5. Contraception Flashcards
1
Q
Contraceptive effectiveness depends on what? (2)
A
- Inherent effectiveness in preventing pregnancy
- How consistently and correctly it is used
2
Q
Describe history: Contraception (3)
A
- As patient compliance is key, a method should be chosen that will match patient needs and preferences.
- Knowing what types of contraception have been used before, if any, and previous side effects, is useful in helping a patient choose a type of contraception that will be used consistently and correctly.
- Hx should also screen for contraindications
3
Q
Describe physical exam: Contraception (2)
A
- Blood pressure is important to document prior to starting hormonal contraception.
- Based on Hx, patient may need cervical cultures, Pap test, or pregnancy test.
4
Q
Name absolute CIs to OCP (14)
A
- < 6 wk postpartum if breast-feeding
- Breast CA (current)
- Smoker > 35 y.o. (> 15 cigarette/d)
- Uncontrolled HTN (systolic > 160 mm Hg or diastolic > 100 mm Hg
- Venous thromboembolism (current or Hx)
- Ischemic heart disease
- Valvular heart disease (PulmHTN, A b, Hx of SBE)
- Diabetes with retinopathy/nephropathy/neuropathy
- Migraine headaches with focal neurologic Sx
- Severe cirrhosis
- Liver tumor (adenoma or hepatoma)
- Undiagnosed vaginal bleeding
- Known thrombophilia
- Known or suspected pregnancy
5
Q
Name relative CIs to OCP (8)
A
- Smoker over the age of 35 (< 15 cigarette/d)
- Adequately controlled HTN
- HTN (systolic 140–159 mm Hg, diastolic 90–99 mm Hg)
- Migraine headache over the age of 35
- Currently symptomatic gallbladder disease
- Mild cirrhosis
- Hx of OCP-related cholestasis
- Users of medications that may interfere with OCP metabolism
6
Q
Describe: Natural Family Planning (1)
A
7
Q
Name different Natural Contraceptive Method (5)
A
- Calendar (periodical abstinence)
- Ovulation method (periodical abstinence)
- Symptothermal (periodic abstinence)
- Lactational amenorrhea
- Coitus interruptus/withdrawal
8
Q
Name Percentage of Women with Unintended Pregnancy if: Regular Unprotected Intercourse
A
85%
9
Q
Describe this type of natural contraceptive method: Calendar (3)
A
- Calculate onset and duration of fertile period based on ovulation 12–16 d before menstruation, 5-d sperm survival, and 24-h unfertilized oocyte survival
- Avoid intercourse during 8–10 d of cycle
- Percentage of Women with Unintended Pregnancy: 9% (perfect us) vs 24% (typical use)
10
Q
Describe this type of natural contraceptive method: Ovulation method (3)
A
- Monitor volume and quality Δs in mucus
- Mucus becomes clearer and more elastic as ovulation approaches (spinnarkeit), then viscous, opaque, and impenetrable to sperm after ovulation
- Percentage of Women with Unintended Pregnancy: Perfect us 3%
11
Q
Describe this type of natural contraceptive method: Symptothermal method (3)
A
- Ovulation/cervical mucous method supplemented with calendar method in preovulatory phase and basal body temperature in postovulatory phase
- Basal body temperature:
- Following the postovulatory elevation in progesterone, basal body temperature should rise by at least 0.5°C.
- Percentage of Women with Unintended Pregnancy: 2% (perfect use)
12
Q
Describe this type of natural contraceptive method: Lactational amenorrhea (2)
A
- Temporary postpartum method of contraception based on hormonal suppression of ovulation in breast-feeding women (exclusive breast-feeding only)
- Percentage of Women with Unintended Pregnancy: 2% (perfect use)
13
Q
Describe this type of natural contraceptive method: Coitus interruptus/withdrawal (2)
A
- Male withdraws penis from vagina before ejaculation.
