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ER Week 4 > Contraception > Flashcards

Contraception Flashcards

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1
Q

What percentage of unintended pregnancies occur in women using contraception?

A

50-60%

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2
Q

What proportion of unwanted pregnancies end on abortion?

A

half

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3
Q

What are the main factors to consider when choosing contraception?

A 
STI protection
efficacy
convenience
duration of action
reversibility and time to return to fertility
effect on uterine bleeding
risk of adverse events
affordability
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4
Q

What is the difference between method effectiveness and user effectiveness?

A

method - theoretically effectiveness if used perfectly

user - actual effectiveness when studied in a non-perfect world

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5
Q

In general, what are the classes of contraceptive optoins?

A 
natural methods
barrier methods
hormonal methods
emergency contraception
IUDs
sterilization
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6
Q

What is the least effective version?

A

natural methods - about 25% become pregnant in a year (as opposed to 80%)

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7
Q

WHat is the most effective option?

A

IUD

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8
Q

What is the most cost effective (including cost of failure) option?

A

copper IUD. - since the risk of failure is so low.

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9
Q

In general, what is the natural method?

A

avoiding intercourse and/or ejaculation around the tie of ovulation to prevent conception form occurring

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10
Q

WHat does natural method require?

A

female with a regular predictable cycle

both partners need to be dedicated

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11
Q

What strategies can be used in the natural method?

A

withdrawal method (not really helpful)

caendar method - 5 days prior to 3 days after ovulation

basal body temp

cervical consistency

other ovulation predictors

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12
Q

Ovulation generally occurs ___ days prior to the first day of menses.

A

14 days - the luteal phase is pretty constant

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13
Q

So when do you avoid intercourse?

A

5 days prior to ovulation and 3 days after ovulation

you subtract 18 days from length of shortest cycle and subtract 11 days from length of longest cycle - so you should abstain between days 5 and 21 in a woman who ranges from 28-32 day cycles

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14
Q

What typically happens to basal body temp right during ovulation?

A

dips down

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15
Q

What will cervical mucous look like during ovulation

A

most abundant
watery
consistency of egg whites

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16
Q

What are the version of barrier method

A 
female condom
male condom
spermicide
diaphragm
cervical cap
sponge
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17
Q

condoms win the prize for what?

A

best STI production

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18
Q

which is more effective - male or female condom

A

male

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19
Q

What does diaphragm require before use?

A

need to be fitted by a trained physician

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20
Q

Does a diphragm prevent STIs/

A

decreases, but doesn’t prevent

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21
Q

WHen can you insert and how long do you have ot leave a diaphragm in?

A

insert up to 2 hours before, but need to leave in 6 hours after

not more than 24 hour total

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22
Q

diaprhagms increase risk for what?

A

UTIs

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23
Q

When do you need to refit a diaphragm?

A

if woman gains or loses more than 10 pounds

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24
Q

Describe a cervical cap

A

it’s silicone rubber that fits closer over the cervix than a diaphragm

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25
Q

Why might the cervical cap be a better option?

A

in patients having problems with increased UTIs from diaphragms

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26
Q

Describe the sponge method

A

“today” sponge that has 1000 mg nonoxynol-9
moisten and insert deep into the vagina - leave in place for up to 24 hours

less effective than other methdos

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27
Q

What infections can occur with the sponge method?

A

yeast infections and UTIs

toxic shock if left in, like the others

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28
Q

What are the two general categories of hormonal methods?

A

combined estrogen/progesterone

progesterone only

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29
Q

What is the primary mehanism for E/P combos?

A

inhibition of the midcycle surge of gonadotropin secretion, so ovulation does not occur

also makes mucus thicker

also makes uterus less hospitable for implantation

all pre-fertilizaiton

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30
Q

What are abslute contraindications for combined estrogen/progesteron?

A 
clots or stroke
CAD
estrogen dependent tumor
liver disease
pregnancy
undiagnosed abnormal uterine bleeding
smoker over 35
migraine headaches with neurological symptoms
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31
Q

Wat are the relative contraindications for estrogen/progesterone combos?

A 
obestiy
inherited thrombophilias
anticonvulsant therapy
migraine headaches
hypertension
depression
lactation
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32
Q

What are the non-contraceptive benefits of estrogen/progesterone combos?

A

reduction in dysmenorrhea

reduction in menorrhagia

reduction of ovarian,

endometrial and colorectal cancers

improves acne

improves benign breast disease

improves osteopenia or osteoporosis

decreases functional ovarian cysts

decreases ectopic pregnancy rates

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33
Q

Has there been any proven correlation between combined estrogen/progesteorne and breast cancer risk?

