Ch. 4: Wellness Visits & Contraception Flashcards
13-20 years recommended wellness visit includes
-mesntrual, gyn hx
-sexual history
-alcohol and drug screen
-no pelvic or breast exam
-screening: chlamydia and gonorrhea ONLY if sexually active
counseling/education for 13-20 year olds
-expected body changes
-reproductive life planning
-safer sex practices
immunizations 13-20 year olds
HPV vaccine for cervical cancer prevention
21-29 year old well women visit includes…
- CBE offered
- pelvic exam- periodic, pap test
- screening: chlamydia and gonorrhea if less than 25 and sexually active or has risk factors, HIV screening if sexually active, pap tests
pap smear recommendations 21-29 years
cytology alone every 3 years
counseling/education for 21-29 year olds
-reproductive life planning
-safer sex practices
-breast health: women >20 years old should know about breast self-awareness and when to seek further evaluation
-purpose of pap and how often
-HPV vaccine
ages 30-49 well women visits include
- CBE: yearly aged 40 and older
- pelvic examination
- cervical cancer screening
- mammogram: yearly starting at 40
- HIV screening if sexually active
cervical cancer screening 30-49 recommendations
cytology with HPV testing every 5 years OR cytology alone every 3 years (HPV testing every 5 tears)
infertility is defined as…
the inability to conceive after 1 year of unprotected sex if < 35 y.o
after 6 months if > 35
sperm matures in the…. travels through the…. and out of the…
matures in the epididymis and travels through vas deferens and out the urethra
T/F healthy sperm can survive in the female reproductive tract and retain ability to fertilize egg for 3-5 days
true
female infertility factors include
1. ovulatory dysfunction
2. pelvic pathology
annovulation, luteal-phase insufficiency, poor ovarian reserve, inadequate cervical mucus
pelvic: uterine anomaly, adhesions from surgery or peritonitis, tubal occlusion, endometriosis
male infertility factors include
- low sperm production
- adhesions in vas deferens
- anatomic abnormalities: varicocele, hypospadias, phimosis, retrograde ejaculation
- ED
what is varicocele
abnormal dilation of peri-testicular veins resulting in varicose veins
“bag of worms”
what is hypospadias
congenital defect where urethral meatus is located on ventral surface
what is phimosis
tight foreskin that cannot be retracted
fertility workup (BOTH partners) includes…
prior pregnancies, duration of infertility, and previous evaluation and treatment, frequency of intercourse, sexual dysfunction, STI history, endocrine disorders, chemo hx, current MEDICATIONS, smoking, marijuana use, alcohol use, illicit drugs, environmental exposures, family history of birth defects
fertility workup includes.. diagnostic tests/findings
- pelvic u/s- uterine anomalies, ovarian volume, persistent ovarian cysts
- hysterosalpingogram- shape of uterine cavity, tubal patency
- basal body temperature for ovulation detection
- ovulation prediction tests (detects LH surge)
- AMH level and antral follicle count to determine ovarian reserve
- FSH, LH, estradiol (E2), progesterone levels
- TSH level
- prolactin level
- STI screening if indicated
- semen analysis
**Cav also likes to get a HgbA1c because high blood sugar can disrupt ovulation
what would indicate diminished ovarian reserve?
-AMH
-antral follicle
-FSH
-AMH value less than 1 ng/mL
-Antral follicle count less than 5-7
-FSH greater than 10 IU/L
when should we measure estradiol and FSH vs progesterone
E2 + FSH: between cycle days 2-5
Progesterone: day 21-22
what progesterone level is indicative of ovulation?
> 3 ng/mL
management/treatment for infertility depends on the cause
a. ovulatory dysfunction (PCOS, POI, etc)
ovulation induction therapy with clomiphene citrate, letrozole (preferred)
letrozole regimen includes
-dose
-days to take
-2.5 mg
-cycle days 3 to 7, following spontaneous or progestin-induced bleed
management/treatment for infertility depends on the cause
b. luteal-phase defect
vaginal or IM progesterone
IVF is when…
oocytes are extracted, fertilized in the lab, then transferred through the cervix into the uterus
contraception
-first line for adolescent and adult females
-LARC methods (IUD and progestin-only contraceptive implants)
-highly effective without concerns for inconsistent or incorrect use
drug interactions that may decrease contraceptive efficacy
- drugs that increase production of liver enzyme cytochrome P-450 (rifampin, some anticonvulsants, some antiretrovirals, St. John’s Wort); effects all CHC methods, p-only pills, p-only contraceptive implants
quick start method applies to which contraceptives when switching?
