Contraception Flashcards
What percentage of unintended pregnancies occur in women using contraception?
50-60%
What proportion of unwanted pregnancies end on abortion?
half
What are the main factors to consider when choosing contraception?
STI protection efficacy convenience duration of action reversibility and time to return to fertility effect on uterine bleeding risk of adverse events affordability
What is the difference between method effectiveness and user effectiveness?
method - theoretically effectiveness if used perfectly
user - actual effectiveness when studied in a non-perfect world
In general, what are the classes of contraceptive optoins?
natural methods barrier methods hormonal methods emergency contraception IUDs sterilization
What is the least effective version?
natural methods - about 25% become pregnant in a year (as opposed to 80%)
WHat is the most effective option?
IUD
What is the most cost effective (including cost of failure) option?
copper IUD. - since the risk of failure is so low.
In general, what is the natural method?
avoiding intercourse and/or ejaculation around the tie of ovulation to prevent conception form occurring
WHat does natural method require?
female with a regular predictable cycle
both partners need to be dedicated
What strategies can be used in the natural method?
withdrawal method (not really helpful)
caendar method - 5 days prior to 3 days after ovulation
basal body temp
cervical consistency
other ovulation predictors
Ovulation generally occurs ___ days prior to the first day of menses.
14 days - the luteal phase is pretty constant
So when do you avoid intercourse?
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
What typically happens to basal body temp right during ovulation?
dips down
What will cervical mucous look like during ovulation
most abundant
watery
consistency of egg whites
What are the version of barrier method
female condom male condom spermicide diaphragm cervical cap sponge
condoms win the prize for what?
best STI production
which is more effective - male or female condom
male
What does diaphragm require before use?
need to be fitted by a trained physician
Does a diphragm prevent STIs/
decreases, but doesn’t prevent
WHen can you insert and how long do you have ot leave a diaphragm in?
insert up to 2 hours before, but need to leave in 6 hours after
not more than 24 hour total
diaprhagms increase risk for what?
UTIs
When do you need to refit a diaphragm?
if woman gains or loses more than 10 pounds
Describe a cervical cap
it’s silicone rubber that fits closer over the cervix than a diaphragm
Why might the cervical cap be a better option?
in patients having problems with increased UTIs from diaphragms
Describe the sponge method
“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
What infections can occur with the sponge method?
yeast infections and UTIs
toxic shock if left in, like the others
What are the two general categories of hormonal methods?
combined estrogen/progesterone
progesterone only
What is the primary mehanism for E/P combos?
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
What are abslute contraindications for combined estrogen/progesteron?
clots or stroke CAD estrogen dependent tumor liver disease pregnancy undiagnosed abnormal uterine bleeding smoker over 35 migraine headaches with neurological symptoms
Wat are the relative contraindications for estrogen/progesterone combos?
obestiy inherited thrombophilias anticonvulsant therapy migraine headaches hypertension depression lactation
What are the non-contraceptive benefits of estrogen/progesterone combos?
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
Has there been any proven correlation between combined estrogen/progesteorne and breast cancer risk?
nope
How about for cervical cancer risk?
yes - probably because they are prescribed to sexually active women who are more likely to contract HPV
What are the four general medical interactions that can occur with estrogen/progesterone?
antimicrobials
anticonvulsants
anti-HIV meds
herbal products like st. john’s wort
What are the formatulion options for estrogen/progesteron combos?
oral pills
vaginal ring
transdermal patch
What is monophasic? biphasic? Triphasic?
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
What is the estrogen in these combo pills?
ethinyl estradiol with doses from 10-50 mcg
typically start on a low dose pill
It’s the progestin that typically varies by pill. what are the 5 general options?
first generation second generation third generation spironolactone analogue dienogest
What are the androgenic side effects of the pill?
increased LDL and/or decreased HDL
acne
hirsutism
(earlier generations of progestins ar emore androgenic)
What are the general side effects of the combo pill?
breast tenderness nausea headaches mood changes - anxiety, irritability, depression irregular bleeding or spotting weight changes/fluid retention
What progestin is a typeical go-to because it is the least androgenic of the first and second generations?
norethindrone
has a slight improvement in lipid profile
What is the most widely prescribed prostein?
levonorgestrel
The third generations norgestimate and desogestrel have less androgenic effect, what what is the issue with them?
higher thromboembolic potential - 2-3x more than first and second gens
What progestin is the spironolacton analogue?
drospirenone
What is the benegit for drospirenone?
has both anti-mineralocorticoid and lower androgenic effects, so they have improved weight stability and water retention
also improves also androgenic side effects
What is the risk for drospirenone?
hyperkalemia
increased thromboembolic risk
What is Dienogest? WHat is it marketed for?
the lastest version - Natazia
a 4-phase
it’s marketed for metromennorhagia, but most BC pills will improve that anyway
What is the extended cycle of BC?
three months of fixed dose and then a withdrawal week.