- Percentage of Women with Unintended Pregnancy: 4% (perfect use) vs 27% (typical use)
14
Q
Name barrier methods for contraception (6)
A
- Male condom (Latex, Polyurethane, Lamb skin)
- Female condom - Polyurethane sheath placed in vagina
- Diaphragm
- Cervical cap
- Sponge
- Spermicide
15
Q
Describe Mechanism of Action: Male condom (2)
A
- Mechanical barrier prevents exchange of fluid/semen and ↓ contact of genital lesions.
- Prevent pregnancy and STI
16
Q
Name CIs and cautions: Male condom (2)
A
- Allergy or sensitivity
- No STI protection with lambskin or novelty condoms
17
Q
Describe: Female condom (1)
A
Polyurethane sheath placed in vagina
18
Q
Describe Mechanism of Action: Female condom (3)
A
- Completely lines vagina
- Mechanical barrier prevents exchange of fluid/semen and ↓ contact of genital lesions.
- STI prevention similar to male latex condom
19
Q
Name CIs and Cautions: Female condom (3)
A
- Allergy or sensitivity
- Abnormal vaginal anatomy
- Inability to insert
20
Q
Describe: Diaphragm (1)
A
Intravaginal barrier method used with spermicide
21
Q
Describe the mechanism of action: Diaphragm (2)
A
- Physical barrier between sperm and cervix used in conjunction with spermicide
- Associated with ↓ cervical neoplasia, dysplasia, gonorrhea, PID, and tubal infertility
22
Q
Name CIs and cautions: Diaphragm (8)
A
- Allergy or sensitivity
- Large rectocele, cystocele, or uterine prolapse (↓ efficacy)
- ↑Risk BV and UTI
- Vaginal bleeding
- Cervical or uterine CA or dysplasia
- Current vaginal or cervical infection or PID
- Recurrent vaginal, cervical or UTI
- Requires specialist fitting and reassessment with changes in weight and parity
23
Q
Describe: Cervical cap (1)
A
Intravaginal barrier method used with spermicide
24
Q
Describe mechanism of action: Cervical cap (2)
A
- Silicone cap acts as physical barrier between sperm and cervix used in conjunction with spermicide
- Protects against chlamydia and gonorrhea
25
Name CIs and Cautions: Cervical cap (6)
* Allergy or sensitivity
* Vaginal bleeding
* Cervical or uterine CA or dysplasia
* Current vaginal or cervical infection or PID
* Recurrent vaginal, cervical or UTI
* Requires specialist fitting and reassessment with changes in weight and parity
26
Describe: Sponge (1)
Intravaginal “one- size- ts-all” barrier method
27
Describe Mechanism of Action: Sponge (2)
* 1° mechanism of action provided by sustained release of spermicide impregnated in sponge
* Also absorbs and traps sperm
28
Name CIs and Cautions: Sponge (8)
* Allergy or sensitivity
* Abnormal vaginal anatomy or bleeding
* Inability to insert
* Hx of Toxic-Shock Syndrome (TSS) or recurrent UTI
* Does not protect against STIs
* Cervical or uterine CA or dysplasia
* Current vaginal or cervical infection or PID
* Recurrent vaginal, cervical or UTI
29
Describe mechanism of action: Spermicide (1)
Made of surfactants that destroy the sperm cell membrane by altering the lipid layer
30
Name CIs and Cautions: Spermicide (2)
* Allergy or sensitivity
* Should be used with another contraceptive method
31
Contraception can be divided into what? (2)
* Combined hormonal formulations
* Combined oral contraceptives
* Transdermal patch
* Vaginal contraceptive ring
* Progestin only
* Progestin-only pill
* Depo-Provera injection
* Implantable options (not available in Canada)
32
Describe: The Combined OCP (5)
* Different formulations of OCPs:
* Monophasic (fixed amount of E and P)
* Biphasic (fixed amount of E, ↑ amount of P in second half of cycle)
* Triphasic (fixed or variable amount of E, P ↑ in 3 equal phases)
* With perfect use = 99.9% effective
* With typical use, failure rate ↑ to 3% to 8%
* Effect of body weight on efficacy is controversial
* Contraindications should be considered prior to starting an OCP
33
Some patients may experience more benefits or side effects from one formulation of OCP over a different formulation due what? (1)
to different levels of E and type of progestin
34
Name benefits of OCP (12)
* Cycle regulation
* ↑ bone mineral density
* ↓ Dysmenorrhea and moliminal Sx
* ↓ Menstrual flow (amenorrhea in 2%–3%)
* ↓ Acne and hirsutism
* ↓ Endometrial cancer
* ↓ Ovarian cancer
* Fewer ovarian cysts
* Possibly fewer benign breast cysts
* Decreased ovarian fibroids
* Decreased colorectal cancer
* Decreased salpingitis
35
Name side effects of OCP (5)
* Most resolve in first 3 cycles:
* Breast tenderness
* Nausea
* Irregular bleeding
* Chloasma
* No evidence for weight gain and/ or mood Ds
36
Name risks of OCP (5)
* Risk of VTE is 9/10,000 compared with nonusers (3/10,000). Highest risk in first year of use.