A

nope

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34
Q

How about for cervical cancer risk?

A

yes - probably because they are prescribed to sexually active women who are more likely to contract HPV

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35
Q

What are the four general medical interactions that can occur with estrogen/progesterone?

A

antimicrobials
anticonvulsants
anti-HIV meds
herbal products like st. john’s wort

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36
Q

What are the formatulion options for estrogen/progesteron combos?

A

oral pills
vaginal ring
transdermal patch

37
Q

What is monophasic? biphasic? Triphasic?

A

monophasic - 3 wks of hormone and 1 wek of placebo. and 3 weeks ar eall the same

biphasic - 1.5 weeks of one recipe, 1.5 weeks of a different recipe, then 1 placebo week

triphaic - different recipes for each of the 3 weeks and 1 week of placebo

38
Q

What is the estrogen in these combo pills?

A

ethinyl estradiol with doses from 10-50 mcg

typically start on a low dose pill

39
Q

It’s the progestin that typically varies by pill. what are the 5 general options?

A 
first generation
second generation
third generation
spironolactone analogue
dienogest
40
Q

What are the androgenic side effects of the pill?

A

increased LDL and/or decreased HDL
acne
hirsutism

(earlier generations of progestins ar emore androgenic)

41
Q

What are the general side effects of the combo pill?

A 
breast tenderness
nausea
headaches
mood changes - anxiety, irritability, depression
irregular bleeding or spotting
weight changes/fluid retention
42
Q

What progestin is a typeical go-to because it is the least androgenic of the first and second generations?

A

norethindrone

has a slight improvement in lipid profile

43
Q

What is the most widely prescribed prostein?

A

levonorgestrel

44
Q

The third generations norgestimate and desogestrel have less androgenic effect, what what is the issue with them?

A

higher thromboembolic potential - 2-3x more than first and second gens

45
Q

What progestin is the spironolacton analogue?

A

drospirenone

46
Q

What is the benegit for drospirenone?

A

has both anti-mineralocorticoid and lower androgenic effects, so they have improved weight stability and water retention

also improves also androgenic side effects

47
Q

What is the risk for drospirenone?

A

hyperkalemia

increased thromboembolic risk

48
Q

What is Dienogest? WHat is it marketed for?

A

the lastest version - Natazia

a 4-phase

it’s marketed for metromennorhagia, but most BC pills will improve that anyway

49
Q

What is the extended cycle of BC?

A

three months of fixed dose and then a withdrawal week.

50
Q

How do you prescribe the “right” pill?

A
  1. start with low to moderate dose of estrogen
  2. with appropriate progestin for her comorbid conditiosn
  3. allow 2-3 cycles to assess
  4. adjust based on side effects
  5. follow-up
51
Q

What are the common side effects of the combo pill?

A

breakthrough bleeding

no withdrawal bleed

typical hormone related side effects: breast tenderness, nausea, vomiting, headaches, elevated blood pressure, etc.

52
Q

If the woman has no withdrawal bleeding and she wants it, what can you tweak?

A

increase the estrogen

53
Q

Describe the NuvaRing

A

15 mcg ethyl estradiol with 12- mcg of etonogestrel

you wear it intravaginally for 3 weeks and then take it out for one

54
Q

Describe the transdermal patch

A

ortho evra - ethinl estradiol and norelgestromin

you place the patch on buttock, abdomen, upper arm or torso - change once a week for 3 weeks and then one week without

55
Q

How does the patch compare to OCPs?

A

similar efficacy
greater failure raire in obese women
better compliance
more breakthrough bleeding, breast discomfort, dysmenorrhea, site reactions

56
Q

What are the 4 options for progesterone only versions?

A

injection
pill
IUD
implantable

57
Q

Why would you choose progesterone only?

A

those who want effective contraception, but need to want to avoid estrogen
- medical contraindications, side effects with estrogen, nursing moms

58
Q

What are the issues with progesterone only?

A

irregular bleeding - usually unpredictable bleeding and spotting that can sometimes last for weeks or months

other side effects from androgenicity

duration of effect and return to fertility can extend with depo

chance of breakthrough ovulation if pill is missed with the oral formulation

effects on bone health

59
Q

What are the benefits to progesterone only?

