Contraception Flashcards
What is method effectiveness?
What is user effectiveness?
method: theoretical effectiveness if utilized perfectly
**user: **actual effectiveness when studied in a non-perfect world
What is natural methods of BC?
What is required for this to work?
avoid sex &/or ejaculation around time of ovulation to prevent conception
NEED: a female with regular cycles
How do we determine a woman’s fertie window?
Ovulation is 14 days PRIOR to 1st day of menses
- subtract 18 days from length of shortest cycle
- subtract 11 days from longest cycle
avoid intercourse 5 days b4 and 3 days after ovulation
Descirbe how the following can aid in ovulation tracking:
temp
cervical mucous
temp: raises basal temp at least 0.5 F due to progesterone [after ovulation]
mucous: @ ovulation = most abundant, watery, has consistency of egg whites
What is the best form of STI protection?
condoms!!
male is more effective than female
***most effectiveif used with spermicide [nonoxynol-9]
The diaphragm…what are some caveats to keep in mind with it?
- needs to be fitted to pt by a trained doctor
- decreases STI’s but does not prevent
- ^^^ UTIs
- MUST leave in at least 6 hrs post coitus, insert 2 hrs prior to coitus [<24 hrs total]
- MUST be refit to pt if: greater than 10lb weight change, pregnancy since last fitting, pelvic surgery
- MUST be pt who is comfortable doing a self exam
What are some caveats with the CERVICAL CAP method
- similar to diaphragm; MUST be fitted by physician, be ok w/ self exams, & leave in 6 hrs post sex [max of 48 hrs]
- harder to fit & use
- usually an option if pt is having UTI problems w/ diaphragm
- ^^ risk of toxic shock
- ^^risk of cervical dysplasia????
- BEST in primiparous women
How does the “sponge” work?
what are some caveats with this?
sponge: circular disc w/ nonoxynol9 [spermicide] in it, moisten w/ tap water & insert
- leave in place up to 24 hrs
- less effective than other methods
- ^^rate of yeast infxn, UTIs, 7 TSS if left in place for extended period
What type [class] of contraception is spermicide classified as?
how does it work?
Actually is part of barrier method category
- damages cell membranes of sperm & bacteria
- Risks:
- topical irritation
- best if used with condom or diaphragm
How do the combined estrogen/progesterone BCs work?
1’ mechanism is E/P induced inhibition of midcycle LH surge–>inhibits ovulation
- estrogen inhibits FSH
- Progesterone inhibits LH
- also prevents sperm penetration by changing cervical mucous consistency
what are the absolute contraindications for using a combo P/E BC?
- previous thromboembolic event/stroke
- Hx of CAD
- Hx of E dependent tumor
- liver disease
- pregnancy
- unDx’d abnormal uterine bleeding
- smoker over 35 yo
- migraine HA’s w/ neuro Sx’s
What are some relative contraindications for E/P use?
- obesity
- inherited thrombophilias
- anticonvulsant therapy
- migraine HA’s
- HTN
- Depression
- Lactation
What are some benefits [aside from BC] of E/P combo?
- Reduction in dysmenorrea
- 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
What are the risks of combo E/P?
- ^^ thromboembolic event
- breast cancer risks [controversial]
- cervical cancer risk
- medication interxns [antimicrobials like rifampin, anticonvulsants, HIV drugs, herbal produx like St. Johns Wort]
What are the forms of E & P in combo oral bC?
Estrogen: ethinyl estradiol 10-50mcg
Progesterone:
–First Generation: norethindrone, norethindrone acetate, ethynodiol diacetate
–Second Generation: levonorgestel, norgestrel
–Third Generation: norgestimate, desogestrel
–Spironolactone analogue: drospirenone
–Latest iteration: dienogest
What are some androgenic SE’s?
What are some general SE’s?
Androgen SE: ^^LDL +/- decreased HDL, Acne, hirsutism
General SE: breast tenderness, N, HA, mood changes [-], irregular bleeding/spotting, weight change/fluid retention
Can you tell me about 1st & 2nd generation progestins?
Norethindrone- least androgenic of the grp
- Slight improvement in lipid profile which is different than other 1st/2nd gen.
- More androgenic than newer progestins
Levonorgestrel is the most widely perscribed
- In many formulations including Plan B and extended cycle pills as well
How is 3rd gen different than others?
Norgestimate and desogestrel
- Less androgenic effect
- good choice for pts with dyslipidemia, acne or other possible androgenic SE’s
- Higher thromboembolic potential
- 2-3 X higher than first or second generation progestins
What is drspirenone?
a spironolactone analog!!!
