contraception Flashcards
Factors to Consider for contraception
Efficacy
Convenience
Duration of action
Reversibility and time to return of fertility
Effect on uterine bleeding
Frequency of side effects and adverse events
Affordability
Protection against sexually transmitted diseases
LARC
long acting reversible contraception
failure rate for NFP
20%
rate of pregnancy in people not planning for anything
25%
failure rate for withdrawl
18-20%
Lactation Amenorrhea Method
<6mo postpartum
exclusively breastfeeding
amenorrheic
can still get pregnant
Barrier methods
Male Condom-NOT WITH OIL BASED LUBE
Female Condom
effectiveness increased with spermicide
How do you use a diaphragm
- Pregnancy rate 16% with typical use
- Requires fitting by a clinician
- Not for preventing STD
- Leave in 6-8 hrs after intercourse then remove and wash
- May increase risk of UTI
can increase the risk of transmission of HIV positive
Cervical Cap can be left in
for up to 48 hrs
must be fitted like diaphragm
Monophasic pills
dose is the same throughout the pac
Triphasic
dose of progesterone is the same throughout but estrogen changes
when we talk about dosing it is always talking about estrogen dosing
implantable devices are what kind of hormone
progesterone only
benefits of taking BC pills
treats
endometrial cancer
acne
risk of ovarian cancer
dysmenorrhea
if you put someone on continuous extended cycle the need to be on this type of pill
monophasic
might do this with endometriosis
the weeks off
progesterone withdrawal to get withdrawal bleed
most current BC pills contain ____ estrogen
20-35 mcg
most SE with BC are due to
progesterone
PRO GESTASION
in women on a 20 mcg pill what would you do for breakthrough bleeding
after 3 months if their HPO axis is still not on track increase the dose
Very low dose (20 mcg) pills may cause more breakthrough bleeding than higher doses
when would you start people on 20mcg pill
teens and women who have not had bc beforev
has anti-mineralocorticoid and anti-androgen properties
Drospirenone
Marketed for pts with acne
this has a low androgen binding affinity it is indicated for pts with
Norgestimate
Indicated for pts with PCOS, acne
Synthetic progestins have this effect on pts
progestins bind to progesterone and androgen receptors
Androgen binding affinity can cause unwanted side effects (weight gain, acne)
what to do for ASE
i. Irregular menstrual bleeding – 32%
Menses often get lighter and less painful with time
ii. Nausea – 19%
Usually resolves within 3 months
Take W/ food
iii. Weight gain – 14%
iv. Mood swings – 14%
v. Breast tenderness – 11%
vi. Headache – 11%
vii. CV or thromboembolic events
higher rate for pts with hx of migraine of family hxCI for combo pill
Previous thromboembolic event or stroke
Migraine esp w/ aura but menst migraine workds
History of an estrogen-dependent tumor
Liver disease
Pregnancy or breast feeding
Undiagnosed abnormal uterine bleeding- fibroids or endometrial cancer
Cerebral vascular or coronary artery disease (past or current history)
Complicated valvular heart disease
Women over age 35 years who smoke –> increases your risk for thromboembolic event or stroke
indications for progesterone only pill
meaning this person should NOT be on estrogen
pretty much the same as the CI of estrogen combo pill
Migraine headaches with aura but probably anyone now
Age over 35 years and smoker or obese
History of thromboembolic disease
Cardiac disease, especially coronary artery disease or congestive heart failure
Cerebrovascular disease
Early postpartum period
Hypertension with vascular disease or older than 35 years of age
Systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies
Hypertriglyceridemia
what are the risks of progesterone only pill
More breakthrough bleeding
Slightly higher failure rate
Must be taken at the same time (within 3 hours) every day; no placebo period
advantage of a Sunday start
never have period on a weekend
quick start method
neg UPT
back up method for 7 days
First day start
– start on 1st day of menses
Quick start method of BC what do you need
start on day Rx is given (neg UPT)
need to use back up for 7 days
Sunday start
start on 1st Sunday after menses
never have period on weekend!
