Contraception Flashcards
Why use contraception?
Prevent unwanted pregnancies
Space pregnancies
Prevent pregnancy when it’s dangerous or life-threatening to mother
Other Names for Emergency Contraception
Postcoital contraception
“Morning after pill”
Examples of Emergency Contraception
Plan B: levonorgestrel
Plan B One Step: levonorgestrel
Ella: ulipristal
Copper IUD
Oral Hormonal Emergency Contraception (Levonorgestrel)
No pregnancy test or exam
No medical contraindication
OTC
Effective up to 120 after event
SE of Levonorgestrel
N/V Irregular bleeding the month after treatment Dizziness Fatigue HA Breast tenderness
Emergency Contraception that Requires Precautions or Some Contraindications
Ulipristal
IUD insertion
Levonorgestrel MOA
Inhibiting or delaying ovulation
Copper IUD MOA
Interfering with fertilization or tubal transport
Prevent implantation by altering endometrial receptivity
Counseling for Emergency Contraception
Obtain pregnancy test if no menses 3-4 weeks after EC
Discuss risk of pregnancy & STIs with unprotected sex
Encourage patient to start a regular contraception method OR review correct use of current one
EC is back up, not a primary contraceptive method
Considerations for Choosing a Contraceptive Method
Efficacy (failure rate) Safety SE Convenience Cost Personal lifestyle & pattern of sexual activity Reversibility
Goals for Educating Patients
Dispel misconceptions
Review SE & risks
Compare options to maximize choice appropriate to lifestyle & ability to use correctly
Educate proper use
Distinguish between contraception & protection for STIs
Encourage patients to talke about birth control issues with partner
Patient’s personal needs change over time
Discuss EC with all patients
Categories of Contraception
Hormonal
IUD (IUC)
Barrier
Permanent
Options for Contraception Failure
Inappropriate use
Failure to use
Failure of method
Hormonal Methods of Contraception
Oral pills Transdermal patch Injections Intrauterine devices Subdermal implants Intravaginal
MOA of OCP
Suppression of GnRH
Stabilizes endometrium to minimize breakthrough bleeding
Influence of progestin
Types of Suppression of GnRH
Inhibits the LH surge
Prevents ovulation
Suppresses FSH secretion
Prevents ovarian folliculogenesis
The Influence of Progestin in OCPs
Suppress LH secretion
Suppress ovulation
Thickens cervical mucus
Creates atrophic endometrium unfavorable to implantation
Impairs normal tubal motility/peristalsis
Advantages of Newer Progestins
Less effect on carb & lipid metabolism
More effective at reducing acne & hirsutism
Higher HDL/lower LDL
Higher sex hormone binding globulin (SHBG)
Greater affinity to progesterone binding sites
Reduced amenorrhea
Other Uses for OCP
Endometriosis: reduce pain
Treatment for acne or hirsutism
Treatment for heavy, painful or irregular menstrual periods
Reduce occurrence of recurrent ovarian cysts
PCOS
PMS/PMDD
Decreased risk of ovarian CA & colon CA
Decrease menstrual migraine
Reasons for High Dose Estrogen
Spotting or absence of withdrawal bleeding that can’t be managed at lower doses
Dysfunctional uterine bleeding
Reduce recurrent ovarian cysts
OCP Preparation Types
Mono phasic
Multiphasic (biphasic or triphasic)
Extended cycle (withdrawal flow every 12 weeks)
Progestin-only pill
Choosing a Pill Formulation