- both antimineralC & lower androgenic effects
- benefits: improves weight stability/h2o retention & other androgen SE
- downfalls: may ^^serum K+ [contraindicated in certain pts]
***new warning regarding VTE risk
What is dienogest?
latest & greatest Progestin
- 4 phase
- marketed for metromennorhagia
Whats the difference b/w …
monphasic
biphasic/triphasic
extended cycle?
_Monophasic _Same fixed dose for three weeks, then placebo week
Biphasic, Triphasic, +
- Varying doses through first three weeks then placebo week
- Similar SE profile to monophasics
Extended cycle (i.e. Seasonale / Lybrel)
- Seasonale & Seasonique: 84 days fixed dose hormones then placebo week
- Lybrel (Amethyst): Fixed dose of estrogen/progestin 365 days/yr
- Breakthrough bleeding more common, but decreases over time
- ? Whether increased amount of hormone exposure over time will lead to greater long term side effects
How do we prescribe the right pill?
–Start with low to moderate dose estrogen with most appropriate progestin considering co-morbid conditions
–Allow at least 2-3 cycles to assess
–Adjust based on side effects
–Follow-up based on side effects and co-morbid conditions
How/when should a pt take the pills?
How should the physician followup?
ADmin:
–First day of menses vs. Sunday start vs. quick start
–Same time of day every day
–Missed pills- what to do?
Follow up:
–Blood pressure check
Side effects and overall tolerance of pil
What is the quick start approach?
What are the benefits to this method?
- If last menstrual period (LMP) was within the last 5 days, the method can be started immediately.
- if LMP was > 5 days ago and a pregnancy tests (-), assess the last episode of unprotected sex to determine if EC required (or immediately insert copper IUD).
- Instruct women who are using the pill, patch, ring, injection, or implant to use backup contraception for the first 7 days.
Benefits: Significantly improves the continuation rate for OCs. [Westoff]
•Produces better compliance at 3 months in adolescents. [Lara-Torre]
•Research shows that there are no significant differences in the number of bleeding-spotting days or any other bleeding parameter between the immediate and conventional starters
What are some common SE’s to combo EP BC?
How do we Tx each one?
breakthrough bleeding:
- in 1st 10 days, increase estrogen
- after 10 days, increase progestin
no w/drawal bleed:
- do preg test, continue pills
- if pt wants menses to return, then ^^E
typical Hormone related SE’s
- adjust approprote hormone component
how does the nuvaRing [or any other brand vaginal ring] work?
What hormones are involved?
Combo E/P too!!!
- 15 mcg ethinyl estradiol & 120mcg of etonogestrel daily
- wear intravaginally for 3 weeks, then out for one wk
What should you do if the vaginal ring falls out?
What if you leave it in too long?
- out <3hrs= rinse and replace
- out >3hrs = replace and use backup contraception
How long in place?
- in place 3-4 weeks, give a week off and then replace
- if in place >4wks= one week off and use backup contraception for @ least 1 week once replaced
How does vaginal ring compare to oral OCP’s?
- comparable efficacy
- lower dose of hormones
- rapid return to ovulation
- ease and convenience
- eimlar SE’s and contraindications
- Plastic NOT latex
How do you use the Patch?
- which hormones involved
- when should a backup contraceptive be used?
Another combo E/P!
- 20 mcg ethinyl estradiol & 150 mcg of norelgestromin daily
- through the skin [butt, abd, arm, or torso– NOT breast]
- change patch 1x wk for 3 weeks, then go 1 wk patch free
- use backup method when:
- on for >9days
- off for >7days
- falls off >24 hrs
how does the patch compare to OCP’s
- similar efficacy overall
- greater fail rate in women >90kgs
- better compliance
- more breakthrough bleeding, breast discomfort, dysmenorrhea, site rxns
- FDA warns that patch gives off more estrogen than most OCPs…
- imlication for long term???
How does P only BC work?
Why would we use these/who do they benefit?
1’ mechanism is inhibition of ovulation
-progestin effect also causes changes of cervical mucous–> decreased sperm transport and implantation
Pt’s who want effective contraception but want/need to avoid estrogen!!
- medical contraindications to combo OCP
- SE to combo options that are prohibitory
- nursing
Progesterone only BC and issues/SE’s to consider?
- Irregular bleeding
- Other SE’s from androgenicity
- Duration of effect and return to fertility –>??
- Chance of breakthrough ovulation if “pill missed ” with oral formulation
- Effects on bone health
What are the benefits of P only OCP?
