Adolescents & Contraception Flashcards
GAPS
guidelines for adolescent preventative services
- screening, vaccines, counseling to pt (health risk and
guidance)
Interview method used when taking psychosocial history with adolescent
HEEADSSS
Home environment Education and employment Eating Activities, peer-related Drugs Sexuality suicide/depression Safety from injury and violence
How many hours of sleep per night do teenagers need?
8-10
Additional history to Ask teens/ parents
sleep (causing trouble in school? Driving while sleepy?), food security
healthy eating
exposure to loud music
self & resiliency
PE on teenager
PE: scoliosis, breast exam on both genders, height, weight, and BMI, acne, piercings/ tattoos, signs of self injury, acanthosis, visual exam on female genatalia, male = visual inspection + palpate testicles+ inspect for hernia,
What age to start screening for depression?
Age 12 (Adolescent PHQ-9)
when should lipids start to be checked?
age 9-11
when is hearing usually checked in adolescents?
Btw 11-14 using audiometry
risk assessment topics to ask adolescents about?
Risk assessment (HIV, STI, oral health, IPV, violence through social media, tuberculosis, ) Tobacco, alcohol, and drug use (ask first about exposure through family and friends); vaping
when is vision screening done in adolescent years? what chart?
around age 12- Snellen Chart
Vaccines to give/ discuss with adolescents?
Flu
Tdap (btw ages 11-12)
HPV
MenACWY (meningococcal. Quadrivalent recommended)
What is included in sports physicals?
Hx
Cardiac exam
musculoskeletal exam
skin
billing - not covered by health insurance but can be covered if pt has not had a wellness exam within 12 months - usually cash pay with price set by clinic
What to do with adolescent with acne?
ID type and severity
treatment for acne
Topical: benzoyl peroxide, antibiotics, retinoids
Oral ABX: should see results in 5 days. topical first (should be mixed with benzoyl peroxide). Limit use to 3 months and if no results send to derm (ABX resistance concern)
Hormonal agents → estrogen-containing contraceptives; spironolactone
Oral isotretinoin (Accutane); must be on birth control
Other
Evaluating for precocious puberty
Evaluation:
Bone age x-ray - both hand and wrist recommended
LH/FSH and estradiol levels (females)
LH/FSH and testosterone (males) early morning
Lack of features of puberty on exam or failure of progression of changes (Tanner Stages) at least age 14
Delayed puberty
how to evaluate for delayed puberty?
Bone age x-ray
Free T4 and TSH
Serum prolactin, LH, and FSH`
Girls should have had their first cycle within __ years of getting breast buds?
5 years
Boys should get to Tanner stage 5 within ____ years of puberty?
4-5 years
6-12 months after menarche
Primary (idiopathic) no underlying pathology
Consider endometriosis if family hx
Sx: cramping, pelvic pain, n/v/d, HA, fatigue
Workup: almost never need pelvic exam
Only really done if family hx or if fail basic tx
Dysmenorrhea
Tx options for dysmenorrhea
Tx: NSAIDs (do different categories), hormonal contraception may be used
Black cohash, heat, rest
Difference between functional and structural scoliosis
Functional: curvature without rotation poor posture, pain. Reversible
Structural: rotation of spine with curvature.
How to diagnose and examine scoliosis
Diagnoses by AP/lat x-ray of spine (at least 10 degree curvature for diagnosis)
If less than 20 degree curve just monitor.
Exam spine, scapula, shoulders, waist
Adam’s test: lean completely forward and drop head low. Observe from front and side
TBI d/t biomechanical forces, either direct or indirect trauma
Usu rapid onset of short lived impairment of sx
Neuroimaging is usually normal. Most do not lose consciousness
s/s:
HA, nausea, dizziness, vision changes, light/noise sensitivity, concentration
Concussion
How to evaluate and tx concussion
Evaluation: ACE or scap tool. LOC, posturing, or balance problem immediate remove from the area for further evaluation
Rest: physical and brain rest for 24-48hrs (some take 7-14 days)
No school, no screens, no reading, no sports
Long term issues: HA, anxiety, sleep problems possible
12-18 years old
May develop into bipolar disorder
PHQ-2 or PHQ-9 modified for adolescents
Suicide #2 cause of death in adolescents → be straightforward
Depression
(male sterilization) → interrupts the vas deferens, preventing the passage of sperm into seminal fluid
vasectomy
Advantages of vasectomy
ADVANTAGES:
Highly effective, non-hormonal. Preformed in clinic with local anesthetic.