Start with monophasic
Perimenopausal women: lower estradiol pill
Consider androgenic influence of progestin
Breastfeeding women: progesterone only pill
Education for Patients on OCP
When to start pill
Take at same time everyday
Miss 1 pill: take ASAP
Miss 2 pills: double up for 2 days
High risk if next cycle not started on time
Nausea in first days
Notify office if: severe/frequent HA, SOB, chest pain, or edema
Menses shorter, lighter, with less cramping
Contraceptive Patch
Change every 7 days for 3 weeks; then 1 week off
Delivers constant medication
Vaginal Ring
Delivers medication for 3 weeks intravaginally
Remove 1 week, then insert new one
Falls out: rinse with water & reinsert
Absolute Contraindications for Estrogen Contraception
Hx of thromboembolic event, stroke, or known thrombogenic mutation Known CVD, cardiomyopathy, BP 160/100 or greater, complicated valvular HD SLE with positive antibodies Women 35+ who smoke Migraines with aura Women 35+ with migraines Hx of cholestatic jaundice Hepatic CA or benign adenoma Active liver disease or severe cirrhosis Breast CA First 21 days postpartum Undiagnosed abnormal uterine bleeding
Careful Consideration prior to Estrogen Contraception
HTN Anticonvulsant therapy Migraines without aura DM Hx of bariatric surgery with malabsorptive procedure Psychotic depression Ulcerative colitis Obese
Hormone Contraceptive SE
Nausea/bloating Breast tenderness Spotting/break through bleeding Amenorrhea Fatigue Headache Depression/moodiness Decreased libido
Early SE of Hormone Contraceptives
Bloating
Nausea
Breast tenderness
Mood changes
Most Common SE of Hormone Contraception
Breakthrough bleeding
When should you try a preparation with more estrogen?
Instances of amenorrhea
SE of Excess Estrogen
H/V Bloating/edema Hypertension Migraine headache Breast tenderness Decreased libido Weight gain Heavy menstrual flow Leukorrhea
SE of Estrogen Deficiency
Early cycle spotting
Breakthrough bleeding
Amenorrhea
Vaginal dryness
SE of Excess Progestin
Acne Increased appetite/weight gain Fatigue HTN Depression Hirsutism Vaginal yeast infections
SE of Deficient Progestin
Late breakthrough bleeding
Amenorrhea
Heavy menstrual flow
Risks with Estrogen-Progestin Contraception
CVD HTN: mild elevation Stroke: ischemic (low risk) Carb & Lipid Metabolism Venous Thromboembolic disease Increased incidence of cholilithiasis Breast CA Cervical CA
Risk of Ischemic Stroke with Estrogen-Progestin Contraception
Extremely low risk
Estrogen dose dependent
Other factors: smoking, older age, HTN, migraine with aura, obesity, prothrombotic mutations
Carbohydrate & Lipid Metabolism
Mild insulin resistance
Estrogen: serum triglycerides & HDL increase, LDL decrease
Progestin: decrease HDL, increase LDL
Venous Thromboembolic Disease & Estrogen-Progestin Contraception
Dose dependent
Risk varies with type of progestin
Older & obese women at greater risk
Hormonal Contraceptive Drug Interactions that may Decrease OCP Efficacy
Phenobarbitol Phenytoin Cabamazepine Barbituates Griesofulvin Primidone Topiramate Oxcarbazepine St. John's Wart
Hormonal Contraceptive Drug Interactions that don’t have an Effect on Metabolism
Gabapentin
Lamotrigine
Levitiracetam
Tiagabine
What antimicrobial decreases the effectiveness of OCPs?