CHC, progestin-only methods, IUD
just start the new method the same day as d/c the other
BUT: follow backup contraception instructions regardless (7-14 days of second method)
if there is a gap of time between stopping/starting another method and unprotected intercourse occurs you should… (3)
- offer emergency contraception
- start new method no later than next day
- use backup method for 7 days
- advise urine pregnancy test if no withdrawal bleed in 3 weeks
mechanism of action for IUD
1. copper vs
2. Levonorgestrel (LNG-IUS)
COPPER: inhibits sper capacitation, alters tubal/uterine transport of ovum, enzymatic influence on endometrium
LNG-IUS: thicken cervical mucus, produces atrophic endometrium/thins endometrium lining, slows ovum transport through tube, inhibits sperm motility and function
advantages of IUDs
-ease of use
-not coitally dependent
-effective
-reversible
-cost effective when used > 1 year
-can decrease blood loss and dysmenorrhea during menses
-effective for those with CI to estrogen
-can be used during lactation and immediately postpartum
disadvantages of IUDs
-copper
-LNG
COPPER: longer, heavier bleeding, increased dysmenorrhea first few months
IUD: irregular bleeding and spotting first three months of use; absence or decrease of bleeding
what is the risk for PID after IUD insertion?
increased risk for the first 20 days following insertion
absolute contraindications for IUDs (many)
- known/suspected pregnancy
- PP sepsis
- unexplained vaginal bleeding
- cervical cancer
- current breast cancer within the past 5 years (LNG only)
- uterine abnormalities that distort the uterine cavity
- endometrial cancer
- gestational trophoblastic disease with persistently elevated hCG levels
caution with IUD insertion for these folks…
-ischemic heart disease occuring after insertion
-hx of breast cancer with no evidence of disease in the last 5 years
-high likelihood of exposure to chlamydia or gonorrhea
-acquired immunodeficiency syndrome
-systemic lupus erythematosus
-severe cirrhosis
health assessment prior to initiation of IUD includes + physical exam
-STI/PID, vaginitis symptoms
-STI risk factors
-HIV status/exposure
-pap test history of abnormal results
-heavy menses/anemia
-menstrual history
-examine vagina and cervix for signs of infection
-chlamydia and gonorrhea tests/wet prep if indicated by history
-pregnancy test if indicated
-bimanual exam
what should the uterus sound to when placing an IUD?
6 to 9 cm for best placement
what should the IUD strings be trimmed to
3 to 4 cm
timing of placement considerations
-period
-after birth
-abortions
-backup method
-don’t have to wait for period
-placed within 48 hours after delivery (high risk of uterine perforation prior to 4 weeks)
-can be placed immediately following 1st or 2nd trimester abortions
-use backup method for 7 days after LNG-IUS placed
T/F irregular bleeding (spotting/light bleeding/heavy bleeding/prolonged bleeding) is common the first 3-6 months of the copper IUD
TRUE
T/F LNG-IUD has irregular bleeding patterns for first three months commonly followed by amenorrhea
true
what can you recommend to patients with recent IUD placement and bothersome irregular bleeding?
- short term (5-7 days) NSAIDs use may reduce bleeding when it occurs
cramping and pain following insertion
1. if severe
2. if mild
- severe: rule out perforation
- mild: NSAID/other analgesic or remove IUC
s/sx of expulsion of an IUD
cramping, spotting, dyspareunia, lengthening or absence of strings
what should you do if an IUD is expulsed?
- rule out pregnency and infection
- replace IUC if desired
- doxycycline for 5 to 7 days
what should you do if patient has an IUD and is pregnant?
FIRST R/O ECTOPIC PREGNANCY
then:
-remove IUD
pregnant patient with IUD management
-spontaneous abortion vs patient who wants to continue pregnancy
-abortion: treat with doxycycline/ampicillin 5-7 days
-continue pregnancy: advice risk for spontaneous septic abortion if IUD is not removed; MONITOR CLOSELY for infection in pregnancy if unable to remove IUD
if an IUD is embedded…
may need to be removed with dilation and curettage but can remove IUD from uterus with forceps if visualized
PID
-most IUD-related PID occurs within the first…
20 days!
should the IUD be removed if patient has PID?