Cost effective
No effect on sexual function
disadvantages of vasectomy
DISADVANTAGES Takes 2-4 months for effectiveness Requires f/u Post-procedure discomfort, short term Procedure complications: infection, hematoma, granulation, swelling, persistent pain Non-reversible Not STI protection
surgery to remove or interrupt patency of fallopian tubes
Multiple methods
½ sterilizations completed 48hrs postpartum
Female Sterilization`
Advantages of Female Sterilization procedure
Decreased risk of ovarian cancer
No change in menstrual bleeding or pain
DISADVANTAGES of Female Sterilization` procedure
Regret
Invasive surgical procedure
Not STTI protection
Complications: Infection, wound separation; hemorrhage viscus injury, anesthesia complications. Vessel injury, mortality
CI: obesity, issues with anesthesia, adhesive disease from prior injury
Surge in prolactin inhibits ovulation
Must be exclusively breastfeeding
When menstrual cycle returns patient is fertile, often women ovulates before the return of menses
Effective until baby 6 months old
Lactational Amenorrhea Method (LAM) AKA Breastfeeding
Fertility beads, calendar methods, cervical mucus, basal body temp method, etc. that help women ID time they are ovulating
Monitor cycle, needs to be regular for this to work
First year failure rate 12-15%
Can be used to help couples become pregnant
Fertility Awareness Methods (FAM)
decreased risk of cervical cancer, PID, infertility, STI, and ectopic pregnancy
Male condoms
higher failure rate, bulky; makes noise. Can be inserted up to 8hrs before intercourse
Female Condom
placed anytime before intercourse, left in for 6-8 hours (up to 48hrs) after intercourse. Used with spermicide. Require fitting, less convenient, less effective after childbirth
Dis: No STI protection. These can develop an odor, may be difficult to insert, may increase UTI
Cervical caps and diaphragms
sponge filled with spermicide, left in place 6-24 hours after intercourse
Contraceptive Sponge
higher failure rate when used alone. Attack sperm to reduce motility.
Women HIV positive or at high risk of HIV should NOT use!
Some forms require 15 mins before effectiveness
Unpleasant taste, irritation possible
Spermicides
Coitus Interruptus
Withdrawal method
MOA is spermicide
Copper ions inhibit sperm motility. Sperm rarely reach fallopian tube
NOT considered an abortifacient and does not prevent ovulation
Effective for 10-12 years
possible/probable protection against cervical/endometrial cancer
Rapid return to fertility after removal
DISADVANTAGES- may worsen dysmenorrhea
ParaGard Copper IUD
Causes cervical mucus to thicken, preventing sperm from entering the reproductive tract
May inhibit ovulation in 40% of women
Progesterone-Only BC Methods
Taken daily, no hormone-free days
Contains no estrogen
Cost is higher than combined; used less in US
Thickening of cervical mucus occurs 2-4 hours after taking pills and lasts 22 hours (if intercourse occurs within 2 hrs of taking pill it is not as effective)
Must take pill same time everyday
Need back up method for first 2 days
Mini-Pills/POPS
Advantages of Mini-Pills/POPS
↓ menstrual blood loss, cramps, pain 10% amenorrhea May protect against endometrial cancer Rapid return to fertility Poss. reduction in PID No estrogen May be used for smoker over 35 May be used while breastfeeding No thromboembolic complications
Disadvantages of Mini-Pills/POPS
Irregular menses; amenorrhea- increased spotting days
May lead to higher incidence of ovarian follicles
No STI protection
Unforgiving if pill is late or missed
AVOID with active hepatitis, hepatic failure, or jaundice