Rifampicin
Progestin Only Mehtods
Depo medroxyprogesteron acetate (DMPA or DepoProvera)
Progestin implant
Progestin IUD (Mirena, Skyla)
MOA of Progestin Only Methods
Inhibition of gonadotropin secretion Inhibition of follicular maturation & ovulation Thickens cervical mucus Creates thin, atrophic endometrium Ovum transport slowed
Individuals with Progestin Only or Not Hormonal Contraception
Breast feeding Hepatic disease: acute viral hepatitis, hepatocellular adenoma, liver CA, severe cirrhosis, symptomatic, gallbladder disease, cholestasis Post-partum: first weeks Age 35+ & smoker or HTN Hx of DVT/PE/retinal artery occlusion Anticipated major surgery Migraines with aura: any age Migraines without aura: 35+ or
Advantages to Progestin Only Methods
Fewer contraindications
Fewer drug interactions
Long acting
Non-contraceptive benefits
Types of Non-Contraceptive Benefits with Progestin Only
Scanty/no menses Decreased menstrual cramps Decreased risk of endometrial CA, PID Decrease endometriosis pain Low risk of ectopic
Disadvantages to Progestin Only Methods
Menstrual cycle disturbances Possible weight gain Possible moodiness/aggravation of depression Decrease in bone density Increased risk of T2DM
Depot Medroxyprogesterone Acetate (CMPA or DepoProvera)
Administer every 3 months
Safe post delivery
Return to fertility may take 18+ months after last injection
SE of DMPA
Weight gain Dizziness Headache Nervousness Libido decreased Menstrual irregularities
Clinical Advantages of DMPA
Sickle cell anemia: decrease in crises
Intrinsic anticonvulsant effect
Implanon/Nexplanon (Progesterone Implant)
Single rod: etonogestrel
Lasts for 3 years
Upper arm sub-dermally
Jadelle (Progesterone Implant)
2 rods: levonorgestrel
Lasts for 5 years
SE of Progestin IUD/IUC
Irregular bleeding
Breast tenderness
Mood changes
Acne
Non-hormonal IUC
Copper IUD
MOA of Copper IUD
Interfere with sperm transport
Prevents fertilization of ova
SE of Copper IUD
Heavy menses
Dysmenorrhea
Ideal Candidates for IUC
Not planning pregnancy for 1 year
Want reversible form of contraception
Want/need to avoid estrogen
Want “minimal user effort”
IUC Complications
Uterine perforation, embedding, cervical perforation
IUCs Disadvantages & Cautions
PID
Menstrual problems
Expulsion
Pregnancy complication if conception occurs
Risk Factors of Expulsion of IUD
Nulliparity
Heavy menses
Severe dysmenorrhea
Counseling for Expulsion of IUD
Check for string after each menses
Clues of Possible Expulsion of IUC/IUD
Unusual vaginal discharge Cramping or pain Intermenstrual or post-coital spotting Dyspareunia Absence or lengthening of IUD string Presence of IUD at cervical os or in vagina
IUCs & PID
Serious complication
Most commonly in first few weeks after insertion
Aggressive treatment needed
Do not reinsert IUD in patient with hx of PID
IUC Contraindications
Severe uterine distortion Acute pelvic infection Known or suspected pregnancy Wilson's disease or copper allergy Unexplained abnormal uterine bleeding Current breast CA
Barrier Advantages & Indications
Intermittent contraception
STI protection
Decreased cervical neoplasia risk
Barrier Disadvantages & Cautions
Allergic to spermicide, rubber, latex, or polyurethane Abnormalities in vaginal anatomy Inability to learn correct technique Hx of TSS Repeated UTIs
Characteristics Associated with Higher Risk of Failure of Barriers
Frequent intercourse
Failure of Barrier Methods
Lack of trained personnel to fit device
Lack of clinical time to provide instruction in use
Full-term delivery within past 6 weeks
Recent spontaneous abortion or vaginal bleeding of any cause
Diaphragm
Female contraceptive device
Dome-shaped cup
Partially filled with spermicidal cream/jelly
Inserted deep into vagina to cover cervix
Left in vagina 6-8 hours after intercourse
Women not Good Candidates for Diaphragm
Allergic to latex/silicone or spermicides Significant organ prolapse Frequent UTIs HIV infection or high risk Difficulty with insertion Adolescents
Contraindications of a Diaphragm
Hx of TSS
Advantages of a Diaphragm
