4/17 Contraception (health implications + clinical) Flashcards
Of the US unintended pregnancy rate, what % are unintended? how many are aborted?
51% of all pregnancies are “unintended” (mis-timed, unwanted)
half of the 51% are ultimately aborted in the US (25% of ALL pregnancies)
3 problems with the CDC data on contraception?
1) the worst unintended pregnancies and social consequences are in ppl mis-timed, unwanted) makes it difficult to compare data
which age groups have the highest amounts of unintended pregnancy? abortion?
younger age groups (15-19) have the highest rates of “unintended pregnancies” (78%) but the lowest rate of abortion = PROBLEM
older folks (>40) have moderate rates of unintended pregnancies (51%), but they have the highest abortion rates
rate of unintended pregnancy are substantially above average in these population grps
women aged 18–24 unmarried (particularly cohabiting) women, low-income women, women who had not completed high school minority women.
rate of unintended pregnancy declined in these population grps
among adolescents
college graduates
wealthiest women
rate of unintended pregnancy increased in these population grps
poor /disadvantaged populations
less educated women
Of the unintended pregnancies, how many use some form of protection? no protection?
60% of unintended pregnancies occur WITH use of some form of birth control (includes withdrawal)
40% of unintended pregnancies attributable to 5%-7% of sexually active couples who do NOT use ANY form method
what accounts for first-year contraceptive failures?
often seen in methods that require daily use (OCs) or involve sexual activities (condoms, diaphragm, withdrawal, spermicides) and
less often in methods that don’t require as much daily involvement (vasectomy, tubal ligation, IUDs, DMPA – Depo-Provera)
T/F contraceptive continuation rates much higher in adult females compared to young adults
T
What method of contraceptives has the lowest rates of failure?
perfect use (aka supervised use) have lower rates of contraceptive failure, but is not realistic at a population level
Of the contraceptives available, which ones have the highest failure rate?
Unprotected 85% Spermicide 29% Withdrawal 27% Condoms 15% Emergency contraception 15%
Of the contraceptives available, which ones have the lowest failure rate?
Estrogen-containing comb. 8%
Patch 8%
medroxyprogesterone acetate (depo-provera) 3%
IUDs - Copper-T, Mirena 0.8%
Implants 0.05%
Of the contraceptives available, which ones has the highest continuation rates at 1 year among 15-19yo?
Estrogen-containing comb. 30% Patch 11% Ring 30% medroxyprogesterone acetate (depo-provera) 16% IUDs - Copper-T, Mirena 85%
withdrawal as a form of contraceptive?
better than nothing!
effectiveness of estrogen-containing combination oral contraceptive?
method is effective, but increased rates are due to low compliance
contraceptive with the BEST continuation rates for 15-19yo
IUDs - Copper-T, Mirena
effectiveness of emergency contraceptives?
not a lot of people are using it; currently does not show any impact
Rule of 90s
90% of our inmates were the result of teen pregnancy.
90% of illiterate population (not including immigrants) are the result of teen pregnancy.
90% of those who have a baby before 21yo are going to live >10years in poverty
16% of coitus in girls younger 16 are…
involuntary
~ 750,000 teen pregnancies/year is due to
high rates of sexuality and poor rates of contraceptive use
What can we do to lower rates of teen pregnancies?
1) Understand adolescent development (adolescents are NOT young adults!)
2) Education (behavioral change)
How does development affect the teen pregnancy rate?
Piaget’s stages of development known, but counseling and approaches are not adapted accordingly!
early: 12-14: reject family → seek other adults, seek autonomy
mid: (15-17): strong peer allegiance, risk takers/INVINCIBLE, “vanity”, prove autonomy
late (18-20): abstract thinkers, problem solvers
adapt counseling strategies accordingly
Does knowledge-based education lower risk of pregnancies? What other educational techniques can be used?
No. Knowledge change ≠behavioral change (ø delay in activity or change in contraceptive use)
teaching kids about the menstrual cycle or showing pictures of warts/herpes/etc does not work because it just creates avoidance because that’s not how adolescents minds work)
Emphasize skills over knowledge – ex: communication: learn different ways to say no to sex
Does abstinence only programs work?
no. does not affect sexual behavior; often contains false, misleading, or distorted info. on reproductive health
How can parents help lower the teen pregnancy rate?
Parents (parents who talk about sex are more likely to have abstinent kids)
- Discuss values
- Supervise/monitor: latchkey coitus – frequent monitering reduces chances of risky behavior
- Spend time with kids
- Understand normal adolescence
How can physicians help lower the teen pregnancy rate?
elicit information and listen to patients concerns is critical!
Emphasize skills over knowledge – ex: communication: learn different ways to say no to sex
Utilize all windows of opportunity to improve contraceptive use (assure confidentiality, address problems or concerns with use, emphasize benefits, provide demo pill pack, tell them to call if they decide to quit)
two general components of contraceptives
estrogen
progestin
forms of estrogen in contraceptives?
ethinylestradiol (EE) or mestranol
forms of progestin in contraceptives?
progestin: many kinds on the market; all but one (yasmin) are derivatives of 19-nor-testosterone
MoA of estrogen in contraceptives?
1) inhibits GnRH -> decr. FSH
2) potentiates action of progestin by increasing progestrone receptors
3) inhibits follicular maturation and selection of dominant follicle
4) Allows lower dose of progesterone
standard dose of estrogen in contraceptives?
<35-µg EE OCs for new users
MoA of progestin in contraceptives?
1) inhibits GnRH -> no LH surge (greatest anti-ovulatory effect)
2) thickens cervical mucous, making it difficult for sperm to ascend into the uterus
3) progestin-only pills: endometrium is thin and atrophic; could, in theory, interfere with implantation of a blastocyst (embryo).
