Contraception Flashcards
What are factors to consider when choosing birth control method?
Efficacy
Convenience
Duration of actions
Reversibility (time to return to fertility)
Effects on uterine bleeding
Side effects/adverse effects
Affordability
Protection against STDs
Which type of male condom is the only one that protects from HIV virus?
latex
Perfect use of male condoms has a failure rate of what percentage?
2%
Typical male condom use has a failure rate of what percentage?
15%
What combination of male contraception has the same effectiveness of OCPs?
Condom plus contraceptive jelly/foam
Thin polyurethane material with two flexible rings at each end
One ring fits deep inside the vagina while the other remains outside
Female condom
Perfect use of female condoms has a failure rate of what percentage?
5%
Typical female condom use has a failure rate of what percentage?
21%
Mechanical barrier between the vagina and the cervical canal
Dome shaped, circular ring ranging from 50-105mm
Must be fitted by a healthcare provider and requires a prescription
Spermicidal jelly or cream must be placed between this and cervix
Diaphragm
How long must a diaphragm be left in post intercourse?
at least 6-8 hours afterwards
Typical diaphragm use has a failure rate of what percentage?
16%
Perfect use of diaphragm has a failure rate of what percentage?
6%
What are the side effects of diaphragm use?
Bladder irritation
Toxic shock if left too long
Hypersensitivity
The diaphragm can be inserted up to how many hours prior to intercourse?
6 hours
Cup-like silicone diaphragm placed over the cervix with spermicidal jelly
Held in place with suction
Must fit tightly – individualization is essential (fit by a clinician)
Cervical Cap
What is the most common cause of cervical cap failure?
getting dislodged during intercourse
How long must a cervical cap be left in post intercourse?
left in place 8-48 hours following intercourse
When does a diaphragm need to be replaced?
replaced with weight gain (~10lbs) or every two years
What are some disadvantages of the cervical cap?
Refitting after pregnancy or weight changes
Most women have a difficult time mastering placement
Act by disrupting the cell membrane of the spermatozoa
Also a mechanical barrier to the cervical canal
Comes in many forms 🡪 jellies, creams, gels, foam, vaginal sponges,
suppositories
Spermicides
What is the only spermicide available in the US?
Nonoxynol – 9
Spermicides are much more effective when combined with what?
barrier method
Typical spermicide use has a failure rate of what percentage?
29%
Perfect use of spermicide has a failure rate of what percentage?
18%
This oral contraceptive can be used during breastfeeding without affecting milk supply
Progestin only OCP (minipill)
This oral contraception has a slightly higher failure rate than combination OCPs
Not as effective
Progestin only OCP (minipill)
Continuous progestin therapy will result in what for most women after a year?
amenorrhea
This oral contraceptive MUST be taken at the same time every day – no pill-free or placebo pills
Need to take at these at the same time every day preferably within the hour (within 2-3 hours caution)
Progestin only OCP (minipill)
Patients using progestive only OCP pill need to use backup protection x 48 hours when the following happens?
Greater than 3 hours late on taking the pill
Pill is missed
What are the mechanisms of action for the progestin only OCP (minipill)?
Cervical mucus thickens - Hampers the transport of sperm
Endometrial activity is “out of phase” - Making implantation unlikely
Only suppresses ovulation
What are some disadvantages of the progestin only OCP (minipill)?
Not as effective as combined OCPs
Higher rate of breakthrough bleeding
Need to take at same time every day
Acne
Irritability
What is the most popular form of contraception?
Combination OCPs
What are the two forms of combination OCPs?
Monophasic
Multiphasic
What form of combination OCP is described below?
Continuous dose of estrogen and progesterone
Typically better: more regular, less changing around the body, improves acne and period pain
Monophasic
What form of combination OCP is described below?
Varying dose
Usually lower
Triphasic – gradually increasing progesterone
Multiphasic
In combination OCPs, what is the mechanism of action of the progesterone component?
No rise in FSH and LH during the follicular phase, plus no inhibition of midcycle rise in FSH and LH
Thickens cervical mucus
Thins endometrial lining
Alters tubal transport of ova and sperm 🡪 suppresses tubal peristalsis
In combination OCPs, what is the mechanism of action of the estrogenic component?
Inhibit ovulation by suppressing hypothalamic release of FSH and LH
Prevents maturation of follicles
Inhibit ovum implantation
Decrease time available for fertilization
Break down the corpus luteum
What are the four types of OCPs?
21-7
24-4 (Yaz)
84-7 (Seasonique)
Continuous (Lybrel)
Estrogen dose in combination OCPs typically fall within this range?
10 to 30 micrograms
What is the most common estrogen dose in combination OCPs?