Safe/reusable Inexpensive Offer some protection against gonorrhea & chlamydia Immediately effective & reversible No hormonal SE Can be used during breastfeeding
Disadvantages of a Diaphragm
Willing to insert before each sexual experience & left in place for 6 hours post sexual experience Requires skill to insert Must be within reach prior to coitus May increase frequency of UTIs Refitting after childbirth Not available everywhere
Failure Rate of Correct Diaphragm Use
6%
Failure Rate of Typical Diaphragm Use
12%
Cervical Cap
Reusable, deep rubber cup that fits over cervix
Used with spermicide & remain in for 6-8 hours
Efficacy of Cervical Cap
Nulliparous: 86%
Paroud women: 71%
SE of Cervical Cap
UTIs
Vaginal infections
TSS
Contraceptive Sponge
Disk with nontoxynol-9
Moisten with tap water prior to insertion
One size fits all
Benefit for 24 hours
Left in place for 6 hours after intercourse
Increased risk of TSS
Define Female Condom
Lines vagina & shields introits providing physical barrier during intercourse
Problems with Female Condom
Breakage
Slippage
Incorrect penetration
Failure Rate of Correct Female Condom Use
5%
Failure Rate of Typical Female Condom Use
21%
Male Condom Advantages
Accessible & portable Inexpensive Male participation Erection enhancement Hygienic Prevention of sperm allergy Proof of protection Decreased risk of STIs
Male Condom Disadvantages
Reduced sensitivity Interference with erection Interruption of coitus Latex allergy Embarressment Breakage/slippage
Failure Rate of Typical Male Condom Use
18%
Failure Rate of Correct Male Condom Use
2%
Advantages & Indications of Spermicides
Purchased OTC Used without partner involvement Immediate protection Back-up option Mid-cycle use to augment other methods Emergency measure if condom breaks Provides lubrication
Disadvantages & Cautions of Spermicides
Irritation
Vaginitis
Irritate vaginal lining & enhance spread of viruses
Failure Rate of Typical Spermicide Use
28%
Failure Rate of Correct Spermicide Use
18%
Withdrawal Method of Contraception
Coitus interrupted
Require men to withdraw before ejaculation
Failure occurs if not timed correctly or pre-ejaculatory fluid contains sperm
Failure Rate of Correct Use of Withdrawal
4%
Failure Rate of Typical Use of Withdrawal
22%
Lactation as a Method of Contraception
Breastfeeding delays ovulation
Subfertility
Lactation can only be relied upon to prevent pregnancy when:
Woman is
Factors Contributing to Low Utilization of Fertility Awareness-Based Methods
Information limited
Provider bias against or lack of education about methods
Complicated
High failure rate
Fertility Awareness Not Recommended when:
Recent menarche
Recent childbirth
Approaching menopause
Recent discontinuation of hormonal contraceptives
Currently breastfeeding
Cycles 32 days
Unable to interpret fertility signs correctly
Persistent vaginal infections that affect signs of fertility
Fertility Awareness Methods
Ovulation method
Symptothermal
Cervical mucus
BBT alone
Ovulation Method of Fertility Awareness
Predict fertile time based on recent cycle history
Symptothermal Method of Fertility Awareness
BBT & cervical mucus
Other symptoms of ovulation
Cervical Mucus Method of Fertility Awareness
Increase in amount
Thin & slippery
BBT Alone Method of Fertility Awareness
BBT increases 0.5-1 degree at ovulation
Failure Rate of Correct Use of Fertility Awareness Methods
Failure Rate of Typical use of Fertility Awareness Methods
24%
Failure Rate of Typical Use of Sterilization
Failure Rate of Correct Use of Sterilization
Timing of Surgical Sterilization of Women
C-section
Early postpartum
Interval: laparoscopic or hysteroscopic as office procedure
Types of Laparoscopic Sterilization in Women
Bipolar electrocautery
Mechanical devices: clips/bands
Tubal excision
Tubal Ligation
No contraindications
Decreases risk of ovarian CA
Failure may lead to ectopic pregnancies
Factors Associated with Regret of Female Sterilization
Young age:
Male Sterilization
Safer
Less expensive
Lower failure rate
No increased risk of: impotence, testicular or prostate CA, atherosclerotic disease, immunologic disease