not necessary unless current high risk for STI or no clinical improvement within 48-72 hours of antibiotic initiation
IUD waring signs (hint: PAINS)
- Period late.missed; abnormal spotting or bleeding
- Abdominal pain
- Infection- VAGINAL DISCHARGE
- Not feeling well- fever, aches, chills
- String missing, shorter, or longer
Progestin-Only implant: etonogestrel (Nexplanon)
-use length
-how does it work
-MOA
-3 years
-placed subdermally
-provides low dose sustained release of progestin etonogestrel
-MOA: suppresses LH- ovulation inhibited in almost all users, produces atrophic endometrium, thickens cervical mucus
advantages of nexplanon
-ease of use
-effective
-reversible (ovulated within 6 weeks of removal)
-no estrogen
-can be used during lactation and immediately pp
-long term contraception (3 years)
-reduced dysmenorrhea and pain
disadvantages of Nexplanon
-clinical insertion and removal
-pain, bruising, infection at insertion site
-irregular, prolonged, more frequent uterine bleeding esp in the first few months
-may have amenorrhea
-does not protect against STIs
possible side effects with Nexplanon include
-increased incidence of functional ovarian cysts
-headache
-emotional lability
-breast tenderness
-loss of libido
-vaginal secretion changes- dryness
-acne
absolute CI to nexplanon use (1)
do not use if breast cancer in last 5 years
pregnancy-also do pregnancy test!
when should nexplanon be inserted so no backup method is needed?
within days 1 to 5 of menses
if nexplanon is inserted other than days 1 to 5 of menses…
use backup method for 7 days
combined oral contraceptives have both estrogen and progestin, whose MOA’s include..
estrogen: inhibits ovulation through suppression of FSH, potentiates action of progestin, stabilizes endometrium for less unscheduled bleeding and spotting
progestin: provides most of the contraceptive effect; inhibits ovulation through suppression of LH surge; inhibits sperm penetration by thickening cervical mucus; progestins available vary in bioavailability, dose needed for ovulation inhibition, and half life
monophasic vs multiphasic
monophasic: deliver constant amount of estrogen/progestin throughout cycle
multiphaseic: vary amount of E and P delivered throughout the cycle
different generations of progestin
1. first generation progestins
-con
norethindrone, northindrone acetate, ethynodiol diacetate
lowest potency, short half life, lower doses more likely to have unscheduled bleeding
- second generation progestins
pro and con
norgestrel, levonorgesterel
more potent and longer half life designed to decrease unscheduled bleeding and spotting, associated with more androgen-related side effects (acne, hirstuism)
- third generation progestins
-why were they designed?
desogestrel, norgestimate
designed to maintain potency of second-generation progestins but with less androgenic effects
- fourth generation progestins
a. Drospirenone- analgue of spironolactone, a potassium-sparing diuretic; progestogenic effect, anti androgenic properties
b. dienogest- a 19-nortestosterone with slightly different structure to maintain strong progestin effect and exert an antiandrogenic effect
the first three generations of progestin are derived from…
testosterone
COC can help reduce incidence of… (LOTS)
-acne
-dysmenorrhea
-PID
-endometriosis
-iron-deficiency anemia
-osteoporosis
-benign breast conditions
-functional ovarian cysts
-ovarian cancer, endometrial cancer, colorectal cancer,
-menstrual migraine headaches
-PMS, PMDD
side effects/possible adverse effects of COC’s
-ESTROGENIC side effects
-nausea
-increased breast size/breast tenderness
-chloasma
-telangiectasia
-cervical eversion/ectopy
-increased BP
-increased cholesterol concentration in gallbladder bile
-migraine headaches
-increased triglycerides
-arterial thrombosis
-VTE
side effects/possible adverse effects of COC’s
-PROGESTERENIC effects
-breast tenderness
-fatigue
-depressive symptoms
-increased insulin resistance
-constipation/bloating
-precipitation of gallbladder sludge or stones
-cyclic weight gain
possible androgenic side effects of COCs (4)
- increased appetite/weight gain
- hirsutism
- acne, oily skin
- increased LDL cholesterol
ABSOLUTE contraindications to COC use (13)
- smoker 35 years of age or older, 15 or more cigs/day
- multiple risk factors for cardiovascular disease
- Hypertension (160/100) or hypertension with vascular disease
- DVT or PE or history of one
- major surgery with prolonged immobilization
- hx of or current ischemic heart disease, stroke, complicated valvular heart disease
- migrain headaches with aura at any age
- breast cancer within the past 5 years
- diabetes with nephropathy, retinopathy, or diabetes longer than 20 years
- active viral hepatitis, severe cirrhosis, hepatocellular adenoma, malignant hepatoma
- SLE (LUPUS) with + or unknown antiphospholipid antibodies
- solid organ transplantation with complicatons
- less than 21 days postpartum regardless of breastfeeding status
category 3 CI to COC use
