contraception Flashcards
Groups with the largest increase in unintended pregnancies are
Low education
Low income
Cohabiting women (not married)
(black women also more likely to have unintended births)
Barriers to contraception are
unnecessary screening exams and tests
Inability to receive contraceptive on same day as visit
Difficulty obtaining continued contraceptive supplies
teens: understanding confidentiality laws
Routine pregnancy screening is NOT necessary if
<7 days after start of normal menses
no sexual intercourse since start of last normal menses
Correct and compliant use of contraception
<7 days after spontaneous or induced abortion
w/in 4 weeks postpartum
fully or near fully breastfeeding, amenorrheic, and <6 months postpartum
If you dont meet reasonable certainty, when can you start contraception regardless (except IUD)
If benefits>risks;
start contraception and have patient get a pregnancy test in 2-4 weeks
(not IUD bc they have a higher risk of complications- spontaneous, preterm, septic aboriton)
Key medical history before starting contraceptives are
PMHx: hormonal cancer, obesity, liver dz, gallbladder dz, migraines w/ aura, HTN, VTE, Sz, DM
Med use
SHx: smoking, sexual (high risk for STI)
FHx: cancer, DVT/VTE
The 3 MOA of contraceptives take
- Inhibit ovulation
- Prevent sperm from reaching egg
- Inhibit implantation
What are the types of contraception
Natural family planning Barrier/ Spermicidal Combined Hormonal Contraception Progestin only contraception Long Acting Reversible Contraception Emergency Contraception Sterilization
Rate types of contraception by effectiveness
Worst: NFP, spermicide
Eh: condoms, withdrawal
Better: Depo, pill, patch, ring, diaphragm
Best: Implant, sterilization, IUD
What is the standard days method
For women w/ cycles 26-32 days long, NO SEX days 8-19
What is the calendar method
Monitor cycles for 6 months, then abstain form sex when fertile
Fertility starts: length of shortest cycle-18 days
Fertility ends: length of longest cycle-11 days
What is the cervical mucus/2 day method
check cervical mucus daily
“Peak” day is last day of stretchy, clear mucus
Fertility starts with first signs of clear mucus-4 days after peak day
If no mucus for 2 days, you can have sex
What is the basal body temp method
Check basal temp when you wake up every morning before getting out of bed
Rise in temp of 0.5-1.0 degree= ovulation occurred
don’t have sex from end of period-3 days after temp increase
What is the symptothermal method
combo of cervical mucus assessment and basal body temp
also monitor for signs of ovulation (cramping, spotting, tender breasts); fertility is from first sign of ovulation-3 days after temp rise of 4 days after peak mucus
What are the types of male condoms
Latex
Polyurethane: more likely to slip and break
Natural (lamb cecum): lower level of STI protection
*Avoid petroleum or oil based vaginal products with latex condoms!
How do female barrier methods work
mechanical barrier to sperm entering cervical canal
Spermicide attacks flagella and body= reduced motility
How long does spermicide require to activate
15 minutes
What is in the transdermal patch
150 Norelgestromin/ 20 ethinyl estradiol
What is in the vaginal ring
120 etonorgestrel/ 15 ethinyl estradiol
When can you start CHC
any time!
No backup needed if you start in the first 5 days of a bleed
**Prescribe 1 year supply at initiation and follow up!
What do you need to monitor prior to initiating CHC
Blood Pressure
No routine follow up needed
How do CHC work
Suppress ovulation**
thicken cervical mucus
thin endometrium= hard for implantation
slow tubal motility
Limitations to using CHC include
current breast cancer severe HTN or vascular disease complicated DM (or DM >20 years) heart disease migraine with aura seizure disorder liver/gallbladder disease smoke 15+ cigarettes per day
What happens if you miss 1 CHC pill
Take it ASAP and take the next pill as usual
What happens if you miss 2 CHC pills
Take the most recently missed one ASAP
Continue as usual the next day (you will have an extra pill in your pack)
Use backup for 7 days or EC if needed
What if you miss 2 pills from the last hormonal week
dont take the placebo week pills, start a new pack the next day
When can you start POPs
any time!
No backup needed if you start in the first 5 days of bleed
Prescribe 1 year supply at a time
NO monitoring necessary
How do POP work
Thicken cervical mucus
thin endometrium
Suppress ovulation 50% of the time
slow sperm motility
ADE of POP include
Increased spotting/bleeding
intermittent amenorrhea
Limitations to taking POPs include
Current breast cancer, liver disease, meds that increase hepatic clearance (anti-convulsant, rifampin, St johns wort)
What is a missed pill with POP
If you wait >3 hours of normal time
if you vomit or have severe diarrhea w/in 3 hours after taking a POP
What do you do if you miss a POP pill
take another pill, use backup for 2 days
consider EC
How do you prescribe Depo-Provera (progestin injectable)
can start any time
no backup needed if you start w/in 7 days of bleed
Repeat injections every 13 weeks
Limitations to using Depo-provera
current breast cancer severe HTN heart disease vascular disease migraine w aura liver disease changes in bleeding patterns weight gain (5.4 lb in first year) decreased bone mineral density
What are LARCs
Copper IUD (10 years!) Levonorgestrel IUD
What are the types of LNG-IUD
Mirena: 5 years
Kyleena: 5 years
Liletta: 4 years
Skyla: 3 years
What is in Nexplanon
single 68mg etonorgestrel rod
IUD are preferred for
adolescents
parous or nulliparous
When can you place an IUD
anytime if reasonably certain not pregnant
Cu-IUD, no back up needed after insertion
LNG-IUD no back up if inserted in first 7 days of bleed
What must you monitor with IUDs
bimanual exam and cervical inspection
STD screening at time of insertion
no routine follow up!
