Clin: Contraception, Sterilization - Wootton Flashcards
what are the two general contraceptive mechanisms?
- inhibit the formation and release of the egg
2. impose a mechanical, chemical, or temporal barrier between the sperm and egg
suppression of hypothalamic gonadotropin-releasing factors with subsequent suppression of pituitary production of FSH and LH
- progesterone component is major player suppressing LH and therefore ovulation (also thickens cervical mucus)
- estrogen component mainly improves cycle control by stabilizing the endometrium and allows less breakthrough bleeding
combination estrogen and progesterone pills
MOA: primarily thickens cervical mucus, making it impermeable
- ovulation continues in 40% of users
- mainly used in breastfeeding women and women who have a contraindication to estrogen
progestin only
why must progestin only pills be taken at the same time every day?
because the low dose!
- if pt is more than 3 hrs late taking the pills, then need to use a backup method for 48 hours
what are the benefits of hormonal oral contraceptives?
- menstrual cycle regularity
- improve dysmenorrhea
- decrease risk of iron def anemia (shorter, less heavy cycles)
- lower incidence of endometrial and ovarian cancers, benign breast and ovarian disease
what are the minor side effects of oral contraceptives?
- breakthrough bleeding
- amenorrhea
- bloating
- weight gain
- breast tenderness
- nausea
- fatigue
what are the serious side effects of oral contraceptives?
- venous thrombosis
- pulmonary embolism
- cholestasis and gallbladder disease
- stroke and MI
- hepatic tumors
estrogen and progesterone
- applied for 3 weeks
- caution with women >198lbs
- same SA as oral contraceptives, but increased risk of thrombosis
transdermal patch
estrogen and progesterone
- associated with greater compliance d/t once a month use (insert in vagina for 3 weeks)
- can be removed up to 3 hrs without affecting efficacy
- better tolerated since not going through GI tract
- less breakthrough bleeding
vaginal ring (Nuvaring)
new vaginal ring: segesterone acetate and ethinyl estradiol
- 13 months, 1 reusable ring
- place in vagina for 21 days, remove for 7, reuse
- same indications/SA/contraindications as other combination products
- has not been studied in women w/BMI >29
annovera vaginal ring
who CANNOT use oral contraceptives?
- women over 35 who smoke
- hx of thromboembolic event
- hx of CAD, cerebral vascular dz, congestive heart failure or migraine with aura, uncontrolled HTN
- diabetes, chronic HTN, SLE
IM injection every 11-13 weeks
- maintains level of progestin for 14 weeks
- preferred to be given w/in first 5 days of menses (if not, use a backup method for 2 weeks)
- efficacy is roughly equivalent to sterilization, NOT altered by weight
Depot medroxyprogesterone acetate (depot provera)
what is the MOA of depot provera?
- thickening cervical mucus
- decidualization of the endometrium
- blocks LH surge and ovulation
what is the main concern with depot provera?
- alteration of bone metabolism associated with increased estrogen levels
- particular concern for adolescents
- reversible after discontinuation
- FDA BLACK BOX warning: should consider alternate method after 2 years
what are the side effects of depo-provera?
- irregular bleeding (decreases with use, up to 80% become amenorrheic after 5 years)
- weight gain
- exacerbation of depression
what are the indications for depot-provera?
- can use when estrogen is contraindicated
- seizure disorders
- sickle cell anemia (decreased number of crisis)
- anemia secondary to menorrhagia
- endometriosis
what are the contraindications of depot-provera?
- known or suspected pregnancy
- unevaluated vaginal bleeding
- known/suspected malignancy of breast
- active thrombophlebitis, or hx of thromboembolic events, or cerebrovascular disease
- liver dysfunction/disease
single, radiopaque, rod-shaped implant containing 68mg estonogestrel 4cm long and 2mm in diameter
- use for 3 years (preferred insert in first 5 days of menses, if not -> backup method for 7 days)
nexplanon
- can be used in breast feeding pt
what is the mOA of nexplanon?
- thickens cervical mucus
- inhibits ovulation
what are the side effects of nexplanon?
- irregularly irregular bleeding
- headache
- vaginitis
- weight increase
- acne
- breast pain
what are the contraindications of nexplanon?