25 micrograms most common
In combination OCPs, which component varies the most?
Progesterone
Which progesterone is the least androgenic?
Norgestimate
Which progesterone is the most androgenic?
Levonesterone
What are some advantages of combination OCPs?
High efficacy
Non-contraceptive benefits
What are some disadvantages of combination OCPs?
Must be taken daily
Multiple side effects
Can put patient in a hypercoagulable state
Increased risk for Cardiovascular complications, gallbladder disease, liver disease
Low dose estrogen – breakthrough bleeding
What are some non-contraceptive benefits of combination OCPs?
Reduction in: dysmenorrhea, menorrhagia, acne, Ovarian cysts, Ovarian cancer, Endometrial cancer
Relief of: PMS, PMDD symptoms (Yaz – the only pill approved for this)
Yaz is the only pill approved for this
Relief of PMDD symptoms
Perfect use of combination OCPs has a failure rate of how many births?
1/300 births
Typical use of combination OCPs has a failure rate of how many births?
1/12 births
What is the plan of care if a patient misses a combination OCP?
If you miss one day, still protected, double up the next day
If you miss two days, not protected, and need backup protection for 7 days
Initiation of combination OCPs: Describe the Quick Start method
Start the day the Rx is given as long as pregnancy is reasonably excluded
Back up protection needed for 7 days
Initiation of combination OCPs: Describe the Sunday Start
Start the first Sunday after next period
Back up protection needed for 7 days
Initiation of combination oral OCPs: Describe the First Day Start
Start on the first day of menses
Maximum contraceptive effect 🡪 backup is not required
List the absolute contraindications of combination oral contraceptives?
Previous thromboembolic event or thrombophlebitis (DVT/PE, CVA, Afib)
Thrombogenic mutations
Known or suspected breast cancer (history of estrogen-dependent tumor)
Liver disease (metabolized in liver)
Known or suspected pregnancy
Though inadvertent use during early pregnancy has not been associated with any risk of congenital anomalies
Undiagnosed abnormal uterine bleeding
Cerebral vascular or coronary artery disease
Women over 35 who smoke (>15 cigarettes a day)
Congenital hyperlipidemia
List the cautions of combination oral contraceptives?
Women with hypertension 🡪 especially poorly controlled
Women receiving certain anticonvulsants (decreases effectiveness)
Migraine headaches (Especially classic migraines with auras, increased risk of stroke)
Diabetes mellitus (not recommended in young diabetics – can progress/worsen CAD, vasculitis)
Antibiotics (may make OCPs less effective)
Lupus (SLE)
5cm vaginal ring which releases a constant level of ethinyl estradiol
and etonogesterel
Designed to be left in place during intercourse
Nuvaring
How long can the Nuvaring be removed?
Can be taken out for up to 3 hours
How is the Nuvaring used?
Ring is worn in the vaginal x 3 weeks, followed by one ring-free week
Transdermal birth control
Applied to buttock, lower abdomen, upper outer arm
Due to elevated estrogen component, consider thromboembolic
potential of patient
Caution in women weighing over 198 pounds
The Patch – Ortho Evra
How to use the Patch?
The patch lasts 7 days, then replaced twice
One patch weekly x 3 weeks, then one week off (when period occurs)
What are some of the advantages of the Patch birth control?
Easy to use
Don’t have to remember to take daily
Just as effective as oral combo contraceptives
What are some of the disadvantages of the Patch birth control?
Lower effectiveness in obesity
Skin irritation
CV events
Medroxyprogesterone acetate (DMPA) is also called what?
Depo-Provera
The Depo Shot
What is the mechanism of action of Depo-Provera?
Suppresses ovulation by suppressing the surge of FSH and LH
Thickens cervical mucus
Thins endometrium making it not suitable for implantation
What is the only injectable contraceptive available in the US?
Depo-Provera
What is the dose and injection schedule for Depo-Provera?
150mg IM q 3 months
Depo-Provera recommends caution in adolescents – why is this?
It can decrease bone mineral density and their bones are still forming
How long can a patient use Depo-Provera?
Can only use two years at a time – need a break
When given on time, the theoretical failure rate of Depo-Provera is what percentage?
0.3%
When given on time, the actual failure rate of Depo-Provera is what percentage?
3%
What are some of the advantages of Depo-Provera birth control?
Easy to adhere and parent can control
Amenorrhea
Cheap
Can be used effectively
Good for a forgetful or non-compliant patient
Improves symptoms of endometriosis
Progesterone only
What are some of the disadvantages of Depo-Provera birth control?
Some patients don’t like getting shots
Irregular bleeding when first starting
Weight gain
Decreased bone mineral density
Mood changes and depression
Slow return to fertility
How long does it take to return to fertility after being on Depo-Provera birth control?
