Contraception

Question 1

Nexplanon

Answer 1

• an implantable rod, which secretes progestin
• effective for three years with a typical and perfect use failure rate of 0.05%, making it the most effective form of contraception available
• functions to thicken the cervical mucus and inhibit ovulation
• the most common side effect is irregular, unpredictable vaginal bleeding but others include weight gain, acne, mood swings, and headache

Question 2

What is the primary mechanism through which progestin-based contraceptives work?

Answer 2

they thicken the cervical mucus, suppress the endometrium, and inhibit ovulation

Question 3

Why are IUDs avoided by many women?

Answer 3

because earlier kinds of IUDs were associated with an increased risk of PID and infertility, and even though newer forms are not, the perception persists

Question 4

Hormonal IUDs

Answer 4

• a T-shaped device implanted in the uterus, which releases small amounts of levonorgestrel, a progestin
• functions by thickening the cervical mucus and suppressing the endometrium
• placement is best performed during menstruation when pregnancy can be excluded and the cervix is slightly dilated; risk of expulsion is 1-5% and most cases occur in the first few months after placement
• effective for up to 5 years with a typical and perfect use failure rate of 0.2%
• added benefit of decreasing menstrual blood loss and severity of dysmenorrhea, possibly inducing amenorrhea
• carries a slight risk of infection in the first 20 days; if pregnancy occurs there is an increased risk of ectopic pregnancy, spontaneous abortion, and preterm labor and delivery

Question 5

Copper IUD

Answer 5

• a T-shaped device implanted in the uterus, which releases copper ions
• functions as a spermicide, inhibiting both sperm motility and the acrosomal reaction; as emergency contraception, however, it functions by interfering with implantation
• placement is best performed during menstruation when pregnancy can be excluded and the cervix is slightly dilated; risk of expulsion is 1-5% and most cases occur in the first few months after placement
• effective as emergency contraception and for up to 10 years after placement with a typical and perfect failure rate of 0.8 and 0.6%
• side effects include cramps, heavier or longer periods, and spotting between periods
• carries a slight risk of infection in the first 20 days; if pregnancy occurs there is an increased risk of ectopic pregnancy, spontaneous abortion, and preterm labor and delivery

Question 6

If a patient with an IUD has a positive cervical culture of gonorrhea, chlamydia, or bacterial vaginosis, what is the proper follow up?

Answer 6

• leave the IUD in place and treat the patient
• the IUD only has to be removed if there is evidence of spread to the endometrium or fallopian tubes or if there is failure of the treatment with antibiotics

Question 7

If a patient with an IUD becomes pregnant what are two next steps?

Answer 7

• ensure that the pregnancy is intrauterine because IUDs increase the proportion of pregnancies that are extrauterine
• remove the IUD if the string is visible since 40-50% of patients spontaneously abort if the IUD is left in place

Question 8

What are three pregnancy related complications associated with IUDs?

Answer 8

• increased proportion of ectopic pregnancy
• increased risk of first trimester spontaneous abortion
• increased risk of preterm labor and delivery

Question 9

What is the best time to place an IUD? Why?

Answer 9

during menstruation because this confirms the patient isn’t pregnant and the cervix is usually somewhat dilated during this time

Question 10

Depot Medroxyprogesterone Acetate

Answer 10

• an injectable progestin given IM or subcutaneously, relying not on sustained-release but on a high peak and sustained levels of hormone
• given every 13 weeks with a 2 week safety margin with a perfect and typical use efficacy of 0.2 and 6%
• functions by thickening the cervical mucus and suppressing endometrial proliferation; it blocks the LH surge but not FSH production, so ovulation is incompletely inhibited
• decreases the risk of endometrial carcinoma and iron deficiency and is helpful in managing pain associated with endometriosis, endometrial hyperplasia, and dysmenorrhea
• may suppress estradiol production and cause loss of bone mineral density; however this is moderate and reversible so there is no recommendation to limit use
• it is the contraceptive mostly strongly linked to weight gain
• has a slower return to fertility than implants or IUDs
• contraindications include known or suspected pregnancy, unevaluated vaginal bleeding, known or suspected breast malignancy, and liver dysfunction or disease

Question 11

cOCPs

Answer 11

• pills containing ethinyl estradiol and either a 19-nortestosterones or spironolactone derivative
• the progestational component provides most of the contraceptive effect, suppressing the LH surge to inhibit ovulation, thickening the cervical mucus, and suppressing the endometrium; the estrogenic component suppresses FSH secretion and follicle maturation while regulating the cycle
• have a typical use and perfect use efficacy of 9 and 0.3%
• available in traditional or phasic formulations and with a placebo week or as continuous regimens
• have the added benefit of lowering the incidence of endometrial and ovarian cancers, benign breast and ovarian disease, and pelvic infection
• patients may experience breakthrough bleeding due to the shallow and fragile endometrium being prone to asynchronous breakdown and bleeding; usually resolves spontaneously but may offer a week of exogenous estrogen to stabilize the endometrium
• serious complications like DVT, pulmonary embolism, cholestasis and gallbladder disease, strokes and MI are more likely for women using high-dose formulations and in smokers over age 35
• estrogens may also cause a feeling of bloating and weight gain, breast tenderness, nausea, fatigue, or headache
• contraindicated in women over 35 who smoke or have had a thromboembolism and in women with a history of CAD, CHF, cerebral vascular disease, or migraine with aura

Question 12

cOCPs containing what two hormones?