Minipill, when do you have to use back up mehtod
when miss it more than 3 hours
Combined oral contraceptives- when do you have to use back up method
if >2 pills in a month are missed, use a back-up method for the rest of the pack
benefits of nuvaring
lower absorption of hormones
(no progesterone!)
Rapid return to ovulation after discontinuation
Lower doses of hormones so won’t get a lot of the PMS symptoms
Ease and convenience
Improved cycle control
CI to nuvaring
Same contraindications as estrogen pills
Transdermal estrogen patch risks
Similar side effect and efficacy data to NuvaRing and oral contraceptive pills
Same cardiovascular disease risk as birth control pills
probably need to rotate to avoid irritation
safer than the pill but you still get absorption of estrogen
why does birth control lower libido
estrogen binds to sex hormone binding globulin
lowering libido
name of Injectable contraceptives
Depot medroxyprogesterone acetate (DMPA)
pro/con with Injectable progestin
99.7% effectiveness
Amenorrhea and weight gain may occur
Cannot use > 2 years due to risk of osteoporosis
Recommend giving first injection while the pt is on their period (know they are not pregnant) get a UPREG every time too
Document negative pregnancy test
subdermal implants are what type of hormone?
progesterone only
fertility return with implanon
Contraception is provided for three years
Fertility returns rapidly after removal of the rod
primary reason for d/c the implanon
Irregular bleeding was the primary reason for discontinuation in premarketing studies
ideal candidates for IUD
- Are at low risk of acquiring sexually transmitted infections
- Are not planning a pregnancy for at least one year
- Want to use a reversible contraceptive
- Want or need to avoid estrogen-based methods
CI for IUD
- Severe uterine distortion
a. Bicornuate uterus, cervical stenosis, or leiomyomata distorting the uterine cavity - Active pelvic infection
- Known or suspected pregnancy
- Wilson’s disease or copper allergy (copper IUD)
- Unexplained abnormal uterine bleeding
- Current breast cancer (Mirena IUD)
disadvantages of IUD
Changes in bleeding patterns • Amenorrhea • Unscheduled bleeding Breast tenderness Mood changes Acne
advantages of iUD
Reduction in menses & dysmenorrhea
Treatment of endometrial hyperplasia
Endometrial protection at perimenopause
Treatment of endometriosis
who should the insertion be scheduled
when f/u
- Cycle day 5-10 ideal
- Patient has been abstinent since LMP
- Documented negative pregnancy test
- Screening for STDs
- NSAIDs 30-60 minutes prior to procedure
- Insert IUD
- RTC in 4 weeks to check strings, side effects
ASE for IUD
- Abnormal bleeding
a. Intermenstrual bleeding or spotting
b. Common in first 3 months
c. Heavy bleeding (decreased with NSAIDs) - Pregnancy complications / ectopic pregnancy
- Pain or partner feels strings
- Expulsion (more likely with Skyla)
a. 3-10% copper; 6% Mirena - Infection within first 20 days: 1/1,000
- Perforation: 1/1,000
a. Risk with inexperience,
immobile/retroverted uterus
what can you do for pts with break through bleeding and IUD
put on a very small dose of estrogen
risks of IUD
- Uterine perforation due to inexperienced provider
- Syncope
- Diaphoresis
- Vomiting
- Unable to insert
- Cramping/bleeding
- Expulsion
- Embedment in myometrium
permanent sterilization for women
BTL
primary ocntraception methods for women in the US
OCP Female sterilization condoms male sterilization injectables other
pregnancy rates with diaphragm and spermacide
Pregnancy rate 16% with typical use
Really only effective when you use spermacide
how long can you leave a diaphragm in for
Leave in 6-8 hrs after
who is the diaphragm not recommended for
Not recommended for HIV positive pts
what are the pregnancy rates with a cervical cap and what affects this
Pregnancy rate 16%; 32% if previous births
cervical cap come sin this many sizes and can be left in for how long
