and benign breast disease.
Progesterone-only contraception ?
progestin-only OCPs, Depo-Provera, Nexplanon, and the Mirena IUD
Progesterone-only mechanism of contraception
use progestins to suppress ovulation, thicken the cervical mucus, and make the endometrium unsuitable for implantation.
Primary side effects of Depo-Provera include ? It should be used with caution in women with ?
irregular bleeding, reversible bone demineralization, and a significant delay in return of fertility after discontinuation
-depression and obesity.
Nexplanon
a radiopaque, single-rod, subdermal implant of etonogestrel that is placed in the upper arm of the patient. It provides 3 years of contraception without impacting the patient’s bone density, weight, or mood.
ECPs (emergency contraception) contain high doses of ? and must be taken within ? of intercourse to prevent pregnancy. These pills act to ?
estrogen and progestin or progesterone alone
72 hours
suppress ovulation and to prevent fertilization and implantation. They do not cause abortions.
newer form of emergency contraception that selectively blocks progesterone at receptor sites (SPRM) ?
risks?
effectiveness?
ulipristal (19-norprogesterone)- related to mifepristone (RU 486)
- not yet widely used and is controversial due to its ability to affect an existing pregnancy if present
- higher effectiveness rate than ECPs.
Plan B
a single dose of progesterone-only ECP (Plan B) should be used preferentially for ECP is available, given its increased effectiveness and lower rate of side effects
Emergency IUD insertion (Copper T only) must be performed within ? it can then be used as ?
120 hours of unprotected intercourse
-long-term contraception
both ? and ? are highly effective forms of permanent sterilization. which is safer?
vasectomy and tubal occlusion
Vasectomies are safer, simpler, and more easily reversed than female sterilization.
the most effective tubal ligations are those done ?
immediately postpartum or those utilizing the Essure tubal occlusion system.
When interval laparoscopic approach is undertaken, ? have the highest efficacy in women less than 28 years.
Falope rings
Electrocautery and Falope rings have equal efficacy in women 28 years and older.
? offers a hysteroscopic approach to tubal ligation and the safest and most effective means of permanent birth control. It does not require a ? but it does require ?
Essure
DOES NOT require surgical incision or general anesthesia
DOES require use of a backup method for 3 months and an HSG to confirm complete tubal occlusion.
Reversal rates for tubal occlusion vary from ? depending on the method used for sterilization.
risks?
41% to 84%
-costly and are associated with a higher rate of ectopic pregnancy.
spermicide forms?
chemicals involved?
how they work?
STI protection?
vaginal creams, gels, films, suppositories, and foams
-nonoxynol-9 and octoxynol-9
-disrupt the cell membranes of the spermatozoa and also act as a mechanical barrier to the cervical canal, place 30 min before
do NOT protect against STIs, increase risk (HIV) due to vaginal irritation
absolute CIs for IUD
Known or suspected pregnancy
Undiagnosed abnormal vaginal bleeding
Acute cervical, uterine, or salpingeal infection
Copper allergy or Wilson disease (for ParaGard only)
Current breast cancer (for Mirena only)
relative CIs for IUD
Prior ectopic pregnancy
History of STIs in past 3 months
Uterine anomaly or fibroid distorting the cavity
Current menorrhagia or dysmenorrhea (for ParaGard only)
STI, sexually transmitted infection.
if get pregnant with IUD in, increase rate of ?
spontaneous abortion rate is increased to 40% to 50%
risk of ectopic pregnancy may be as high as 30% to 50%
-risk of ectopic pregnancy in general is reduced compared to no contraception use
both IUDs can be placed safely how soon postpartum
6 weeks
other uses for Mirena
decrease menorrhagia (90% less blood loss) and dysmenorrhea.
- as effective as oral progestins in treating endometriosis, endometrial hyperplasia, and cancer
- protects from PID
will Mirena users have periods?
About 20% of women will experience amenorrhea while using a Mirena IUD for 1 year and 60% will experience amenorrhea after using the Mirena for 5 years.
OCPs place the body in a ? state by interfering with ?
pseudo-pregnancy state by interfering with the pulsatile release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary
-suppresses ovulation
Seasonale, Seasonique
84 consecutive hormonal pills followed by 7 placebo pills, or 7 low-estrogen pills
365-day OCP regimen known as ?
Lybrel
more breakthrough bleeding in this regimen, but no formal monthly or quarterly withdrawal bleed.
Despite common belief, the only antibiotic which lowers the effective of OCPs is ?