CI if taking meds that enhance hepatic clearance (CYP450)
Do not use if conditions that may impair absorption from GI tract (ie coitis)
NO Grapefruit juice
IM injection q13 weeks OR SQ injection q14 weeks at home
DMPA Injection: Depo
MOA: suppresses ovulation by inhibiting LH and FSH surge Thickens cervical mucus Slows tubal and endometrial activity Thins lining of endometrium
Low failure rate (0.2-6%)
Costs 4x greater than pills
High discontinuation rate
Preferred start within 7 days LMP (no backup needed)
If started in different point in cycle need backup for 7 days
DMPA Injection: Depo
Advantages DMPA Injection: Depo
Less menstrual blood loss and anemia
↓ menstrual cramps and pain
After 1 yr, 50% have amenorrhea, 80% after 5 yrs
Allows for spontaneity
Reduces endometrial cancer risk
↓ blood loss for women with fibroids
Good option if anticoagulated or bleeding disorder
Good option if taking anticonvulsant (may decrease seizures)
Good option for developmentally and/or physically challenged
Sig. reduction of ectopic pregnancies
Some reduction PID
Private method
May be used while breastfeeding
disadvantages DMPA Injection: Depo
Irregular bleeding and spotting * Return to fertility may be delayed (several years) No STI protection Need to return to clinic for injections Potential for ↓ BMD If used longer than 2 years Reversible when d/c’ed Encourage weight -bearing exercise, optimal calcium intake, don’t smoke SE: HA, acne, hirsutism May experience breast tenderness, bloating, and vasomotor sx Modest weight gain Metabolic effects: Increased glucose & LDL Decrease HDL
Single implant under skin of upper arm
82% continue to use over 2 years
Effective for at least 3 years
No studies evaluating failure rates
Anti Seizure medications may lower effectiveness
Primary MOA: cervical mucus thickening, may also inhibit ovulation
Thins endometrium
Insertion within 7 days of LMP= no backup; otherwise 7 days of backup
Advantages and Disadvantages similar to all other progestin only methods
Implanon and Nexplanon (Newer version- radiopaque)
Primary MOA: thicken cervical mucus and prevent sperm from entering reproductive tract
Changes in uterotubal fluid can impair sperm motility and ovum migration
Levonorgestrel Intrauterine Systems
The 52 mg have some anovulatory effects
Does not impact implantation and is not an abortifacient
Highly effective, low failure rate
If inserted within 7 days of LMP no backup needed
Can be used in nulliparous women
Can be used in women with multiple partners (concerns for PID d/t string)
Levonorgestrel Intrauterine Systems
Mirena: ___ years, ___ mg levonorgestrel
Skyla: ___ years , ___ mg levonorgestrel → lower progesterone marketed for nulliparous women
Liletta: ___ yrs, ___ mg levonorgestrel
Kyleena: ___ years, ___ mg levonorgestrel
Mirena: 7 years, 52 mg levonorgestrel
Skyla: 3 years , 13.5 mg levonorgestrel → lower progesterone marketed for nulliparous women
Liletta: 3 yrs, 52 mg levonorgestrel
Kyleena: 5 years, 19.5mg levonorgestrel
PAINS
early warning signs of concerns
P: period late (copper IUD), abnormal spotting or bleeding beyond expected
A: abd. pain, pain w intercourse
I: infection exposure (STI), abnormal vaginal discharge
N: not feeling well , fever chills
S: string missing or shorter
MOA: prevention of ovulation by suppression of FSH and LH secretion
Endometrial lining is kept thin
Cervical mucus thickens
Tubal motility is slowed
The 7 placebo pills at the end of the pill pack is a withdrawal bleed, not a period
Combined Hormonal Contraceptives
what kind of women should NOT use spermicides?