-21-42 days pp, non-BF, with other risk factors VTE
-21 to < 30 days pp, breastfeeding, with or w/o risk factors for VTE
-30-42 days pp, breastfeeding, with other risk factors for VTE
-smoker 35 years of age or older, <15 cigs/day
-HTN (adequately controlled or less than 160/100)
-known hyperlipidemia
-hx of breast cancer with no evidence of disease for 5 years
-gallbladder disease that is symptomatic
-mild cirrhosis
-history of bariatric surgery
-moderate to severe inflammatory bowel disease with associated risk for DVT, PE
health assessment prior to COC initiation
(think about the CI’s)
-blood pressure
T/F most broad-spectrum antibiotics (ampicillin, metronidazole, doxycycline, fluconazole) do NOT lower hormone levels or reduce COC effectiveness
TRUE
which medications DO induce cytochrome P-450 enzyme activity and may reduce COC effectiveness
(3 medication types, 2 specific medications)
antibiotics: rifampin, rifapentine, griseofulvin
anticonvulsants: carbamezapine, phenytoin, phenobarbital, topiramate
antiretroviral drugs: protease inhibitors
st John’s wort
Orlistat (weight loss medication)
COC drug interactions
-benzos (diazepam, chlordiazepoxide)
-tricyclic antidepressants
-theophylline
-K-sparing drugs that may cause hyperkalemia: ACE inhibitors, aldosterone antagonists, chronic daily use of NSAIDs (if taking any of the medications- check K+ levels after first cycle of COCs)
T/F unscheduled bleeding/spotting is a common side effect with COCs the first three months of use
TRUE
-educate patients on this
how do we manage unscheduled bleeding/spotting?
-bleeding before withdrawal bleed/completed active pills (2nd half of cycle/luteal phase/secretory phase)
-continued bleeding follow scheduled bleeding (1st half of cycle/follicular phase/proliferative phase)
-unscheduled bleeding with continuous use
- reinforce to take pill daily @ same time
- may consider timing of unscheduled bleeding in cycle:
2a. bleeding BEFORE complete active pills: increase progestin content for more endometrial support
2b. continued bleeding following scheduled bleeding: increase estrogen content of first pills in pack OR decrease progestin content of first pills for more estrogen to proliferate endometrium
2c. unscheduled bleeding with extended cycle or continuous use: take at least 21 active pills, take 3-4 days off for withdrawal bleed to start, restart active pills, and take for at least 21 days before stops again
how should you manage women on COCs that don’t have a withdrawal bleed?
-5% of women after several years of COC use
-rule out pregnancy or other potential causes of amenorrhea
-no intervention required if women is okay with no menses
-change to 30-35 mcg estrogen if on 20 mcg COC or triphasic formulation with lower levels of progestin in early pills
COC instructions for use
- quick start method
- first day start
- quick start method: reasonable certain not pregnant, take first pill on day of office visit; back up contraception for 7 days if >5 days since LMP
- first day start: take first pill on first day of menses; no backup method needed
other important patient education regarding COC use
-warning signs (ACHES)
-take pill at same time each day
-use backup method if compromised by severe diarrhea or vomiting
-use condoms for prevention or STIs/HIV
ACHES
Abdominal pain (severe)
Chest pain (severe)
Headache
Eye problems
Severe leg pain (calf or thigh)
if nausea occurs with COC tell patient to…
take pill with meals or at bedtime
recommended actions after late or missed COC
-one hormonal pill is late <24 hours since a pill should have been taken
-if one hormonal pill has been missed (24-47 hours since a pill should have been taken)
-if two or more consecutive pills have been missed (>48 hours since a pill should have been taken)
- one hormonal pill is late <24 hours since a pill should have been taken: take the late or missed pill ASAP, continue remaining pills at usual time (even if you take 2 pills on the same day), no additional contraceptive protection, emergency contraception can be considered for those who missed pills early in cycle or in last week of previous cycle
- if one hormonal pill has been missed (24-47 hours since a pill should have been taken): SAME ^^^^^
- two or more missed pills:
-take most recent pill ASAP
-continue taking pills at same time (even if taking 2 same day)
-use backup contraception/abstinence until hormonal pills have been taken 7 consecutive days
-emergency contraception should be considered if hormonal pills were missed during the first week and unprotected intercourse occurred in the previous 5 days
-emergency contraception may also be considered at other times as appropriate
with two or more consecutive missed COC pills
- if pills were missed in the LAST week of hormonal pills (days 15-21)
-omit hormone-free interval by finishing the hormonal pills in the current pack and start new pack the next day
-if unable to start new pack immediately, use backup contraception until hormonal pills been taken 7 consecutive days