A

eventually reductin of menstrual flow

no increased risk fo stroke, MI or thromboembolic event

reduced risk of endometrial cancer and PID with the minipill and depo

60
Q

What is the oral formation of progesterone only?

A

minipill

61
Q

Why is the re a higher failure fate for the minipill comapred to combo pills?

A

you need to take it within 3 hours of your usual time, or backup contraception is needed

62
Q

How is depo given?

A

every 3 months

63
Q

when should you give the shot?

A

within 5 days of first menstrual day

64
Q

What is the concern with depo?

A

bone health - there is evidence for bone resorption and reduction in BMD presumably due to induced estrogen deficiency
usually recommend useing only 2 years

also can take a year to return to fertility

65
Q

What are the two progesterone implants?

A

implanon/Nexplanon

Jadelle (levonorgestrel)

66
Q

How long is nexplanon good for?

A

3 years (one rod system)

67
Q

How long is Jadelle good for?

A

5 years (it’s a two rod system)

not available in the US yet

68
Q

What are the mechanisms for emergency contraception?

A

depends on timing within the menstrual cycle….can inhibit ovulation or prevent fertilization.

there is a greater possibility of a post-fertilization effect with the endometrial effect

it does NOT actually abort an established pregnancy

69
Q

What are the options for emergency contraception?

A

plan B
Ella
combo pill packs
immediate copper IUD placement

70
Q

Describe plan B

A

progestin only, so less nausea and vomiting

two step or a one step taken within 72 hours

71
Q

How long out can ella be used?

A

up to 120 hours or five days!

72
Q

What is ella?

A

a progesteron agonist/antagonist combo

73
Q

What are the side effects of Ella?

A

HA, nausea, abdominal discomort, dysmenorrhea, fatigue, dizziness

74
Q

How can you use a combo pack for emergency contraception?

A

depending on estrogen/progestin dose, taking 2-4 pills initially within 72 hours of unprotected intercourse and repeating dose in 12 hours

may cause nausea, so pre-medicate.

75
Q

Emergency contraception can reduce risk of pregnancy by what percent?

A

75-95%

76
Q

What are the three IUDs available in the US

A

copper IUD - paragard
Mirena - slow release progesterone (levonorgestrel)
Skyla - lower dose levonorgestrel

77
Q

What is the mechanism of the copper IUD?

A

indces a foreign body reaction in endometrium with resulting inflammatory response preventing viable sperm from reaching fallopian tubes

78
Q

how long is the paragard effective?

A

10 years

79
Q

How long is mirena effective? skyla/

A

mirena - 5 years

skyla - 3 years

80
Q

What is the mechanism for mirena and skyla?

A

inhibits ovulation and inhibit ssperm survival and implantation

81
Q

Why would a woman go for a copper IUD?

A

want more regular periods
want no hormones
no history of dysmenorrhea
no history of menorrhagia

82
Q

WHy would a woman go for mirena

A

ok with irregular bleeding/ammenorrhea

history of dysmenorrhea
history of menorrhagia

83
Q

Does IUD increase risk for PID?

A

not in the longterm - it does increase risk during the first month after insertion - so you need to check for STDs prior to insertion - it’s really the STD that increases the risk, not the IUD

84
Q

What are the contraindications for IUD

A 
pregnancy
congenital or acquired uterine cavity malformation
acute STD
cervicitis/vaginitis
postpartum endometriotis or infected aboriton within 3 montsh
known or suspected uterine or cervical neoplasia
unresolved abnormal pap smear
genital bleeding of unknown cause
acute liver disease
immunodeficiency
hx of previous IUD removal
allergy to copper
breast carcinoma
artificial ehart valves
wilson's disease
contraindications or sensitivity to levonorgestrel
85
Q

How is a surgical tubal occlusion usually completed?

A

usually laparoscopic ligation and section removal, clips, rings, coils, plugs or cauterization

can be done during a c section

i

86
Q

What are the risks for tubals?

A

surgical risks

if pregnancy does occur afterwards, highe risk for ectopic pregnancy

87
Q

What are the nonsurgical methods for tubal ligation?

A

essure - microinserts placed into proximal fallopian tubes - trigger inflammatory process to close the tube

adiana - low level radiofrquency delivered to the tube and then put in a micro-insert in

88
Q

How long should women use backup contraception after nonsurgical tubal?

A

3 months

89
Q

What do you need to do post-vasectomy before they can stop using backup?

A
  1. must have a semen analysis to assure no motile sperm

2. approxiately 20 ejactionations or 3 months

ER Week 4 (15 decks)

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