* Stroke and MI (if Ethinyl Estradiol (EE) \> 50 mg )
* ↑ Gallbladder disease
* Breast CA risk controversial
* Cervical CA risk uncertain
37
Describe: Patch (Evra) (5)
* 200 mg Norelgestromin 35 mg EE/d
* Apply to buttock, upper outer arm, lower abdo, upper torso
* If patch falls off, reapply new patch
* Backup if off \>24 h
* Failure Rate Perfect Use (Typical Use): 0.3 (8)
38
Describe initation: Patch (Evra) (2)
* Start: use backup unless start on first day of menses
* 1 patch weekly × 3 wk, then 1 wk patch-free week
39
Describe CI/Risks/Benefits/side effects: Patch (Evra) (6)
* CI (Same as OCP Plus): ↓ Efficacy cacy if body weight \>90 kg
* Risks/ Benefits: Same as OCP
* Side Effects:
* Same as OCP
* Breast discomfort
* (↑ vs. OCP)
* Local skin reaction
40
Describe: Vaginal ring (NuvaRing) (3)
* 15 mg Ethinylestradiol and 120 mg etonogestrel/d
* Effective for up to 4 wk protection
* Failure Rate Perfect Use (Typical Use): 0.3 (6)
41
Describe: initiation Vaginal ring (NuvaRing) (3)
* Start: cycle day 1–5
* Left in place × 3 wk, removed for 1 wk
* If ring removed \> 3 h need backup
42
43
Describe CI/Risks/Benefits/side effects: Vaginal ring (NuvaRing) (6)
* CI (Same as OCP Plus):
* Uterovaginal prolapsed
* Vaginal stenosis (prevent retention of ring)
* Risks/Benefits: No studies, assumed to be similar
* Side effects:
* Same as OCP
* Vaginities
* Leukorrhea
44
Name: Good Candidates for Progesterone Only (8)
* CI or sensitivity to E
* \>35 yr and smoker
* Migraine headaches
* Breast-feeding
* Endometriosis
* Sickle cell disease
* Anticonvulsant Rx
* Difficulty complying with daily pill (for DMPA)
45
True or false
The P component is predominantly responsible for the contraceptive effect.
True
46
Name the most common reason patients discontinue the OCP is what? (1)
abnormal bleeding
47
Irregular bleeding that continues beyond ___ must be investigated.
3 mo
48
Describe: “Pill breaks” (3)
* not necessary and ↑ risk of pregnancy.
* Continuous use of pill is safe
* If pill-free interval \> 7d → ↑ risk of ovulation and conception.
49
50
After discontinuing the pill, patch, or ring, fertility is restored when? (1)
within 1 to 3 mo.