transdermal contraceptive patch use
-delivers continuous daily systemic dose of progestin and estrogen; new patch applied each week for 3 weeks followed by 1 week without patch to induce withdrawal bleeding
side effects of transdermal contraceptive patch
-skin irritation at application site
-other side effects similar to COCs
CI’s to transdermal contraceptive patch are same as
COCs
-smoker 35 years olds (15 cigs/day), hypertension, ischemic heart disease or stroke, hx of DVT or PE, breast cancer in the last 5 years, multiple risk factors for arterial cardiovascular disease, major surgery with prolonger immobilization, migraine with aura, diabetes with nephropathy, active viral hepatitis or severe cirrhosis, systemic lupus with positive or unknown antiphospholipid antibodies, less than 21 days PP
special considerations with transdermal contraception use
-may be less effective in women who weight > 200 lbs (more than 90kg)
instructions for using the method/where you can apply it
- quick start method
- first day start
- quick start method: reasonably certain not pregnant, apply patch on day of office visit; if more than 5 days since you LMP use backup method for 7 days
- first day start: apply patch on first day of menses; no backup contraception needed
apply on butt, abdomen, upper torso front or back (NOT breasts), upper outer arm)- ROTATE APPLICATION SITE
apply new patch on same day each week for total of 3 weeks
do NOT wear patch on week 4; withdrawal bleeding will occur
recommended actions after delayed application or detachment with contraceptive patch
- delayed application of detachment for < 48 hours since patch should have been applied or reattached
- > 48 hours since a patch should have been applied or reattached
- delayed application of detachment for < 48 hours since patch should have been applied or reattached
-apply new patch ASAP
-if patch detached < 24 hours since patch was applied, try to reapply the patch
-keep same patch change day
-no additional contraceptive protection needed
-emergency contraception not usually needed, but can be considered - > 48 hours since a patch should have been applied or reattached
-apply new patch ASAP
-keep same patch change day
-use backup contraception until patch has been worn 7 consecutive days
-if detachment or delayed application happened in the third patch week: omit the hormone-free week by finishing the third week of patch use and starting a new patch immediately; if unable to start a new patch immediately, use backup contraception until new patch has been worn for 7 consecutive days
-emergency contraception should be considered if delay app/detachment happened the first week of the patch use and unprotected intercourse in previous 5 days
-emergency contraception can be considered at other times too
what about if the patch is left on too long?
There is a two-day (48 hours) period of continued release of adequate contraceptive steroid levels when the patch is left on for two extra days. If users change the patch within this window, the patch change day remains the same, and there is no need for back-up contraception.
contraceptive vaginal ring (Nuvaring)
worn in vagina three weeks followed 1 week without to induce withdrawal bleeding; delivers continuous systemic dose of estrogen (ethinyl estradiol) and progestin (etonogestrel)
contraindications and side effects of Nuvaring are the same as
COC’s
instructions for using Nuvaring
-can use quick start or first day start
-wash hands prior to insertion
-fold ring and gently insert into vagina
-exact position of ring in vagina is not important
-leave ring in for 3 weeks, then remove for 1
-insert new ring in 7 days
recommended actions after delayed insertion or reinsertion of contraceptive vaginal ring
-delayed insertion or new ring OR delayed reinsertion < 48 hours since a ring should have been inserted
-delayed insertion of a new ring or delayed reinsertion for > or = to 48 hours since ring should have been inserted
- delayed insertion or new ring OR delayed reinsertion < 48 hours since a ring should have been inserted
-insert ring ASAP
-keep the ring in until the scheduled ring removal day
-no additional contraceptive protection is needed/emergency contraception not necessary - delayed insertion of a new ring or delayed reinsertion for > or = to 48 hours since ring should have been inserted
-insert ring ASAP
-keep ring in until the scheduled ring removal day
-use backup contraception until a ring has been worn 7 consecutive days
-if ring removal occurred in third week of ring use: omit hormone free week by finishing third week of ring use and starting a new ring immediately; if unable to start new ring immediately, use backup until 7 consecutive days of new ring has been worn
-emergency contraception should be considered if delayed insertion or reinsertion occurred within the first week of ring use and unprotected intercourse occurred in the previous 5 days
contraceptive vaginal ring (Annovera)
annual ring!
