CONTRACEPTION

Question 1

What are three main factors to consider when choosing a form of contraception?

Answer 1

-Has the pt had any DVTs/thromboembolic events or is a smoker?
-Can the pt remember to take something everyday for protection?
-Does the pt want to be able to have unprotected sex (important to know for barrier protection)?

Question 2

Tell me, what are the progestin only containing contraception options?

Answer 2

Progestin only pill, Levonorgestrel IUD (LNG-IUD), Nexplanon, and DMPA (progestin only injection every 3 months - not as effective as other progestin only).

Question 3

What does progestin do to the uterus?

Answer 3

Progesterone thins out the uterine lining, so there is less menstrual bleeding when it comes down to it.

Question 4

A female patient comes to my office wanting to discuss the forms of contraception. She is 37 and smokes. She has heavy periods, producing quarter-sized clots during the first four days of menses. She randomly unprotected sex with 2 different male partners. She cannot remember to take a pill everyday. She’s asking what is the best form of contraception. Explain your reasoning.

Answer 4

-Since she has unprotected sex, barrier contraception is not a good option.
-She is over 35 and smokes, so any contraception with a combination of both estrogen and progesterone is super contraindicated.
-She has heavy menses, so progetin containing contraception can help to reduce the intensity of bleeding and also the frequency.
-She can’t remember to take a pill daily, so that rules out progestin only pills. This leaves a progesterone containing IUD (LNG-IUD) and subdermal implant (NEXPLANON) and DMPA as the best options.

Question 5

What are the contraceptive options that contain a combination of estrogen and progesterone?

Answer 5

combined OCPs, estrogen patch, and a ring (NUVA ring).

Question 6

What is typical use effectiveness when it comes to contraception?

Answer 6

The efficacy of the contraceptive when it is not properly used or forgotten.

Question 7

What is perfect use effectiveness when it comes to contraception?

Answer 7

The efficacy of the contraceptive when it is used right and not forgotten.

Question 8

What are some options for emergency contraception?

Answer 8

-Yuzpe regimen - take two pills (estrogen only and progestin only) together immediately after sex and then again 12 hours after.
-Take Levonorgestrel 0.75 mg pill once immediately after sex and then again 12 hours after (PLAN B) within 3 days of the unprotected sex.
-Take 1.5 mg LNG pill once immediately after sex (PLAN B one step).
-Ulipristal (ELLA) -one dose of a progestin receptor modulator.
-Copper IUD within 5 days of sex.

Question 9

What is the efficacy of most emergency contraception?

What is the exception?

Answer 9

75%.

Copper IUD is the exception, with an efficacy of 99%,

*making the COPPER IUD the best emergency contraceptive out there.

Question 10

Aside from reducing bleeding by thinning out the endometrium, what does progestin do to ensure contraception?

Answer 10

Progestin works by preventing ovulation and increasing the cervical mucus plug thickness.

Question 11

What does estrogen do in terms of contraception?

Answer 11

Estrogen is useless for contraception on its own. It must be given with progestin. However, it causes the endometrium to be stable and firm, not bleeding. Estrogen also prevents the follicular phase (prevents ovaries from having mature follicles that are ready for ovulation).

Question 11

When you start progestin only contraceptives, why is there initially increased bleeding in some pts?

Answer 11

Because progestin thins out the endometrium, so if their endometrium is thick already, it must shed and bleed to thin out. However, after that, the thinned out layer won’t bleed as much as before.

Question 12

What are the most common side effects of oral contraceptives (progestin only or estrogen and progesterone combination)?

Answer 12

Nausea and vomiting and fluid retention and breast soreness and mild increase in bp.

Question 13

What are the main risks of taking estrogen?

Answer 13

Estrogen can cause increased risk of DVT in all women, strokes in women with migraines w/ aura, and MIs in women who smoke and are over 35-years-old.

Question 14

What are the benefits of any type of oral contraception?

Answer 14

-Help to reduce bleeding from menses.
-Helps to relieve painful periods (dysmenorrhea) in adenomyosis or endometriosis or in endometriosis.
-Reduces the risk of ovarian cancer, endometrial cancer, and colon cancer.

Question 15

How often do you change out the combination patch?

Answer 15

Once a week for three weeks and then nothing the four week to allow for withdrawal bleeding.

Question 16

How long do you wear the combination patch?

Answer 16

21 days and then allow 7 days of nothing for withdrawal bleeding.

Question 17

What does DPMA do for menstrual cycle?

Answer 17

It seriously disrupts it and causes amenorrhea for the three months that it’s in the body.

*Aside: I remember them giving to pts as a last resort for when they had uncontrollable abnormal uterine bleeding to completely stop it.

Question 18

How long can the subdermal implant be in the arm vs how long a hormonal IUD can stay in?

Answer 18

3 years for subdermal device.

5 years for the hormonal IUD.

Question 19

How long can a copper IUD stay in?

Answer 19

10 years.

Question 20

What are the options for hormonal IUDs and their approved length of stay in the uterus.

Answer 20

-Mirena - LNG IUD for 5 years.
-Skylar LNG IUD for teens and lasts for 3 years.
-Liletta - LNG IUD is most affordable and useful for 3 years.

*they all release different doses of progestin daily.

Question 21

What is adenomyosis?

Answer 21

When the lining of the uterus grows within the myometrium. The uterus is painful with periods and boggy and enlarged uniformly.

Question 22

What is endometriosis?

Answer 22

A condition where the endometrium (lining of the uterus) grows outside of the uterus (such as in the ovaries or the peritoneum).

Question 23

What is a leiyomyoma?

Answer 23

Benign tumors that grow within the myometrium (muscle wall of the uterus).

Question 24

What causes painful periods in both adenomyosis and endometriosis?

Answer 24

The endometrium bleeds with each menstrual cycle. So, the blood coming from the endometrium can either pool and cause irritation in the wall of the uterus (adenomyosis) or the ovaries or peritoneum (endometriosis).

Question 25

What are contraindications to IUDs?

Answer 25

-If there is a current STI.
-If there was Pelvic Inflammatory Disease (PID) within the past 3 months.
-If there is a current pregnancy.
-If there is anything distorting the uterine cavity.
- If there is breast or endometrial cancer - for LNG IUDs, not copper.
-If there is untreated cervical cancer.
-If there is unexplained vaginal bleeding.

Question 26

Why is it important to avoid IUDs whenever there is unexplained vaginal bleeding?

Answer 26

B/c LNG IUDs can reduce the amount and frequency of menses, thereby masking the bleeding and underlying condition.

Question 26

What contraception should we avoid in women with Pelvic tuberculosis?

What about Wilson’s disease?

Answer 26

Avoid any IUDs b/c pelvic tuberculosis is an infection that can cause inoculation of the IUD.

Avoid copper containing IUDs in Wilson’s disease.

Question 27

Who should not take emergency contraception?

Answer 27

Women who have a known pregnancy or those who have unexplained vaginal bleeding.

Question 28

When can we be confident that emergency contraception failed?

Answer 28

If the pt fails to have a period after 21 days from taking the emergency contraception.

Question 29

What is a risk of taking DPMA?

Answer 29

Osteoporosis.

Question 30

Is controlled htn a contraindication to taking oral combined contraception?

Answer 30

No, but uncontrolled hypertension is a contraindication to OCPs.

Question 31

What is the difference in the side effect profile for Plan B vs the Yupze method?

Answer 31

Plan B has progestin only, so there is no nausea and vomiting associated with it.