6-18 months
Single rod progesterone (Etonogesterol) implant
40 x 2mm semi-rigid rod (matchstick)
Implanon/Nexplanon
What is the mechanism of action for Implanon/Nexplanon?
Suppresses ovulation
Altered endometrium
Increases cervical mucus
What are some of the advantages of the Implanon/Nexplanon birth control?
Easy to adhere and parent can control
Can be used effectively
Good for a forgetful or non-compliant patient
Progesterone only
Not associated with osteoporosis
Good for diabetics
How long is the Implanon/Nexplanon effective?
Effective for three years
What are some of the disadvantages of the Implanon/Nexplanon birth control?
Unscheduled bleeding
Bleeding and hematoma formation at insertion site
Headache
Weight gain (less than Depo)
Acne
Breast tenderness
Emotional lability
What is the discontinuation rate of the Implanon/Nexplanon birth control due to unscheduled bleeding?
14.8% discontinuation rate in the US
When is the Implanon/Nexplanon birth control effective after implantation?
Effective within 24 hours of placement
However, still recommend condoms for 3-4 weeks
The perfect patient for this is at low risk for STI, parous, and in a
monogamous relationship
Mechanism of action not completely understood
IUDs
IUDs DO NOT act as abortifacients but if you get pregnant with an
IUD your risk for spontaneous abortion goes up what percentage?
50%
What are the indications for IUDs?
Low risk for STDs
Desire long-term, reversible contraception
Women with what conditions for which IUD may be optimal?
Diabetes
Menorrhagia/dysmenorrhea
Thromboembolism
Breastfeeding
Breast cancer
Liver disease
What are the contraindications of IUDs?
Pregnancy
PID (Current or within the past 3 months)
Current STDs
Puerperal or postabortion sepsis (Current or within the last 3 months)
Purulent cervicitis
Undiagnosed abnormal vaginal bleeding
Malignancy of genital tract
Uterine anomalies or fibroids distorting cavity in way incompatible to IUD insertion
Allergy to any component of the IUD or Wilson disease
What are some issues with IUDs?
Risk of PID (associated with insertion, not the string)
Does not increase the risk of tubal pregnancy, but if pregnancy is
discovered while having an IUD, high risk for tubal pregnancy
Expulsion of IUD
Perforation during insertion (rare)
Migration through myometrium (very rare)
Which type of IUD is described below?
Single rod Levonorgesterel-releasing implant
T shaped device with progestin in the middle of the main shaft of the device
Two monofilament strings are attached to the vertical arm to allow easy removal and patient to check for placement during the course of usage
Good for 5 years
Mirena IUD
How long is the Mirena IUD effective?
Good for 5 years
What is the expulsion rate for Mirena IUD?
1-5%
What is the mechanism of action for the Mirena IUD?
Thickens cervical mucus 🡪 impedes sperm ascent
Alters uterotubal fluid 🡪 interfere with sperm migration
Thins endometrium 🡪 implantation unlikely
If pregnancy was to occur, testing should be done to rule out what?
ectopic as 50% are in the tube
After Mirena IUD insertion, can be accompanied by irregular bleeding for typically how long after insertion?
the first 3 months
What percentage of patients with a Mirena IUD become amenorrheic?
20-25%
What is the efficacy of the Mirena IUD?
0.2 pregnancies/100 women
What are the advantages of the Mirena IUD?
Quick return to fertility
Improves spontaneity of intercourse
Decreased bleeding
Can be used as a treatment option for menorrhagia
What are the disadvantages of the Mirena IUD?
High initial cost
Requires office procedure for insertion
Risk of ectopic pregnancy if do become pregnant on IUD
T380A
Copper IUD – containing 380mm² of copper attached to the arms and
wound around the body
Two monofilament strings are attached to the vertical arm to allow easy removal and patient to check for placement during the course of usage
Paragard IUD
The Paragard IUD is approved for up to how long?
Approved for up to 10 years
Which IUD can be used as emergency contraceptive if placed within 72 hours of unprotected sex?
Paragard IUD
How soon after birth can the Paragard IUD be placed?
Placement typically done at the 6 week post partum visit but can be
placed within 10 minutes of delivery of placenta
What is the mechanism of action of the Paragard IUD?
Interference with ova fertilization or implantation
Activity on the endometrium that may promote phagocytosis of sperm
(promotes inflammation)
What is the efficacy of the Paragard IUD?
0.5-0.8 pregnancies per 100 women
What are the advantages of the Paragard IUD?
Duration of usage
Can be used as emergent contraception
Option for patients who have difficulty with hormonal-based contraception
What are the disadvantages of the Paragard IUD?
