Contraception Flashcards
A 17 year old nulligravid female consults you regarding contraception. She has migraines that are associated with visual aura. She has one male partner and has never used birth control in her life. She states that she wants a reliable method. Her boyfriend sometimes uses condoms.
contraception counseling
-One has to find the best method for each patient, or it will not work!
-Ask:
-What has the patient used in the past? What worked well? What did not? Why?
-Does the patient want to get pregnant in the future? If so, when?
-Can the patient swallow pills?
-Can the patient remember to take something daily? Weekly?
-What side effect profile is best?
-Is a monthly period desired? How often does the patient want to have periods?
-Failure rates:
-With no contraceptive use, a healthy couple having regular intercourse can expect a conception rate of 85% within one year
-Perfect use is achieved only if a patient uses a method exactly as prescribed
-Typical use is the average failure rate as the device is used by most patients
long acting reversible contraception (LARC)
-The method of choice today for heterosexually active patients who do not want to conceive in the near future and who want a reliable form of contraception
-Refers to:
-Intrauterine devices
-Subdermal contraceptive implant
types of contraceptive methods
-Hormonal contraception
-Barrier methods
-Sterilization
-Emergency contraception
hormonal contraception
-All hormonal contraceptives have the same mechanisms of action
-Suppression of ovulation
-Thick, tenacious cervical mucus
-Creation of atrophic endometrium
-OCP
-contraceptive patch
-contraceptive vaginal ring
-subdermal contraceptive implant
-depot medroxyprogesterone acetate (DMPA) injection
-lactational amenorrhea method
-Estrogen + progestin containing agents: Most OC’s, vaginal contraceptive ring, contraceptive patch
-progestin-only agents: some OCs, subdermal contraceptive implant, depot medroxyprogesterone acetate (DMPA) injection
contraindications to hormonal contraception
-unexplained vaginal bleeding
-suspected or known pregnancy
-sensitivity to agent
-hx of embolic events
-moderate-severe HTN
-thrombogenic cardiac disease
-uncontrolled DM
-known severe liver ds
->= 35yo or greater AND 1/2 PPD smoker or greater
-migraine with aura
-known or suspected breast carcinoma
migraine with aura and hormonal contraceptives
-History of migraine with aura is an independent risk factor for stroke
-Avoid estrogen containing hormonal contraceptives
-May use progesterone-only hormonal contraceptives
-Depot medroxyprogesterone acetate (DMPA)
-Drospirenone oral contraceptive
-Norethindrone oral contraceptive
obesity
-Patients who are obese may use any hormonal contraceptive
-While there is an increased risk of VTE, there is an even greater risk of such events with pregnancy
-Due to changes in clearance, obese patients may benefit from use of a higher dose estrogen pill
chronic HTN
-Patients with BPs of <140/90 mm Hg may use combined hormonal contraceptives (CHC)
-Those with BPs of 140-159/90-99 mm Hg should use CHCs only if there is no other acceptable method
-Patients with BPs of >160/100 mm Hg should not use CHCs
-Progestin-only contraceptives do not affect BP significantly
pts using liver enzyme-inducing antiepileptic agents
-Avoid estrogen-containing contraceptives in patients using:
-Carbamazepine
-Felbamate
-Oxcarbazepine
-Phenobarbital
-Phenytoin
-Primidone
-Rufinamide
-DMPA is an acceptable alternative
antibiotic and antiretroviral use
-Except for rifampin and rifabutin, there are no other known antibiotics, antifungals, or antiparasitic agents that significantly affect OCs
-Despite the theoretical risk of antiretroviral use with OCs, only fosamprenavir seems to interfere with hormonal contraceptives
anticoagulant use
-Progestin-only contraceptives may be used in patients using anticoagulants
-Use of CHCs must be individualized
serious adverse drug reactions of hormonal contraceptives
-Embolic events
-Myocardial infarction
-Cerebrovascular accident
-Deep vein thrombosis
-Pulmonary embolus
-These events are much more common in estrogen-containing products
-However, they are still possible with use of progestin-only agents
wt gain and oral contraceptives or contraceptive patch
-A 2014 Cochrane review found that there was no evidence of causal association between weight gain and combination contraceptives from four trials including a placebo group or “no intervention” group
association between hormonal contraceptives and breast and cervical carcinomas
-A 2017 study found a relative risk of invasive breast CA of 1.20 among current or recent users of any hormonal contraceptive method