Answer 12

• ethinyl estradiol

- either a 19-nortestosterone or a spironolactone

Question 13

What is the role of the estrogen component in cOCPs? What about the role of the progestational component?

Answer 13

• estrogen suppresses FSH and therefore follicle maturation, potentiates the action of the progestational component, improves cycle control by stabilizing the endometrium for more regular cycles with less breakthrough bleeding
• the progestational component provides most of the contraceptive effect by suppressing the LH surge and therefore ovulation, thickening the cervical mucus, and suppressing the endometrium
• in summary, progesterone is for contraception and estrogen is for regulation of the cycle

Question 14

What is a phasic cOCP?

Answer 14

one in which the ratio of estrogen and progestin varies throughout a pill pack in an effort to lower the total dose of hormones received by the patient

Question 15

What are continuous cOCPs?

Answer 15

those without a placebo week, which produce shorter or less frequent menstrual periods

Question 16

Progestin-Only OCPs

Answer 16

• function primarily by thickening the cervical mucus; ovulation continues normally in roughly half of patients
• have a typical and perfect use efficacy of 9 and 0.3%; because the dosages of progestin are so low, scheduled dosing is incredibly important and if a woman is more than 3 hours late, a backup contraceptive method should be used for 48 hours
• most useful in women who are lactating since lactation has the added benefit of suppressing ovulation and in women who are over 40 years old; a good choice for women with contraindications to estrogen

Question 17

Estrogens have what side effects as hormonal therapy and as contraception?

Answer 17

• they affect lipid metabolism
• potentiate sodium and water retention
• increase renin substrate
• stimulate the CYP450 system
• increase sex hormone-binding globulin
• reduce antithrombin III

Question 18

Progestins have what side effects?

Answer 18

• increase sebum
• stimulate facial and body hair growth
• induce smooth muscle relaxation
• increase the risk of cholestatic jaundice

Question 19

What are the contraindications for cOCPs?

Answer 19

• women with a history of migraine with aura, blood clots, estrogen-responsive breast cancer, cerebral vascular disease, CHF, CAD, or liver disease
• women over 35 who smoke or have a history of migraine or hypertension
• women who are breastfeeding

Question 20

Contraceptive Patch

Answer 20

• a transdermal patch containing synthetic estrogen and progestins
• change every week for three weeks and then leave off for one week to allow for withdrawal bleeding
• typical and perfect use efficacy are 9 and 0.3%, but efficacy is markedly diminished in women weighing more than 198 pounds
• side effects are similar to those of cOCPs with a risk of thrombosis as the primary indication and there is an added risk of skin irritation from the adhesive

Question 21

Contraceptive Ring

Answer 21

• releases a sustained amount of estrogen and progestin daily
• left in place for three weeks and then left out for one week to allow for withdrawal bleeding; can be taken out of the vagina for three hours if desired without altering efficacy
• typical and perfect use efficacy are 9 and 0.3%
• decreased risk of breakthrough bleeding compared to cOCPs

Question 22

What kind of condom protects against HIV transmission?

Answer 22

only latex

Question 23

Why do condoms have a reservoir tip?

Answer 23

to decrease the rate of condom breakage

Question 24

Contraceptive Sponge

Answer 24

• a small sponge containing spermicide
• has a dimple designed to fit over the cervix during intercourse and should be left in place for at least 6 hours after intercourse
• more effective in nulliparous women because it is available in only one size and is more likely to stay in place; efficacy is 21 and 9% for typical and perfect use

Question 25

Contraceptive Diaphragm

Answer 25

• a small, latex dome-shaped device placed with spermicide in the center and along the rim
• placed to cover the anterior vaginal wall and cervix; should use the largest that is comfortably inserted and should be placed so the cervix can be felt through the dome
• can be inserted up to 6 hours before intercourse and must be left in place for 6-8 hours after
• efficacy is 12 and 6% for typical and perfect use
• side effects include risk of UTI since it presses against the urethra to cause urinary stasis and the spermicide affects normal vaginal flora

Question 26

Spermicides

Answer 26

• compounds containing nonoxynol-9
• inserted high into the vagina against the cervix 10-30 minutes before intercourse and effective for no more than one hour

Question 27

Explain the calendar method of natural family planning.

Answer 27

• the woman charts her periods for 6 months to calculate the fertile period
• the first day of the period is determined by subtracting 18 days form the total length of the shortest cycle
• the final day of the fertile period is determined by subtracting 11 days from the length of the longest cycle

Question 28

Explain the basal body temperature method of natural family planning.