Why did the formulation and dose of progestins decrease over the last few decades?
Development of more selective (less androgenic) agents to decrease risk of strokes and clots seen in first iterations
Does birth control prevent all stages of pregnancy?
prevents follicular maturation, it might inhibit nidation, may block fertilization, but it does NOT interrupt after after implantation
High vs. low dose of contraception?
estrogen:
low 35
Use low dose only because there is no evidence that there is higher efficacy on higher doses
∆ btwn Monophasic versus multiphasic contraceptives?
monophasic - provide the same level of hormones throughout the pill cycle
multiphasic - induce a steady state of hormones, but at three different levels during the pill cycle
21 versus 28 packs contraceptive?
28 packs:
21 are active, 7 are placebo
24 are active, 4 are placebo
21 packs: 3 weeks on, 1 week off
purpose of having a 28 pack where 24 are active, 4 are placebo over having the 21 are active, 7 are placebo formulation?
decreases # days of bleeding; follicle doesn’t get as far (progestin suppress follicular growth). Also gives you a bigger safety window if one forgets to take the pill 1-2 days
why is the continuous combined: >21 active pills (one on market is 84); bad?
bleed is really significant early on (2x the amt of unscheduled or breakthrough bleeding before getting to an amenorrheic state)
people use withdrawal bleed as a sign that they’re not pregnant = not true!
what is breakthrough bleeding caused by in birth control caused by?
caused by progestin; causes spiral arterioles spasm (causes vascular fragility) -> unscheduled bleed
(thought it was also estrogen withdrawal…?)
what increases risk of thrombosis in birth control?
Thrombosis is an ESTROGEN-DEPENDENT event; dose dependent at leavels >35µg EE
Does OC cause breast cancer?
conclusions from various studies differ, but have shown that
- current or former OC use (age of initiation, duration) is NOT associated with an increased breast cancer risk
- OC use increases incidence of breast cancer, but decreases after discontinued usage
- Breast Ca in current/ recent users less clinically advanced
- No additional risk with family history breast Ca
OC use decreases risk of this type of cancer
ovarian cancer
endometrial cancer
why is there decreased risk of ovarian cancer and endometrial cancer with the use of standard birth control?
ovarian = decreased proliferation and the level of the ovaries
endometrial = progestin exposure prevents endometrial growth/ hyperplasia that can eventually progress to cancer.
does OC cause weight gain?
NO
Who should consider OC?
No use
Broken/skipped condom/diaphragm
Missed >2 OC pills, injection (>13/5), patch (off >2 days), ring ( >3hrs)
what is lactational amenorrhea?
full breast feeders during first 6 months do not experience periods…
How do diaphragms compare to condoms in terms of
- preventing pregnancy
- STIs
- failure rates
pregnancy: worse
STI: worse
failure rates: worse
3 forms of contraception that contain estrogen and progesterone?
Combination Pill
Ring
Patch
How is the combination pill used?
what are some problems associated with combination pill?
Take daily at same time of day; perfect use is challenging
Estrogen levels vary by pill (10-50µg)
How is the ring used?
what are some problems associated with the ring?
Sits @ cervical mucosa
Wear for 3w; remove for 1w; may remove <3 hrs during sex
spotting and breakthrough bleeding is common
How is the patch used?
what are some problems associated with the patch?
Wear one patch/week x 3w
No patch for fourth week
Less effective for overweight women > 90kg
May irritate skin
ABSOLUTE contraindications for use of combination contraceptive (estrogen and progestin)
1) Thromboembolic d/o’s (pt or family hx of APS, previous clots, Factor V Leiden, Protein S/C deficiency, etc)
2) Impaired Liver Function (can’t metabolize the steroids)
3) Abnormal vaginal bleeding
4) Pregnancy
5) Smokers >35y (smoking affects the endothelium)
6) Breast Cancer
RELATIVE contraindications for use of combination contraceptive (estrogen and progestin)
1) Diabetes
2) Gall bladder dz
3) Migraines (only if there are focal neurological findings, eg seizures)
4) HTN
5) Hypertriglyercides (estrogen will raise)
What are contraceptives that only have progesterone?
Shot (Depo-Provera - medroxyprogesterone acetate contraception) MiniPill IUD (Merena) Rod Emergency Contraception “Plan B”
Problems with the Depo-Provera - medroxyprogesterone acetate contraception?
1) May take 12+ months to become preg after last shot
2) Weight gain, esp in teens
3) Erratic bleeding, amenorrhea
4) possible decreased bone mineral density
Why is the Depo-Provera - medroxyprogesterone acetate contraception limited to 2 years of use?
limited to 2 years due to possible decreased bone mineral density: recovery w re-exposure to endogenous estrogens or discontinued use
how is Depo-Provera - medroxyprogesterone acetate contraception administered?
IM or SC inj every 3m
Problems with MiniPill
‘Probable’ higher failure rate than combination pills due to increased unscheduled bleeding, resulting in lower continuation rates
contraindications for IUD?
Uterine malformations Acute infections (chlamydia or gonorrhea) - must screen for infections, otherwise there is an increase risk for PID
T/F copper IUDs prevent ovulation and prevents the sperm fertilization of the egg
FALSE. copper IUD does not prevent ovulation, but prevents the sperm fertilization of the egg
contraindications for rod contraception?
Current breast cancer
problems for rod contraception?
More unscheduled bleeding than combination pills (main reason why many women quit)
Emergency Contraception “Plan B” - perks?
Available OTC for 17+
Available to younger patients by prescription