- How should a pt take the oral “minipill” drug?
- eventual redxn on menses flow
- NO ^^risk of stroke, MI or TE event
- reduced risk of endometrial cancer and PID [w/ Depo/medroxyprogest. acetate]
Admin
- 1st day menses vs. Sunday start vs. immediate
- take daily like combo pill, at same time every day
- ****timing **is critical –>must be taken w/in 3 hrs of normal time otherwise backup contraception is needed**
- no w/drawal bleed week
- highe failure rates
How does the injectable form of P only work?
What is one of the major concerns/SE’s of this?
aka medroxyprogesterone acetate [DEpo-provera]
- IM injexn every 3 months
- start w/in 5 days of 1st menstrual day
SE’s BONE HEALTH!!!
- bone resorption & redxn in BMD due to induced estrogen deficiency
- will normalize in healthy pts once DMPA is discontinued
- limit use to 2 years [recommended]
- if longer, BMD needs 2 be followed, & Ca+ & w8 bearing exercise prescribed
- *****BLACK BOX WARNING ??? idk what for
P only implants…how do they work?
- rods are implanted subQ under skin & removed once no longer effective
- Implanon/nexplanon [etonogestrel]
- 1 rod, lasts 3 yrs & FDA approved
- Jadelle [levonorgestrel]
- 2 rods, lasts 5 yrs (not available in US)
- Implanon/nexplanon [etonogestrel]
What is the possible future of hormonal contraception?
MALE HORMONAL CONTRACEPTION!
- still developing
- hope to use testosterone +/- GnRH analogs or P to suppress spermatogenesis
What is the definition of emergency contraception?
what is the main mechanism for EC’s?
Significant risk?
prevention of pregnancy w/in 72-120 hrs of unprotected sex or failure of a contraceptive method
MOA: depends on time w/in menstrual cycle…
- can inhibit ovulation OR
- prevent fertilization
****greater possibility of post-fertilization effect [endometrial changes inhospitable to fertilized ovum]
Will a hormonal EC abort an established pregnancy?
NO
What is the main hormone of Plan B?
HOw effective is Plan B?
What is the difference b/w 2 step & 1 step?
MOA: P only
effectiveness:
- 95% effective if used w/in 24hrs of unprotected sex
- 89% if used w/in 72hrs
Two Step: 1 tablet w/in 72 hrs of unprotected sex, take 2nd tablet 12 hrs later
One step: take w/in 72 hrs of unprotected sex
***Available OTC to ALL ages since June 2013
What is different about Ella EC?
newest formulation of EC that uses P agonist/antagonist
- can use up to 120 hrs [or 5 days] after unprotected sex!!!***
- SE’s: HA, N, abd discomfort, dysmenorrhea, fatigue, dizzy
COmbo pill packs of EC…
how are they taken?
major SE?
combo pill packs = E + P
- depending on E/P dose, take 2-4 pills w/in 72 hrs and repeat dose in 12 hrs
- may cause N!! premedicate if necessary
What are some issues to remember about EC?
What is the biggest one?
- can reduce risk of pregnancy by 75-95%
- politically controversial
- state/pharmacy variability in availability
****BIGGEST issue is: **remember to counsel **repro age sexually active women about this option
What is the MOA and duration of effectiveness for each of the following:
Copper IUD [Paragaurd]
Mirena
Skyla
copper IUD: pre-fertilization effect
- induces foreign body rxn in endometrium–>inflam response–> prevents sperm 4m reaching fallopian tubes
- lasts 10 years!!
Mirena (slow release P: levonorgestrel)
- inhibits ovulation & sperm survival/implantation
- lasts 5 yrs
- ***other benefits: decreases menses blood loss & relieves dysmenorrhea
Skyla: low dose levonorgesterel, lasts 3 yrs, approved for nulliparous women
Who are good candidates for copper IUD?
For LNG IUD (mirena, skyla)
copper:
- want more regular periods
- no hormones
- no Hx of dysmenorrhea, or menorrhagia
LNG IUD:
- ok w/ irregular bleeding
- ok w/ amenorrhea
- Hx of dysmenorrhea or menorrhagia is ok
Do IUDS cause PID?
NO, incidence is similar to general population
- risk is ^^only during 1st month after insertion
- preexisting STI at time of insertion, not iud itself, ^^risk
- RULE OUT GC/Chlamydia prior to insertion
- IUDs DONT cause infertility
What are contraindications for IUDs?