Rifampin
Medications That Reduce the Efficacy of Oral Contraceptives
Barbiturates, Carbamazepine (Tegretol), Griseofulvin, Phenytoin (Dilantin), Rifampin, St. John’s wort, Topiramate (Topamax)
Medications Whose Efficacies Are Changed by Oral Contraceptives
Chlordiazepoxide (Librium), Diazepam (Valium), Hypoglycemics, Methyldopa, Phenothiazides, Theophylline, TCAs
complications with OCPs
DVT, PE, CVA, MI, HTN
cholelithiasis, cholecystitis, benign liver adenomas, cervical adenocarcinoma, retinal thrombosis
cancer risk with OCPs?
increased incidence of gall bladder disease and benign hepatic tumors
- reduced incidence of ovarian cancer, endometrial cancer, ectopic pregnancy, PID, and benign breast disease
- no conclusive findings on breast cancer
Absolute Contraindications to OCPs
thromboembolism, PE, CAD, CVA, smokers over 35 yrs, breast/endometrial cancer, unexplained vaginal bleeding, abnormal liver function, known/suspected pregnancy, severe hypercholesterolemia/triglyceridemia
Relative Contraindications to OCPs
uterine fibroids, lactaction, DM, SCD, hepatic disease, HTN, SLE, age 40+ and high risk for vascular disease, migraines, seizures, elective sx
Decrease risk of serious diseases with OCPs
Ovarian cancer Endometrial cancer Ectopic pregnancy (combination pills only) Severe anemia Pelvic inflammatory disease Salpingitis
quality-of-life problems improved with OCPs
Iron deficiency anemia Dysmenorrhea Functional ovarian cysts Benign breast disease Osteoporosis (increased bone density) Rheumatoid arthritis
Treat/manage many disorders with OCPs
Dysfunctional uterine bleeding Control of bleeding in bleeding disorders and anovulation Dysmenorrhea Endometriosis Acne/hirsutism Premenstrual syndrome
The contraceptive patch with the brand name ? releases ?
risk ?
Ortho Evra
releases progestin (150 mg per day) and ethinyl estradiol (20 mg per day), 3 wks on, 1 wk off
-increased risk VTE vs OCPs
-same MOA of OCPs
-decreased effectiveness in markedly overweight women (>198 lb or 90 kg).
The hormone-releasing vaginal ring with the brand name of ? releases a daily dose of ?
NuvaRing
15 mcg of ethinyl estradiol and 120 mcg of etonogestrel (the active form of desogestrel)
-placed in the vagina for 3 weeks, removed for 1 week to allow for a withdrawal bleed
POPs are ideal for nursing mothers and women for whom estrogens are contraindicated, including ?
women over 35 years who smoke and women with HTN, CAD, collagen vascular disorder (CVD), lupus, migraines, and those with a personal history of thromboembolism.
Depo-Provera (medroxyprogesterone acetate; DMPA) injected how often ?
SEs?
decreases periods?
every 3 months
- irregular menstrual bleeding, depression, weight gain, hair loss, and headache
- 50% of DMPA users will have amenorrhea after 1 year
Women using DMPA may experience ?
a reversible decrease in bone mineralization if using 2+ yrs (similar to that seen in lactating women, due to the decrease in ovarian estradiol production)
-others: weight gain, mood changes, irregular bleeding, delay in the return of regular ovulation (6-18 months)
Depo-Provera benefits
reduces the risk of endometrial cancer and PID and amount of menstrual bleeding
-tx of menorrhagia, dysmenorrhea, endometriosis, menstrual-related anemia, and endometrial hyperplasia
Regarding ECPs, ? are preferred over ?
levonorgestrel methods preferred over estrogen–progesterone regimens since levonorgestrel is more effective and has fewer side effects.
relative and absolute contraindications for ECP?
CIs that apply to OCPs (hx of CVA, MI, DVT, PE) do not apply to ECPs, but repeated use of ECP is not recommended in this high-risk group
-can get OTC if 17+ yrs
What device can be inserted in the uterine cavity within 120 hours (or 5 days) of unprotected intercourse as a form of emergency contraception? MOA?
effective?
The Copper T IUD
elicits a sterile inflammatory response within the uterus, making the environment unsuitable for fertilization.
MOST effective form of emergency contraception
Tubal ligation can be performed in the immediate postpartum period (?), or outside the postpartum period via a ? or via ?
- postpartum sterilization [PPS]
- laparoscopic approach (laparoscopic tubal ligation [LTL])
- hysteroscopic tubal occlusion (Essure).
PPS most common method
the modified Pomeroy tubal ligation (aka Parkland): a 2-3 cm segment of tube is doubly ligated and intervening segment removed
sterilization that can be performed laparoscopically
bipolar cautery, Silastic banding with Falope rings, or clipping with Hulka clips or Filshie clips
nonincisional hysteroscopic approaches
Essure: flexible microinserts are introduced into the uterine portions of the fallopian tubes. An outer spring coil molds to the shape of the fallopian tube to anchor the microinsert. Over about 12 weeks, sterilization is accomplished as in-growth of tissue around the coils results in tissue barrier occlusion in the fallopian tubes, check closed off with HSG