one ring used for 13, 28 day cycles; inserted and left in place for 21 days, removed for 7 days to allow withdrawal bleed, then reinserted (if so desired, can also use continuously)
CI’s the same as COCs in addition to,,,
not recommended if using hepatitis C drug combination
how should the Annovera ring be cleaned if being removed every 3 weeks?
clean with mild soap and water, pat dry, and place in provided case during 1 week dose-free interval
progestin only pills mechanism of actions (3)
- thickens cervical mucus
- produces atrophic endometrium
- inhibits ovulation- inconsistent/variable
who is a good candidate for progestin only pills?
patients unable to take estrogen
(postpartum, stroke, DVT hx, smoker >35, cirrhosis, hypertension)
disadvantage of POPS
-strict daily dosing!!
serum progestin levels peak shortly after taking POP, then decline to nearly undetectable levels 24 hours later
POPs possible side effects (4)
- increased incidence of follicular cysts
- menstrual cycle irregularities
- mastalgia
- depression
CI’s to POP use
absolute CI: if breast cancer within last 5 year
category 3 CI:
-hx of breast cancer with no evidence of disease for 5 years
-severe cirrhosis
-hx of bariatric surgery w/ malabsorptive procedure
-ischemic heart disease or stroke while on POP
-SLE and positive or unknown antiphospholipid antibodies
-taking ritonavir-boosted protease inhibitors as part of HIV/AIDS treatment
general instructions for POP use
- quick start method
- first day start
- timing
- if more than 3 hours late
- quick start: reasonably certain not pregnant, take first pill on day of office visit; backup contraception for 48 hours if > 5 days since LMP
- first day: take first pill on first day of menses; no backup contraception needed
- take pill at same time each day
- if more than 3 hours late: use backup contraception for 48 hours
- advise may have irregular periods or amenorrhea
progestin-only injectable contraception (DMPA) MOA
-inhibits ovulation through suppression of FSH and LH
-produces atrophic endometrium
-thickens cervical mucus
T/F DMPA results in abscence of menstrual bleeding in as many as 50% of individuals be end of first year of use (four injections), by end of second year its 70%
true!
advantages of DMPA
-can be used during lactation and immediately postpartum
-minimal drug interaction profile
-may decrease pain r/t endometriosis
-may decrease intravascular sickling in patient with sickle cell disease
disadvantages of DMPA (depo)
-there are many
-menstrual cycle irregularities
-mastalgia
-depression
-no protection against STI’s/HIV
-NOT IMMEDIATELY REVERSIBLE: requires 3 months to be eliminated
-requires routine 3 month injection schedule
-weight gain: average is 5.4 lbs after first year; 13.8 after 4 years
-in some individuals, 6-12 MONTH DELAYED RETURN TO FERTILITY
-decreased BONE DENSITY in long term (>5 years) user (NOTE: returned to normal after d/c)
-may decrease HDL, may increase LDL
1 absolute CI to depo use
breast cancer in the last 5 years
category 3 CIs: hypertension, hx of breast cancer, ischemic heart disease or stroke hx, SLE, diabetes with nephropathy, retinopathy, etc., severe cirrhosis, SLE, Rheumatoid arthritis, unexplained vaginal bleeding
patient instruction for using depo
-importance of adhering to 3 month (13 weeks) injection schedule
-quick start: admin injection when reasonable certain not pregnant; if > 5 days since LMP use backup contraception for 7 days
-first day: admin injection first day of period; no backup needed
-counsel on irregular bleeding
what happens if they are late for a depo injection? how many weeks?
can be given up to 2 weeks late (15 weeks from last injection) without needing additional contraceptive protection
what about if patient is > 2 weeks late for injection (> 15 weeks)
give injection if reasonable certain patient is not pregnant; use backup for 7 days
procedure for injection of DEPO
-IM vs SQ
-IM: in deltoid or glute
-SQ: anterior thigh or abdominal wall
-do NOT massage injection site
emergency contraception (EC) includes… (4)
- levonorgestrel pill (Plan B)
- UPA pill (ella)
- combination of ethnyl estradiol and norgestrel or levonorgestrel pills (COC)
- copper-releasing IUD
MOA for EC
a. emergency contraception pill:
-inhibits or delays ovulation
-will NOT disrupt established pregnancy; minimal endometrial effect
b. copper-releasing IUD: prevents fertilization and interferes with implantation
levonorgestrel ECP may be less effective if treatment is delayed beyond how many hours?
72 hours
T/F UPA has shown no significant decrease in effectiveness up to 120 hours after sex??
true
how effective is the copper IUD in reducing pregnancy risk
99%
which ECP is available without prescription?
levonorgestrel ECP (Plan B)
instructions for using emergency contraception
a. ECP
-nausea concerns??