- pregnancy
- congenital or acquired uterine cavity malformation
- acute STD, cevicitis or vaginitis
- postpartum endometritis or infected abortion w/in 3 months
- known or suspected uterine or cervical neoplasia
- unresolved abnormal pap
- genitl bleeding of unknown cause
- acute liver disease
- immunodeficiency states
- Hx of previously inserted IUD that hasnt been removed, allergy of Cu+, known or suspected breast carcinoma
- artificial heart valves
- Wilsons disease [for paragaurd]
- sensitivity to levonorgestrel
Is sterilization permanent?
how is tubal ligation performed?
how is vasectomy performed?
You should consider it permanent…although som reversible procedures exist they have limited success and come with many issues
tubal ligation: laparoscopic procedure or during Csxn/postpartum
- most SE’s are related to surgery
- post tubal ligation: ^^risk for ectopic pregnancy [if preg does happen] & decreased risk of ov.Ca
Vasectomy: in dr office under local anesthesia
- safe & effective [and cheaper than female sterilization]
- multiple diff techniques
What are non-surgical methods of tubal ligation?
What is a caveat of this type?
What is a major contraindication for NSTL?
transcervical implants!!!
Essure: microinserts placed into proximal fallopian tubes–>expand & tissue grows around them=occlusion
Adiana: low level radiofrequency delivered to fallopian tubes= lesion
- microinserts placed in fallopian tubes
**although less invasive [faster recovery w/ less discomfort], 3 mo backup contraception is needed
Contraindication: woman who has delivered a baby, miscarried, or had an abortion w/in **6wks for Essure **or 3 months for Adiana
What are the adverse side effect for vasectomy?
What should be part of follow up for vasectomy?
SE: mostly procedure related
Follow up: MUST have semen analysis to assure no motile sperm***
- approx 20 ejaculations or 3 months following?
- need to use other form of contraception until cleared
**risk/benefit ratio is in favor of vasectomy over tubal ligation
*****3 months of other form of contraception should be used
What is an immediate form of EC?
insert a copper IUD
What are the 3 targets of hormone contraception?
- Ovary = 1’ MOA
- GnRH & LH/FSH suppression hence inhibition/delay of ovulation [no follicle development & no LH surge]
- combo E/P = 95-99% effective
- low level P only: 50% med & high level Ponly preps 94-99%
- Cervix = backup
- viscosity of cervical mucous doesn’t promote sperm transit into uterus
- all preps do this. P ^^ viscosity most
- Uterus = back up of the back up
- causes thin endometrial lining, not supportive of preg if fertilized inspite of 1 or 2
- all methods likely do this
Describe hormone levels of women on BC compared to:
non-preg menstruating female
a pregnant female
One more time: summary of MOA for hormonal contraceptives?
- No ovarian cycle
- Inhospitable cervical mucous
- Lackluster uterus
39 yo G2P2 postpartum visit
nursing still, healthy
Doesnt know if she wants another child…contraception options?
DON’T offer: combo E/P drugs since nursing
DO: P only [minipill] unless (+) she doesnt want another kid–> then talk about TL etc
**stay away from Depo??
17 yo in for PE
sexually active [2 previous partners, current BF of 4 mo]
uses condoms “when remember”
generally healthy [irr menses, mild depression in past w/o meds]
contraception options?
Possibilities:
- Depo might be good for her–>delays return to fertility
- IUD would be a good long-term option
***BIGGEST thing: educate her about protxn, condom use, STI prevention
25 yo med student
long term relationship [1 previous partner]
no Hx of STIs
HX of migraine HAs, otherwise very healthy
wnats to get thru boards b4 talking marriage/future
CONTRACEPTION OPTIONS?
IUD are great options here
CAUTION: E might b an issue here–>due to migraines–> if no aura, then could do a combo pill but must monitor it
44yo G3p3003
married w/ Hx of fertility problems (now “done” having kids)
overweight, no Hx of STIs
mild HTN controlled w/ ACEi
hypercholE–>on statin
CONTRACEPTION OPTIONS?
POSSIBILITIES:
- TL or vasectomy are great option
- if financial issues/sterilization concerns= could do P only
- watch androgenic effects on lipids
- could do Paragaurd –> watch for really heavy periods
CAUTION: HTN is an issue for E use
37yo G4P4
3rd marriage
Hx of PID @ age 23
smokes 1.5 p/day
depression–>takes SSRI
uses condoms
CONTRACEPTION OPTIONS?
POSSIBILITIES:
- paragaurd
- implant
NO:
- E since over 35 and smoker
- P +/- E, both can have mental health implications/changes–> monitor
***counsel on STI protxn