women at high risk of HIV or who are HIV positive
Advantages of Combined Hormonal Contraceptives
↓ blood loss and anemia
Can manipulate frequency and timing of bleeding
Can ↓ risk of internal hemorrhage from ovulation in women on anticoagulants or with bleeding disorders
Can provide progestin for women with anovulation/PCOS to reduce risk of endometrial cancer
Allows for sexual spontaneity
↓ risk ovarian, endometrial, and colorectal cancer
↓ risk of benign breast masses; reduced risk of corpus luteum cysts (ovarian)
May improve acne (takes up to 6 mos)
↓ vasomotor sx for perimenopausal women
Possible ↑ BMD
Disadvantages of Combined Hormonal Contraceptives
May spot during first few cycles
Lack of withdrawal bleeding can cause concern
↓ libido and anorgasmia are possible
Daily pill taking
Not as private as other methods
No ↑ risk for squamous cell cervical carcinoma, BUT ↑ risk of adenocarcinoma; recommend routine PAP testing
↑ risk of hepatocellular carcinoma in COC users with > 50 ug formulation
No protection from STI
SE: n/v, weight gain, HA, bloating, breast tenderness, chloasma, varicosities and spider veins
COC
Combined Oral Contraceptives
COC Complications:
VTE; less risk than when pregnant. Risk is lower with estrogen doses <35mcg
MI or stroke: no increased risk using low dose, do not smoke, do not have HTN, and do not have migraines with neurological findings
Women at risk: smokers over 35, HTN, DM, dyslipidemia, obesity, migraines with aura (stroke only)
HTN : 1% of users develop. Self-corrects 1-3 months after d/c
Cholelithiasis: Greater risk with 50mcg estrogen formulations. Use cautiously in gallbladder disease
Visual changes: rare retinal thrombosis. Contact lenses may have dry eyes
ACHES Mnemonic → warning signs when on COC
A- abdominal pain C- chest pain H- headaches E- eye changes S- Severe leg pain
Initiation of COC:
Typical start
Sunday start
Quick start
No pelvic exam needed prior to initiation if asymptomatic
Typical start → first day of next menses, no backup needed
Sunday start → first Sunday after start of menses. Backup needed 7 days
Quick start → preferred method. Backup needed for 7 days
when does ovulation occur in menstrual cycle?
surge of FSH and LH
This is where combined hormonal contraceptives work
Maintains steady state of hormones, unike COCs, which peak and wane daily
one ring up to 42 days
Can be removed for intercourse if reinserted within 3 hrs
Vaginal Contraceptive Ring (Nuvaring)
Advantages of Vaginal Contraceptive Ring (Nuvaring)
No concerns r/t GI absorption Less withdrawal bleeding and spotting Irregular bleeding risk low ↑ compliance Typically not felt Lowest serum estrogen and progestin levels of any combined hormonal method privacy Little weight gain
Disadvantages of Vaginal Contraceptive Ring (Nuvaring)
Withdrawal bleeding may continue past ring-free interval (spotting)
May be uncomfortable with placing and removing
Low risk of expulsion
Advantages of Weekly Patch (Xulane)
No concerns r/t GI absorption
No daily pill
May bathe, swim, etc
Active up to 9 days
Disadvantages of Weekly Patch (Xulane)
20% breakthrough bleeding first cycle No STI protection Application site detachment or skin irritation Potential for skin pigment changes Breast discomfort may be higher WARNING: higher concentrations of circulating estrogen at steady state than COCs 60% higher than with women on 35 mcg EE Increased risk of VTE and CV events Risk estimated to be doubled!
Failure rate slightly higher than other methods
Miss 1 pill in 24-48 hrs; just take another
Miss more than 2, use backup method
Combined Oral Contraceptives “The Pill”
same levels of estrogen and progesterone in each pill → PREFERRED
Monophasic
amounts of estrogen and progesterone varies
Multiphasic
Progestin only option when contraception failed or was not used
Behind the counter
If under 18 → require prescription
NOT an abortion pill
MOA: Delay or inhibition of ovulation
Take as soon as possible, up to 5 days after intercourse
Emergency Contraception → Plan B
Regular vs. Extended Use Contraception
Extended use: delay of withdrawal bleeding longer than 28 days
No need for withdrawal bleed week
Less likelihood of ovulation. Less risk of pregnancy
Decreased missed days of work
Avoids s/s a/w hormone withdrawal period