- take ASPA after unprotected sex and within 120 hours for max effect
- if using COC for EC, take in two doses 12 hours apart
- if using COC for EC, consider anti-nausea medication 1 hour prior to first dose
- if individual vomits within 2 hours of taking pills, may need a repeat dose
- ECP will no provide ongoing pregnancy protection like the IUD
what should a patient do following Plan B or COCs
resume current method or begin new method immediately; wait until next day to start or restart oral contraceptives to prevent N/V; abstain for 7 days
instructions following UPA use for EC
start hormonal method no sooner than 5 days after UPA, as may reduce effectiveness of EC; use additional contraception with any hormonal method for 7 days
when should a patient be advised to take a pregnancy test after ECP?
if no withdrawal bleed within 3 weeks of ECP
copper IUD as EC
-can be inserted up to…
5 days after first unprotected sex since LMP
vaginal spermicide
male condom
female condom
typical use effectiveness/first year failure rates
vaginal spermicide: 28%
male condom: 18%
female condom: 21%
vaginal spermicide MOA
-nonoxynol-9 is an active ingredient; destroys sperm cell membrane
-CI: do not use in patients at high risk for HIV
-use: use spermicide with each act of intercourse; leave spermicide in place for at least 6 hors following last intercourse
what type of lubricants should you use with condoms?
water-soluble lubricants (KY-jelly)
avoid oil-based lubricants with latex condoms like baby oil, petroleum jelly
female condom advantages over male condoms
its stronger than latex and is less likely to tear or break
CI to female condom (1)
nitrite allergy
T/F you can use a female condom with a male condom
FALSE
they may adhere and cause dislodgment
caya diaphragm MOA (2)
both barrier and spermicide
reusable silicone device that fits over the cervix and holds spermicide in place over cervical os
advantages of caya diaphragm
-cost effect (can be used 1-2 years)
-some protection against STDs
-no systemic effects
-may use with male condom for increased effectiveness
disadvantages of caya diaphragm
-requires visit to clinician for examination for proper fit
-potential risk of toxic shock
CI for diaphragm use
@ high risk for HIV
diaphragm can be used how many weeks pp
6 weeks
how is the diaphragm used?
-when to insert
-how to set up
-repeated intercourse
-how long should it be left in after sex
-insert just prior ot up to 2 hours before sex
-place 1 tsp of spermicidal gel into each fold of diaphragm
-insert so cervix is completely covered and positioned behind symphysis pubis
-if repeated intercourse: insert another application of spermicide in vagina; do not remove diaphragm
-leave diaphragm in at least 6 hours following last intercourse
how often should diaphragm be replaced?
every 2 years
never leave a diaphragm in for more than…
24 hours
warning signs of toxic shock with diaphragm use
- fever
- N/V/Diarrhea
- syncope/weakness
- joint muscle aches
- rash resembling sunburn
cervical cap MOA
-spermicide and barrier
-also needs to be fitted by clinician
-CI: @ high risk for HIV (any contraception with spermicide)
-wait until 6 weeks pp
-do NOT use after recent abortion or during any vaginal bleeding/menses
cervical cap can be left in place up to…
48 hours
cervical cap use instructions
-insert 15 minutes prior to intercourse
-fill one third cap with spermicide
-not necessary to reinsert spermicide with repeated intercourse
-leave in place at least 6 hours, no more than 48 hours
contraceptive sponge description/MOA/CIs
-barrier and spermicide
-can be used with male condom
-significant decrease in efficacy for parous women versus nulliparous
-not recommended for patients at high risk for HIV
-wait until 6 weeks pp
instructions for using contraceptive sponge
-moisten with tap water prior to use
-leave in place at least 6 hours after last intercourse
-no additional spermicide with repeated intercourse
-do not wear the sponge for more than 24-30 hours
-DISCARD sponge after use
fertility awareness-based methods description (FABMs)
-based on these indicators (5)
method of contraception that uses abstinence during estimated fertile period based on all or some of the following indicators:
a. menstrual cycle pattern (calendar method)
b. BBT- determine ovulation
c. evaluation of cervical mucus (ovulation/Billings method)- determines ovulation
d. sympto-thermal method: combines BBT with evaluation of cervical mucus and cervical position/consistency
e. standard days method: consider fertile days 8 through 19 of each menstrual cycle
MOA of FABMs
intercourse avoided during fertile period
- ovum remains fertile for 24 hours
- sperm viability about 72 hours
- most pregnancies occur when intercourse happens before ovulation
failure rate for FABMS with typical use
24%
FABMs are not recommended for patients with..