- known/suspected pregnancy
- current/past hx thrombosis
- liver tumors or active liver dz
- undiagnosed abnormal bleeding
- known/suspected breast cancer (only absolute)
what are the risks with IUDs?
- increased risk of infection within first 20 days
- increased risk ectopic pregnancy
- if becomes pregnant, should be offered removal if the strings are visible (decreases risk of spontaneous abortion d/t IUD)
- risk of uterine perforation at time of insertion requiring laparoscopy for removal
- risk of malposition and necessitating hysteroscopy for removal
what are the contraindications for IUD’s?
- breast cancer (levonorgestrel ones only)
- recent puerperal sepsis
- recent septic abortion
- active cervical infection
- Wilson’s dz (copper only)
- uterine malformations (uterine septums/firoids/significantly enlarged uterus (>10cm)
how long are Mirena/Kyleena good for?
5 years
how long is Liletta good for?
3 years
how long is Skyla good for, and who was it designed for?
3 years
- made for nulliparous women (smaller uterus)
what are the benefits of IUD?
- decrease in menstrual blood loss
- less dysmenorrhea
- protection of endometrial lining from unopposed estrogen
how long is paragard good for?
10 years
what is the MOA of paragard?
copper interferes with sperm transport or fertilization and prevention of implantation
vaginal liner that is recommended to be left in 6-8 hours after intercourse
- 3% breakage rate
female condom
NOTE: diaphragms must be left in for 6-8 hrs also (but MUST be used with spermicide!)
women who use diaphragms are at an increased risk for what?
UTI
- d/t urinary stasis from pressure on the urethra and altered vaginal flora from spermicide
smaller version of diaphragm
- applied to cervix itself - high risk of displacement and TSS
- used with spermicide
- left in place for 6 hours after intercourse, no more than 48
cervical cap (FemCap)
small, pillow shaped, contains spermicide
- dimple in middle fits over the cervix/opposite end has elastic loop for removal
- 1 size
- more effective in nulliparous women
- left in place for 6 hours, no more than 30 (increased risk TSS)
sponge
when a woman assesses her cervical mucus and notes changes around ovulation (spinnbarkeit)
- avoid sex for 4 days after peak
cervical mucus method
combines cervical mucus and basal body temp methods
- awareness of other signs of ovulation: cramping, breast tenderness, changes in position or firmness of cervix
symptothermal method
what is the Yuzpe method?
emergency contraception
- combined oral regimen of tablets within 72 hours of unprotected sex
progestin only (levonorgestrel)
- 2 pills taken 12 hrs apart
- OTC for women over 17
- must be used within 120hrs of unprotected sex
- failure rate is 1.1% (worsens after 72 hrs)
plan B
ulipristal acetate 30mg
- indicated for up to 5 days after unprotected sex
- postpones follicular rupture, inhibits/delays ovulation
Ella
what is the most frequently used birth control method in the US?
sterilization
- 1 in 3 married couples use
- should be considered permanent
what are the post-op complications of a vasectomy?
- bleeding
- hematomas
- acute/chronic pain
- local skin infection
NOTE: not immediately effective (complete azoospermia obtained w/in 10 weeks)
how is female sterilization performed?
laparoscopy, mini-laparotomy, hysteroscopy, or at time of c-section
small incision, low rate of complications
- occlude the fallopian tubes via: electrocautery, clips, bands, or salpingectomy
laparoscopy
fast, increase risk of thermal injury to surrounding tissues, poor reversibility, greater risk of ectopic pregnancy if failure occurs
electrocautery
most reversible method (little tissue damage), but greatest failure rate (>1%)
hulka clips
lower failure rate than hulka because of larger diameter
filshie clips
intermediate reversibility and failure rate, higher incidence of post-op pain, increased risk of bleeding
bands (fallope rings)
removal of entire fallopian tube
- increasing in use d/t recent literature regarding decrease in ovarian cancer risk
salpingectomy
what is the most common female sterilization methods world-wide?
mini-laparotomy
- use small infra-umbilical incision in postpartum period or suprapubic incision as an interval procedure
transcervical approach to tubal ligations
- 99.8% effective
- 3.6cm stainless steel inner coil and nickel titanium outer coil placed into fallopian tube with aide of hysteroscope
- must use backup method for 3 months, and then have an hysterosalpingogram (HSG) to document complete sterilization
hysteroscopy
- good for obese patients