51
Is a pelvic exam required before prescribing OCP? (1)
Not necessary
52
Is routine lab screening necessary before prescribing the OCP (1)
No
53
Name injectable and oral progesterone (2)
* Injectable: Depo-provera (DMPA)
* Oral P: P-only pill/mini-pill
54
Describe posology: Depo-provera (DMPA) (1)
* 150 mg IM q12 wk
55
Describe mechanism of action: Depo-provera (DMPA) (3)
* Inhibits secretion of pituitary gonadotropins → suppress ovulation
* ↑ Viscosity of cervical mucus
* Induces decidualization of endometrium
56
Describe absolute CI: Depo-provera (DMPA) (3)
“PUB”:
* **p**regnancy known or suspected
* **u**nexplained vaginal bleeding
* **b**reast CA (current)
57
Describe relative CI: Depo-provera (DMPA) (3)
* “ASH”:
* Active viral hepatitis
* Severe cirrhosis
* Hepatic adenoma
58
Name side effects: Depo-provera (DMPA) (4)
* Menstrual cycle disturbance (spotting or unwanted amenorrhea)
* Hormonal (headache, acne, ↓ libido, nausea, breast tenderness)
* Weight gain (~2.5 kg after rst year)
* Mood (controversial)
59
Describe posology: P-only pill/mini-pill (1)
0.35 mg norethindrone
60
Describe: P-only pill/mini-pill (4)
* P-only pill/mini-pill 0.35 mg norethindrone
* Failure rate = 0.5% with perfect use (must take pill at same time daily)
* Failure rate = 5% –10% with typical use
* No hormone-free interval
61
Describe the mechanism of action of P-only pill/mini-pill (2)
* Cervical mucus D (↓ volume, ↑ viscosity, alter molecular structure → minimal sperm penetration)
* May suppress ovulation (40% ) and ↓ receptivity of endometrium
62
Name absolute CI: P-only pill/mini-pill (2)
* Pregnancy (known)
* Breast CA (current)
63
Name relative CI: P-only pill/mini-pill (2)
* Active viral hepatitis
* Liver tumors
64
Name side effects: P-only pill/mini-pill (2)
* Headache
* Bloating
* Nausea
* Acne
* Spotting (most common reason for discontinuing)
65
Describe: Intrauterine Device (3)
* Long-acting reversible contraception
* Lowest failure rate because not compliance dependent
* Because of such low failure rates, the risk of ectopic pregnancy is low. However, if a pregnancy is conceived with an IUD in place, risk of ectopic pregnancy is high.
66
Name IuD available for use in Canada (2)
* Copper IUD
* levonorgestrel-releasing intrauterine system (LNG-IUS)
67
Describe: Copper IUD (4)
* Has a vertical stem with a copper wire wound around
* Efficacy (Pearl index): 1.26/100WY
* Failure rate (%): 0.8
* Duration of effect: 5 yr
68
Describe the mechanism of action: Copper IUD (4)
Prevention of fertilization through:
* Foreign body reaction (sterile inflammation) → endometrial D causing ↓ sperm transport and impaired implantation
* Direct effect of copper ions on sperm motility
* ↓ ability to penetrate cervical mucus
* Inhibit implantation postfertilization
69
Name side effets: Copper IUD (3)
* Pelvic pain (~6% of users will discontinue use due to pain)
* ↑ Menstrual ow (up to 65% )
* Spotting
70
Describe: levonorgestrel-releasing intrauterine system (LNG-IUS) (4)
* Slow release of levonorgestrel (20 mg/d) from small polyethylene T-shaped frame 13.5 mg/d new option, lasts 3 yr
* Efficacy (Pearl index): 0.09/100WY
* Failure rate (%): 0.1
* Duration of effect: 5 yr
71
Describe the mechanism of action: levonorgestrel-releasing intrauterine system (LNG-IUS) (5)
Prevention of fertilization through:
* Foreign body reaction and endometrial decidualization and glandular atrophy
* Endometrial E and P receptor suppression
* Thickened cervical mucus as barrier to sperm transport
* Some women have ovulation inhibition
* Inhibit implantation postfertilization
72
Name benefits: levonorgestrel-releasing intrauterine system (LNG-IUS) (4)
* Decreased menstrual flow (in over 75% of patients)
* Decreased endometrial CA
* Improved dysmenorrhea