Limitations to IUD are
cervical cancer
purulent cervicitis
current gonorrhea or chlamydia, or high likelihood to exposure
increased risk of spontaneous abortion and preterm delivery if you become pregnant on an IUD
What is the MOA of LNG-IUD
thicken cervical mucus
slow tubal motility
alter endometrium= no implantation
5-15% anovulatory effect
If IUD fails, you have a higher chance of
Ectopic pregnancy
What is the MOA of Cu-IUD
coper ions inhibit sperm motility so sperm rarely reach fallopian tube= no fertilization
inflammatory reaction of endometrium phagocytizes sperm
ADE of Cu-IUD is
increased menstrual blood loss and dysmenorrhea
What is the MOA of nexplanon (etonorgestrel implant)
thicken cervical mucus
inhibit ovulation
atrophic endometrium
How do you insert nexplanon
at any time if reasonably certain not pregnant
no backup needed if in first 5 days of bleed
Limitations of nexplanon include
current breast cancer
liver disease
unpredictable, irregular menstrual bleeding
What is the MOS of emergency contraception
if taken before ovulation: disrupt normal follicular development, block LH surge, inhibit ovulation
-Cu-IUD has different method, provides EC for 5 days after unprotected sex
What happens if you take emergency contraception after ovulation
they are not abortifacient and do not disturb implanted pregnancy
little effect on ovarian hormone production at this time
What are the available EC pills
Ulipristal acetate single dose
Levonorgestrel 1.5 single dose or split dose (q12 hr)
Combined estrogen/progestin in 2 doses (not as effective, lots of ADE)
ADE of EC are
nausea vomiting (if you vomit w/in 3 hrs of taking EC, take another dose and consider taking Meclizine before your second try)
How do you prescribe EC
Cu-IUD: insert w/in 5 days
ECP: ASAP, w/in 5 days
Do you need contraception after taking Ulipristal acetate
Use backup for 14 days, or until next menses
you can start another form of contraception at any time
*If no withdrawal bleed in 3 weeks of taking UPA, take a pregnancy test
Do you need contraception after taking the LNG or combined ECP
Use backup for 7 days
can start any contraceptive immediately
If no withdrawal bleed in 3 weeks, take a pregnancy test
What are sterilization techniques for women
Hysteroscopic: tubal occlusion (wire)- need to confirm after
Laparoscopic (abd): tubal ligation
(irreversible)
What are risk factors for regretting sterilization
<30 y/o low parity sterilization at time of c-section change in marital status poverty minority status misinformed of risks hurried decision
Do you need additional contraception after vasectomy
yes, until 2 consecutive sperm samples show no motile sperm!
1% of men request reversal, low regret
What contraceptive methods have the highest rate of continuation at 1 year in 15-24 year olds
LARC**
Cu-Iud, OCP, Ring, Depo, Patch
Can teens use Depo
Yes! discuss ADE with them before administering, but it should not prevent you from using this method
Preferred contraception for teens is
IUD!!!
ACOG says these are first line!
If obese, do not use
Ortho evra patch Depo provera shot \+/- OCP (VTE risk) \+/-LNG-IUD (weight gain) (but these are not contraindications)
Obese adolescents are noted to have
earlier coital debut
higher rates of unprotected sex
Hormonal contraception decreases the risk of
endometrial hyperplasia and cancer! wahoo!
ACOG recommends use of contraceptives until
menopause, or age 50-55
These methods are preferred for >45 y/o
POP
Implants
LNG-IUD
Cu-IUD
If >45, do not use
COC
Depo
(bc they have risks related to chronic conditions that come with age)
How long do you need to use backup when starting contraceptives
Cu-IUD: none
POP: x 2 days
All others: x 7 days
In postpartum women, when can you start contraceptives
CHC: breastfeeding, 4 wks// not BF, 3 wks// VTE RF, 4-6 wks POP: anytime Depo: anytime Cu-IUD: anytime (as long as no sepsis) LNG-IUD: anytime (as long as no sepsis) Nexplanon: anytime
When should you start contraceptives post-abortion
CHC: anytime w/in 7 days POP: anytime, w/in 7 days Depo: anytime IUD: anytime, w/in 7 days (no septic abortion) Nexplanon: anytime, w/in 7 days
At contraception follow ups, you should
assess satisfaction
concerns about method use
changes in health status or meds
consider assessing weight changes