High initial cost
Office procedure for insertion
Does not help with bleeding issues
May increase dysmenorrhea
5-10% have increased bleeding
Mirena strings should be cut longer than Paragard strings. Why is this?
Mirena pulls itself higher into the uterine cavity
Therapy to reduce high rates of unintended pregnancy and abortion
after unprotected intercourse or after a failure of a contraceptive
barrier method
Emergency Contraception
What is the efficacy of emergency contraception?
Reduce number of pregnancies by at least 75%
Which emergency contraception is described below?
1500 ug levonorgestrel
Alters tubal transport of ova and/or sperm preventing ovulation or
fertilization, alter endometrium possibly preventing implantation
Does NOT terminate an existing pregnancy
Must be given within 72 hours
Plan B One Step
What is the failure rate of the emergency contraceptive Plan B One Step?
Failure rate of 11%
What is the most common side effect of Plan B One Step?
nausea and vomiting
What is the time frame in which Plan B One Step must be taken?
within 72 hours
What is the failure rate of the emergency contraceptive Paragard IUD?
Failure rate 0.1%
What is the time frame in which Paragard IUD must be inserted for emergency contraception?
May be inserted within 7 days
What is the time frame in which the emergency contraceptive Ulipristal (Ella) must be taken?
Must be used within 5 days
What is the mechanism of action of the emergency contraceptive Ulipristal (Ella)?
Classified as a SPRM
Essentially causes delay in ovulation
Used for 1st trimester abortion in the US
Not available in the US as a form of emergency contraceptive though
trails suggest 99% effectiveness rate
Mifepristone (RU 486)
What is the mechanism of action of lactation as a contraceptive?
Women who breastfeed have a delay in resumption of ovulation
postpartum due to prolactin-induced inhibition of pulsatile GnRH
To make lactation an option for contraception, what conditions must be met?
Breastfeeding should be all that the infant receives
you have to do it continuously in order for prolactin levels to remain elevated
Why is lactation as a form of contraception troublesome?
May be anovulatory for up to six months post partum
Ovulation can occur as early as five weeks post partum
Important – ovulation return occurs before return of menses!
Periodic abstinence
Coitus is avoided during the time of the cycle when a fertilizable ovum and motile sperm could meet in the oviduct
Accurate predictions of ovulation are essential
Natural Family Planning
In order for Natural Family Planning to be an option, what condition must be met?
Women must have regular clockwork menses
What percentage of fertile women have enough variability in their cycle to make reliable predictions unlikely in natural family planning?
20%
Which method is the least reliable method of natural family planning?
Calendar Method
What are the failure rates of the calendar method?
failure rates of 5-35%
Which method of natural family planning is described below?
Evidence of ovulation is obtained by taking first morning basal body
temperature vaginally or rectally and charting the value
Temperature Method (natural family planning)
With ovulation, the temperature abruptly rises how many degrees and remains at that plateau until menses?
0.5-1.0 F
Which day following temperature rise is considered the end of the fertile period?
the third day
Which method of natural family planning is described below?
Evaluated daily
Uses changes in cervical mucus secretions as affected by hormonal changes to predict ovulation
Cervical Mucus Method
Which method of natural family planning is described below?
Tracking fertility by counting days
Ovulation ordinarily occurs 14 days before the first day of the next menstrual cycle
Luteal phase is a relatively constant 14 days for normal women
Requires regular monthly intervals between menses
Fertile interval lasts from days 10-17
Calendar Method
Several days prior to ovulation, mucus becomes what consistency?
thin and watery
“egg white” consistency
What is the major disadvantage of the cervical mucus method?
Difficulty in interpreting changes
Which method of natural family planning is described below?
Measure urine LH daily
Typically start around day 10 and look for spike in LH
Turns positive just like a urine pregnancy test
Ovulation Predictor Kit
What are the disadvantages of the Ovulation Predictor Kit?
Expensive and impractical for birth control
When is the Ovulation Predictor Kit the most useful?
Useful in infertility
What is the failure rate of female sterilization?
0.4%-1.8% failure rate
Which type of female sterilization is described below?
Small metallic implant placed into the fallopian tubes
Induces scar tissue to form over implant, blocking the tubes
Essure (non-surgical)
How long does it take for Essure to become effective?
Takes 3 months to scar down
Essure carries a high incidence of what if they become pregnant?
ectopic pregnancies
If the Essure fails, what is the next step?
If it fails, usually go ahead and do tubal ligation
Which type of female sterilization is described below?
Outpatient surgery done under local or general anesthesia
Effective immediately
Not quite permanent, but reversal rates are poor
Bilateral Tubal Ligation
Bilateral Tubal Ligation carries a high incidence of what if they become pregnant?
ectopic pregnancies