* Prevents endometrial hyperplasia in women taking tamoxifen
73
Name absolute CIs to IuD use (10)
* Pregnancy
* Current, recurrent, or recent (within 3 mo) PID or STI
* Puerperal sepsis
* Immediate postseptic abortion
* Severely distorted uterine cavity
* Unexplained vaginal bleeding
* Cervical or endometrial CA
* Malignant trophoblastic disease
* Copper allergy or Wilson disease (for copper IUD)
* Breast CA (for LNG-IUS)
74
Name relative CIs to IuD use (10)
* RFs for STI or HIV
* Impaired response HIV positive Steroid Rx to infection
* From 48 h to 4 wk postpartum (due to expulsion risk)
* Ovarian CA
* Benign Gestational Trophoblastic Disease
75
Name risks of Depo Provera (2)
* Delayed return of fertility—average 9 mo delay before full fertility restored
* ↓Bone mineral density—appears to be reversible after discontinuing DMPA
76
Describe pain of IUD (3)
* Pain may be a physiologic response to device,
* but possibility of infection, malposition/perforation, or pregnancy should be R/O.
* With persistent pain, U/S is used to investigate IUD placement.
77
Describe: Emergency Contraception (EC) (1)
* Any method of contraception which is used after intercourse and before potential time of implantation
78
Name indications: Emergency Contraception (EC) (1)
* women wishing to avoid pregnancy and present within 5 d of unprotected sexual intercourse (copper IUD may be considered for up to 7 d)
79
Describe mechanism of action: Emergency Contraception (EC) (1)
differs between types of EC and timing of initiation, but can include interference with follicle maturation, ovulation, cervical mucus consistency, endometrial receptivity, corpus luteum support, fertilization, zygote development, transport, and adhesion/implantation
80
Name types of Emergency Contraception (EC) (4)
* Plan B
* Yuzpe Method
* Postcoital Insertion of Copper IUD
* Permanent Contraception
81
Describe: Plan B (3)
* Levonorgestrel-only method (consisting of **2 doses of 750 micrograms taken orally 12 h apart**) of 750 mg levonorgestrel taken orally 12 h apart
* Only product approved by Health Canada for EC
* May alternatively take levonorgestrel 1.5 mg orally as a single dose
82
Describe: Yuzpe Method (2)
* Oral administration of **2 doses of 100 mg Ethinyl estradiol** and **500 mg levonorgestrel 12 h apart**
* “Ovral” tablets were commonly used to provide these doses, but no longer available in Canada
83
Describe: Postcoital Insertion of Copper IUD (1)
Can be placed up to 7 d after intercourse to prevent conception and left in place to provide ongoing contraception
84
Describe: Permanent Contraception (2)
* Tubal interruption: 0.2% of women experience an unwanted pregnancy in the first year
* Vasectomy: 0.1% to 0.15% of women experience an unwanted pregnancy in the first year
85
True or False
## Footnote
Vasectomy is a less invasive and more cost-effective procedure than conventional tubal interruption.
True
86
True or False
## Footnote
Regret after sterilization is not infrequent
True
87
Counseling before sterilization should include what?
* discussion of alternative methods of contraception
* risks, complications
* potential for regret
* possibility of failure and difficulty
* expense
* and no guarantee of success for reversal.
88
Describe: Ectopic Pregnancy with IUDs (2)
* IUD does not ↑ risk of ectopic pregnancy. H
* However, if pregnancy occurs with IUD in place, ectopic must be R/O.
89
Name: Indications for Emergency Contraception (EC) (9)
* Failure to use a contraceptive
* Condom break/leakage
* Dislodgment of diaphragmor cervical cap
* Two or more missed pills
* Depo-Provera injection over
* 2 wk late (\> 14 wk)
* Ejaculation on external genitalia
* Mistimed fertility awareness
* Sexual assault (and not using reliable contraceptive method