Answer 28

• the woman’s temperature is checked daily upon awakening and before getting out of bed
• a rise in basal body temperature of 0.5 degrees is indicative of ovulation and the couple must abstain from intercourse from the end of the menstrual period until three days after the temperature increase

Question 29

Explain the cervical mucus method of natural family planning.

Answer 29

• the vagina is usually dry after menstruation and then a thick, sticky mucus appears; the mucus then becomes thin, stretchy, and clear which we call spinnbarkeit; the last day of wetness is called the peak and coincides with ovulation
• the fertile period occurs with the first signs of mucus and continues until four days after the peak

Question 30

Describe the symptothermal method of natural family planning.

Answer 30

• combines the assessment of cervical mucus and basal body temperature methods
• the fertile period is from the first sign of ovulation until 3 days after temperature rise or 4 days after peak mucus

Question 31

When is lactational amenorrhea effective contraceptive?

Answer 31

• for up to 6 months as long as menses has not resumed and there is exclusive or near exclusive (>85%) breastfeeding
• importantly, pumping does not have the same effect as suckling on ovulation

Question 32

When is emergency contraception effective?

Answer 32

most effective within the first 24 hours but may be used to prevent pregnancy if used within five days

Question 33

Emergency Contraception

Answer 33

• today, we use progestin-only EC, which is better tolerated than the cOCP regimen known as the Yuzpe method
• consists of a single-dose or two-dose regiment of levonorgestrel taken 12 hours apart
• available for behind-the-counter dispensing to women over 17 without a prescription and to women under 17 with a prescription
• most effective within the first 24 hours but may be used to prevent pregnancy if used within five days
• a prescription-only ulipristal acetate formulation is just as effective for the first 72 hours but more effective from 72-120 hours
• all methods work by preventing ovulation and fertilization, except for the copper IUD which works be preventing implantation

Question 34

What is the gender distribution for surgical sterilization procedures?

Answer 34

⅓ are performed on men and ⅔ on women

Question 35

What are the advantages of vasectomy over female sterilization procedures? What is the advantage of tubal ligation over vasectomy?

Answer 35

• because it is performed outside the abdominal cavity, it is safer, more easily performed, less expensive, and more effective
• the primary benefit of a tubal is that it offers immediate sterility

Question 36

What are the complications of tubal ligation?

Answer 36

• bleeding, hematomas, acute and chronic pain, local skin infections can occur
• some studies find a risk of depression and change in body image in women post-ligation

Question 37

What is the failure rate of vasectomy and what are the most common reasons for failure?

Answer 37

• there is about a 1% failure rate with vasectomy

- most cases result from intercourse too soon after the procedure rather than from recanalization

Question 38

Why does vasectomy not convey immediate sterility?

Answer 38

because multiple ejaculations are required before the proximal collecting system is emptied of sperm

Question 39

How long after a vasectomy is sterility usually achieved?

Answer 39

complete azoospermia is usually obtained at 10 weeks post-procedure

Question 40

What is the advantage of salpingectomy over other methods of female sterilization?

Answer 40

there is some belief that salpingectomy reduces the rates of ovarian cancer

Question 41

What are the risks and benefits of electrocautery-based methods for tubal ligation?

Answer 41

• these methods are fast
• but they carry a risk of inadvertent electrical damage to other structures, have poorer reversibility, and a greater incidence of ectopic pregnancy when failure does occur

Question 42

Which form of electrocautery is safest and why?

Answer 42

bipolar is after because it carries less risk of spark injury to adjacent tissue

Question 43

What is unique about the use of a Hulka clip for female sterilization?

Answer 43

it is the most readily reversible because it does minimal tissue damage; for this reason it also has the greatest failure rate

Question 44

What is unique about the use of a Falope ring for female sterilization?

Answer 44

it has intermediate reversibility and failure rates as well as a higher incidence of post-operative pain

Question 45

What is unique about the use of a Filshie clip for female sterilization?

Answer 45

it has a lower failure rate than the Hulka clip, is easy to apply, and has an atraumatic locking device

Question 46

Describe the Essure method of female sterilization.

Answer 46

• it is a transcervical approach in which a inner steel coil and outer nickel titanium coil are placed into each fallopian tube, inducing scaring
• requires roughly three months to take effect and should be confirmed with a hysterosalpingography

Question 47

If a patient has undergone tubal reversal and becomes pregnant, what should your first thought be?

Answer 47

you must presume it is ectopic until intrauterine pregnancy has been confirmed

Question 48

How do we confirm sterilization following vasectomy?

Answer 48

sperm analysis is performed 3-4 months and 20 ejaculates after the procedure

Question 49

How do we confirm sterilization after placement of Essure?

Answer 49

using a hysterosalpingogram

Question 50

What are the risks of female sterilization?

Answer 50

• ectopic pregnancy

- regret

Question 51

What are risk factors for regret following female sterilization?

Answer 51

• age, especially less than 25, is the strongest predictor
• completion of procedure within one year of delivery
• low parity
• minority status
• change in marital status
• low access or incomplete information
• decision made under pressure from partner or medical indication

Question 52

Which forms of hormonal contraception are safe to use while breast feeding?

Answer 52

progesterone-only forms