-irregular menses
-perimenopausal
-recently postpartum
-have had recent menarche
instructions for using the method
a. Calendar method
-shortest cycle length vs longest cycle length
-track menstrual cycle intervals for several months
-from shortest cycle subtract 18 days: this determines first fertile day
-from longest cycle subtract 11 days: this determine last fertile day
^^use these numbers to determine abstinence
instructions for using the method
b. BBT method
- take temp each morning before rising
a. BBT thermometer: temp can be oral, vaginal, or rectal (but maintain same route)
b. record BBT chart
c. temp increase of 0.4 degrees F or higher at ovulation- remains elevated for 3 days
d. abstain from intercourse until 3 days temp increase occurs
instructions for using the method
c. ovulation method (cervical mucus)
- inspect cervical mucus/secretions on underwear/toilet tissue
- determine consistency- elastic, slippery, wet by touch indicates pre-ovulatory
2a. amount increases; becomes thinner and more elastic around time of ovulation
2b. after ovulation, mucus becomes thick, tacky, cloudy - abstain from intercourse during “wet days” at onset of increased, slippery, thin mucus discharge until 4 days past the peak day (last day of clear, stretchy, slippery secretions)
- abstain from intercourse during menses because of inability to assess mucus
what is mittelschmertz
ovulatory pain
standard days method includes abstaining from intercourse days ___ through ___
8 through 19 of each menstrual cycle
lactational amenorrhea method (LAM)
-MOA
high prolactin: FSH normal and LH decreased so no ovarian follicular development
inhibits pulsatile GnRH
results in annovulation
to make LAM the most effective these things must happen
-breastfeed exclusively
-have no menses
-baby is < 6 months old
-baby is feeding at least every 5 hours/baby is not sleeping through the night yet
-do NOT use vaginal estrogen cream for atrophic vaginitis (estrogen inhibits milk production)
-milk expression by hand or pump does NOT have same fertility inhibiting effect as breastfeeding
vas deferens sterilization in males follow up
confirm vasectomy was successful with semen analysis 3 months after the procedure
vasectomy instructions following procedure
-wear briefs for at least 2 days post procedure
-apply ice pack to scrotum minimum of 4 hours after procedure
-avoid ejaculation for 1 week
-avoid strenuous exercise 1 week
-continue using other contraception for 3 months
special considerations in contraceptive management
-first ovulation following birth occurs…
45 days postpartum in non-lactating women; can occur as early as 25 days pp
how long should you wait to initiate CHC methods in lactating women?
at least 42 days
how long should you wait to initiate CHC methods in NON lactating women?
between 21 to 42 days pp without other VTE risk factors
-lets just say 42 days regardless of breastfeeding status
how long should you wait to initiate progestin-only pills for lactating vs non lactating women
lactating: 21- 30 days
non lactating: may initiate immediately
initiation of IUD- lactating, non lactating
less than 10 minutes after delivery of placenta to less than 4 weeks pp (greater risk of perforation and expulsion)
four weeks of greater postpartum is best!!!
contraception for women older than 40 years old
-most are safe
-CHC (pills, patch, vaginal ring): safe for nonsmoking, nonobese, healthy perimenopausal women
-non contraceptive benefits may be especially attractie to perimenopausal women- relief of VMS, menstrual regulation
-may reduce risk of endometrial hyperplasia/cancer
what is the most common contraceptive method among married women in the US?
sterilization
discontinuation recommendations
CHC
-continue to age 50-55
-must be off method for 14 days to eliminate effect on FSH and estradiol levels (but both are poor predictors of normal fluctuations during perimenopause)
discontinuation recommendations
-progestin only method including LNG-IUS
-continue until age 55
-at age 50-54 check FSH on two occasions at least 1-2 months apart; if both levels are > 30, continue method one more year then stop
discontinuation recommendations
nonhormonal methods (copper IUD, barrier)
-continue until amenorrhea for 1 year
-< 50: continue until amenorrhea for 2 years or 1 year of amenorrhea with two FSH levels > 30 at least 1-2 months apart
contraception for transgender men
-testosterone therapy and GnRH cannot be relied on for contraceptive protection
-testosterone is a teratogen CI in pregnancy
-Copper IUDs, and progestin-only contraceptive methods do not interfere with masculinizing effects of testosterone
-estrogen component of CHC may counteract the masculinizing effects of testosterone