-This risk increased with increased duration of use
-For patients using such a method >10 years, the relative risk was 1.38
-However, there was no increased risk among women using levonorgestrel intrauterine delivery systems
-Several studies have found a statistically nonsignificant increased risk for cervical carcinoma in patients who have ever used OCs
OCPs
-Benefits:
-reduce risk of ovarian carcinoma by 40-50%
-Improved reduction is associated with longer duration of use
-appears to be reduced risk of colorectal and endometrial carcinomas
-COMBINED OCP (dont memorize):
-Monophasic- all same dose
-Biphasic
-Triphasic
-21 days of active pills
-24 days of active pills- better for menstral migraines - weens estrogen down
-28 days of active pills x 90 days (4 menses/yr)
-28 days of active pills x 365 days (no menses)
-combination = estrogen+progestin
-most contain ethinyl estradiol
-one now contains estetrol
progestins used in OCs (dont need to know)
Desogestrel
Dienogest
Drosperinone
Ethynodiol diacetate
Levonorgestrel
Norethindrone
Norgestimate
Norgestrel
how to start OCP
-1st day of menses, OR
-Sunday after 1st day of menses (will avoid menses on the weekend), OR
-Use QuickStart method
-If pt had LMP within 5 days: start today
-If LMP >5 days ago: perform pregnancy test in office; if negative -> pt starts that day -> Use backup method x 1 week
-Advise pt to:
-Take pill at same time each day; bedtime is best
-Nausea is uncommon but possible, especially with higher estrogen doses -> Consider Rx for N/V
-Use condoms for protection against STIs
-Call if pt forgets to take a pill -> Management depends on a variety of factors
use of progestin only OCP
-begins as with COCs (combo)
-If a dose is missed for more than 3 hours, the patient should take the dose as soon as possible and use a backup method for 2 days
Use of depot medroxyprogesterone acetate (DMPA)
-manufacturer states first injection must be in first 5 days of cycle -> but take it anytime with neg pregnancy test
-If administered after first 7 days of cycle -> pt should use backup method for the next week
-deltoid or gluteus (less painful)
-Repeat every 13wks, if desired
-Due to loss of bone mineral density -> weight-bearing exercise and vitamin D and calcium intake
-WHO and ACOG do not recommend routine d/c of DMPA after 2 years of use
-Most become amenorrheic on DMPA, usually following a period of menometrorrhagia lasting up to 3mo
-usually not assoc with severe blood loss
-Decreased fertility can persist for up to 10mo after the last DMPA injection
-only contraceptive thats invisible that does not require sedation or anesthesia -> cant be detected by a sexual partner
ocp reference
-good app
contraceptive patches
-Patients may begin use of the patch at any time of the cycle
-If menses began >5 days ago, the patient should use a backup method for one week
-The patch should not be applied to the breast tissue
-Patients should apply a new patch weekly, rotating sites
-ADRs:
-Allergy to adhesive
-Potential for patch to fall off
-There is conflicting evidence whether there is a significant risk of VTE due to higher dose of ethinyl estradiol
contraceptive vaginal ring: NuvaRing
-Etonogestrel/ethinyl estradiol contraceptive vaginal ring (NuvaRing®)
-May be inserted vaginally at any time of cycle
-If inserted >5 days after menses begins, the patient should use a backup method for 1 week
-May be left in situ x 3-5 weeks
-May then be removed and discarded with a new ring inserted after 1 week
-Otherwise, if the patient prefers to not have menses, the old ring is replaced with a new ring immediately
-Ideally, dont remove for sex, but if desired, may be removed for <2 hours
-Some patients have associated use of NuvaRing® with an increased risk of bacterial vaginosis
-However, one study has found increased concentrations of Lactobacillus in patients using the contraceptive vaginal ring for 12 weeks
contraceptive vaginal ring: Annovera
-Segesterone-ethinyl estradiol
-Contraceptive vaginal ring that can be reused for up to 1 year
-May be inserted vaginally at any time of cycle
-If inserted >5 days after menses begins, the patient should use a backup method for 1 week
-Remove ring after 3 weeks; replace after 1 week
-ADRs:
-Headache
-Nausea
-Vaginal discharge
-Dysmenorrhea
-Mastalgia
-Menometrorrhagia
lactational amenorrhea method (LAM)
-About 90% of patients have resumed menstruation by 13 weeks postpartum
-It is possible to delay menses up to 6 months via LAM due to suppression of the increased production of estradiol and the cyclical secretion of LH from breastfeeding
-Patients should breastfeed (not pump) at least every 4 hours during the day and every 6 hours at night