Leave in vagina 6-8 hrs (up to 48 hrs), then remove and wash
sponge rates of pregnancy
same as the cervical caps
Pregnancy rate 16% for typical use; 32% if previous births
what do you have to do before inserting a sponge
wet with water
Nonoxynol-9 is
spermacide
problems with spermacide
May cause local irritation, some increase in bacterial vaginosis infections, and may be messy
Effectiveness is reduced if the patient does not wait long enough for the spermicide to disperse before having intercourse, if intercourse is delayed for more than one hour after administration
Estrogen/progestin-induced inhibition of the midcycle surge of
gonadotorpin
gnrh
released in pulses from the hypothalamus
determines FSH and LH release (anterior pituitary)
and these control the maturation of the ovarian follicles
Theca cells
has LFH receptors which sti,ulate a precursor to estrogen
granulosa cells have FSH receptors that also have a precursor needed to convert the theca cell precursor into estrogen
negative feedback signal to the pituitary
less FSH means only enough to stimulate one follicle
lactation amenorrhea only works if
- The woman is less than six months postpartum
- She is breastfeeding exclusively (ie: not providing food or other liquid to the infant)
- She is amenorrheic
can you leave a cervical cap, diaphragm, or a sponge in for longer
cervical cap 48 hours
sponger 30
diaphragm 8 hrs
to avoid breakthrough bleeding
monophasic
excess estrogen has this effect on the menstrual cycle
block gnRh and the development of the follicle
rates of pregnancy with OTC
8% with regular use
1% with perfect use
cyclic pills have this on and off
21 or 24 active followed by 7 or 4 inactive pills
nausea weight gain moodiness
progesterone
cardiac SE
estrogen
drospirenone
progesterone with
anti-mineralcorticoid properties that lower testosterone
helps with bloating and acne
PMDD
PCOS
Norgestimate
Ortho Tri-Cyclen and Previfem
these have low androgen binding affinity
drospirenone
Yasmen and angeliq
these have mineralocorticoid
weight gain is the result of
progesterone
Migraine headaches with aura
CI for OCP
increased risk of stroke
NO ESTROGEN
Undiagnosed abnormal uterine bleeding
why is this CI with OCP
Could be fibroids and don’t want to feed
Liver disease
why no OCP
because liver needs to destroy hormones and excess estrogen can cause strain
F/U for OCP
in the months sxs SE satisfaction BP HA assessment with chronic headaches
then can refill prescriptions annually
emergency contraception
copper paraguard (within 5 days) ella and plan B (ASAP)
when can you take emergency contraception
how does it work
with 120 hours but most effective within 72
disrupts uterine lining
with whopping dose of progesterone
and then withdraw = bleeding
hormones in plan be
Plan B contains two 0.75mg tabs levonorgestrel to be taken 12 hrs apart
Plan B One-Step contains one higher dose tab of levonorgestrel
Next Choice One-Step is another brand of levonorgestrel (one pill)
10 year pregnancy rates with copper vs levo
levo 1.1
copper 2,.2
copper IUD CI
Dysmenorrhea or menorrhagia
Wilson’s disease or copper allergy
CI with morena
Hormonal sensitivities
Current breast cancer
uterine distortion that would be CI with IUD
Bicornuate uterus,
cervical stenosis,
or leiomyomata distorting the uterine cavity
Levonorgestrel IUD
200mcg progesterone released daily (Mirena)
Progestin effect is primarily local
Hormonal side effects, such as breast tenderness, mood changes, and acne may occur
Mirena, Skyla
higher expulsion with copper or morena
morena
Tubal ligation (BTL)
Mechanical blockade using clips, rings, coils, or plugs
Coagulation-induced blockage
Coagulation-induced blockage works by
using electrical current or chemical agents
Hysteroscopic Sterilization
Essure
2 part procedure
Fibrotic reaction causing stenosis of tubes
3 mo after fiber placed need to do HSG
Only method of permanent sterilization that gives confirmation of sterilization
Hysteroscopic