How do you prescribe the “right” pill?
- start with low to moderate dose of estrogen
- with appropriate progestin for her comorbid conditiosn
- allow 2-3 cycles to assess
- adjust based on side effects
- follow-up
What are the common side effects of the combo pill?
breakthrough bleeding
no withdrawal bleed
typical hormone related side effects: breast tenderness, nausea, vomiting, headaches, elevated blood pressure, etc.
If the woman has no withdrawal bleeding and she wants it, what can you tweak?
increase the estrogen
Describe the NuvaRing
15 mcg ethyl estradiol with 12- mcg of etonogestrel
you wear it intravaginally for 3 weeks and then take it out for one
Describe the transdermal patch
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
How does the patch compare to OCPs?
similar efficacy
greater failure raire in obese women
better compliance
more breakthrough bleeding, breast discomfort, dysmenorrhea, site reactions
What are the 4 options for progesterone only versions?
injection
pill
IUD
implantable
Why would you choose progesterone only?
those who want effective contraception, but need to want to avoid estrogen
- medical contraindications, side effects with estrogen, nursing moms
What are the issues with progesterone only?
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
What are the benefits to progesterone only?
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
What is the oral formation of progesterone only?
minipill
Why is the re a higher failure fate for the minipill comapred to combo pills?
you need to take it within 3 hours of your usual time, or backup contraception is needed
How is depo given?
every 3 months
when should you give the shot?
within 5 days of first menstrual day
What is the concern with depo?
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
What are the two progesterone implants?
implanon/Nexplanon
Jadelle (levonorgestrel)
How long is nexplanon good for?
3 years (one rod system)
How long is Jadelle good for?
5 years (it’s a two rod system)
not available in the US yet
What are the mechanisms for emergency contraception?
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
What are the options for emergency contraception?
plan B
Ella
combo pill packs
immediate copper IUD placement
Describe plan B
progestin only, so less nausea and vomiting
two step or a one step taken within 72 hours
How long out can ella be used?
up to 120 hours or five days!
What is ella?
a progesteron agonist/antagonist combo
What are the side effects of Ella?
HA, nausea, abdominal discomort, dysmenorrhea, fatigue, dizziness
How can you use a combo pack for emergency contraception?
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.
Emergency contraception can reduce risk of pregnancy by what percent?
75-95%
What are the three IUDs available in the US
copper IUD - paragard
Mirena - slow release progesterone (levonorgestrel)
Skyla - lower dose levonorgestrel
What is the mechanism of the copper IUD?
indces a foreign body reaction in endometrium with resulting inflammatory response preventing viable sperm from reaching fallopian tubes
how long is the paragard effective?
10 years
How long is mirena effective? skyla/
mirena - 5 years
skyla - 3 years
What is the mechanism for mirena and skyla?
inhibits ovulation and inhibit ssperm survival and implantation
Why would a woman go for a copper IUD?
want more regular periods
want no hormones
no history of dysmenorrhea
no history of menorrhagia
WHy would a woman go for mirena
ok with irregular bleeding/ammenorrhea
history of dysmenorrhea
history of menorrhagia
Does IUD increase risk for PID?
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
What are the contraindications for IUD
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
How is a surgical tubal occlusion usually completed?
usually laparoscopic ligation and section removal, clips, rings, coils, plugs or cauterization
can be done during a c section
i
What are the risks for tubals?
surgical risks
if pregnancy does occur afterwards, highe risk for ectopic pregnancy
What are the nonsurgical methods for tubal ligation?
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
How long should women use backup contraception after nonsurgical tubal?
3 months
What do you need to do post-vasectomy before they can stop using backup?
- must have a semen analysis to assure no motile sperm
2. approxiately 20 ejactionations or 3 months