-When menses have resumed, LAM should no longer be used for contraception
-It is costly in terms of the time and effort required
Etonorgestrel subdermal contraceptive implant (Nexplanon®)
-The progestin etonorgestrel is a metabolite of desogestrel, a progestin that is contained in numerous OCs
-Though the manufacturer states that the device must be removed by the end of the 3rd year, ACOG states it is effective for at least 4 years
-Insertion may be performed at any time in the menstrual cycle as long as pregnancy can be ruled out
-Clinicians must be trained and certified in insertion and removal of the implant by the manufacturer
-The device should be placed:
-Subdermally in the nondominant upper arm
-Under the skin overlying the triceps muscle
-About 8-10 cm from the medial epicondyle of the humerus and 3-5 cm posterior to the sulcus between the biceps and triceps muscle
-Insertion usually takes about 1 minute
-At the conclusion of the procedure, the device should be readily palpable
complications associated with subdermal contraceptive implant (nexplanon)
-Deep insertion
-Locate device with high frequency linear ultrasound, MRI
-If the radiologist is inexperienced in identification of these devices, obtain plain film, CT or fluoroscopy after administration of barium
-Then attempt removal by clinician experienced with deeply inserted devices
-Skin infection
-Hematoma formation
-Oligomenorrhea or amenorrhea
-Menorrhagia or menometrorrhagia
-Increased risk of ectopic gestation if patient becomes pregnant
-MIGRATION TO PULMONARY ARTERY- RARE
menorrhagia or menometrorrhagia assoc with subdermal contraceptive implant
-Rule out pregnancy
-Prescribe NSAIDs for 5-7 days
-If unsuccessful, treat with low dose COCs for 2 weeks if there are no contraindications
IUD
-5 are currently available in the United States
-4 levonorgestrel containing IUDs
-One copper IUD
-May be used in nulliparous or adolescent females
-No other tests required prior to insertion (Pap, GC/CT, etc.)
-Use with caution in patients in non-monogamous relationships or whose partners are known or suspected of being non-monogamous
-ADR:
-Perforation
-Expulsion
-PID- MC occurs at the time of insertion
-Unclear association with bacterial vaginosis
Levonorgestrel intrauterine systems (LNG-IUDs)
-Increase production and viscosity of cervical mucus
-Currently, there is no evidence that they are abortifacients
-All are associated with increased risk of amenorrhea
-However, ovulation usually occurs
-Other adverse effects include effects of LNG:
-Ovarian cysts
-Headache
-Breast tenderness
-Weight gain
copper T380A IUD (paragard)
-Copper causes inhibition of sperm transport
-Currently, there is no evidence that it is an abortifacient
-May be used for emergency contraception
-Patients with copper allergy or Wilson’s disease should not use this type of IUD
-Adverse effects include menorrhagia, longer menses, and dysmenorrhea
IUD insertion
-Any of these devices can be inserted at any time during the menstrual cycle as long as pregnancy has been ruled out
-May use paracervical block to reduce pain
-May use ultrasound during insertion if desired and available
contraceptive gel
-Prescription only
-Contains lactic acid and citric acid
-5 gm inserted intravaginally within 60 minutes of having intercourse
-Repeat in 1 hour if additional intercourse is desired
-Normally, the vaginal pH ranges from 3.5-4.5 but increases during sex to 7-8 to be tolerable for sperm
-The contraceptive gel maintains the normal pH during relations
-Also provides a barrier preventing sperm from penetrating the cervix
-About 86% effective with typical use
-ADRs:
-Vulvovaginal irritation (18%)
-Vulvovaginal pruritus (14.5%)
-Vulvovaginal mycotic infection (9.1%)
-Bacterial vaginosis (8.4%)
-Mild burning, pruritus, or pain experienced by male partner (9.8%)
sterilization
-47% of married couples rely on sterilization
-Tubal occlusion (30.2%)
-Vasectomy (17.1%)
tubal occlusion
-May be accomplished via:
-Laparoscopy
-Minilaparotomy or laparotomy
-Methods include:
-Dissection of portion of tube
-Salpingectomy
-Electrocautery
-Clips or rings applied to tube
-Insertion of Essure® into tubal ostia (formerly available)
-Generally, there is a 1% failure rate
-Associated with an increased risk of ectopic gestation
-Complications:
-Bleeding
-Infection
-Formation of pelvic adhesions: Chronic pelvic pain and Increased risk of ectopic gestation
-Failure
Sterilization by laparotomy: modified Pomeroy method
Sterilization by laparotomy: Parkland method
transcervical sterilization
-Transcervical sterilization
-Device was inserted via hysteroscopy into tubal ostia
-No longer available due to discontinuation by manufacturer
