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Pocket Primary Care > Contraception > Flashcards

Contraception Flashcards

1
Q

Background

A

Almost half of all US pregnancies are unintended (pregnancy not desired at time of conception); 33% of women using contraception inconsistently, incorrectly, or not at all -> 95% of these pregnancies

Half of all Us women at risk of unintended pregnancy (sexually active, fertile, not currently pregnant); appropriate to discuss contraception with /all pts of reproductive age

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2
Q

Risk factors

A

Increase rates of unintended pregnancy in women 18-24 y, women living n provert, nonwhite ethnicity, and decrease education

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3
Q

Condition assoc w/increase in health risk from unintended pregnancy

A

Estrogen-sensitive cancer, cyanotic CHD, recent bariatric surgery or transplant, epilepsy, HTN, SLE, APS

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4
Q

Choosing a method

A

counsel pts to choose most effective method she and her partner are able to use successfully

Women with medical issues: refer to CDC Us medical eligibility criteria for contraceptive use

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5
Q

First-year contraceptive failure rates

Implant

A

Perfect use: <1

Typical use:`<1

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6
Q

First-year contraceptive failure rates

Sterilization (tubal or vasectomy)

A

Perfect use: <1

Typical use: <1

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7
Q

First-year contraceptive failure rates

IUD (copper or mirena)

A

Perfect use: <1

Typical use: <1

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8
Q

First-year contraceptive failure rates

Depo Provera

A

Perfect use: <1

Typical use: 6

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9
Q

First-year contraceptive failure rates

Pill (combined or progestin only

A

Perfect use: <1

Typical use: 9

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10
Q

First-year contraceptive failure rates

Patch/Ring

A

Perfect use: <1

Typical use: 9

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11
Q

First-year contraceptive failure rates

Male condom

A

Perfect use: 2

Typical use: 18

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12
Q

First-year contraceptive failure rates

Diaphragm

A

Perfect use: 6

Typical use: 12

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13
Q

First-year contraceptive failure rates

withdrawal

A

Perfect use: 4

Typical use: 22

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14
Q

First-year contraceptive failure rates

Periodic abstinence

A

Perfect use: -

Typical use: 24

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15
Q

First-year contraceptive failure rates

Calendar

A

Perfect use: 5

Typical use: -

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16
Q

First-year contraceptive failure rates

Ovulation method

A

Perfect use: 4

Typical use: -

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17
Q

First-year contraceptive failure rates

Symptotheral

A

Perfect use: <1

Typical use:-

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18
Q

First-year contraceptive failure rates

No method

A

Perfect use: 85

Typical use: 85

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19
Q

Combined Hormonal Methods

overview

A

Combo of synthetic estrogen (usually ethinyl estradiol (EE)) and progestin (multiple types)

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20
Q

Combined Hormonal Methods

Estrogen

A

Suppresses gonadotropin surge -> prevents ovulation

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21
Q

Combined Hormonal Methods

Progestin

A

Affects cervical mucus, tubal peristalsis, and endometrial lining -> decrease sperm motility, prevents egg fertilization and implantation

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22
Q

Combined Hormonal Methods

benefits

A

improvement in menorrhagia, dysmenorrhea, anemia, PMS, acne, hirsutism; decrease risk of ovarian/endometrial CA

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23
Q

Combined Hormonal Methods

risks

A

HTN, VTE ( up to 3-4X increase risk if no underlying RFs; up to 1.8X further w/3rd and 4th gen progestins; absolute risk still low and much < VTE risk w/pregnancy), MI, stroke; risk increase w/older preparations (estrogen >50ug)

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24
Q

Combined Hormonal Methods

Absolute contraindications

A

Hx of DVt/PE or stroke, AMI, known thrombogenic mutations, migraine w/aura or seuro s/sx, smokers older than 35 or 35, active liver disease, known/suspected estrogen-dependent tumor

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25
Q

Combined Hormonal Methods

Vaginal ring

A

Nuvaring (15ug EE, 150ug etonogestrel); flexible plastic ring inserted by pt, intravaginal X3 weeks, removed X1 week; high pt satisfaction rates

26
Q

Combined Hormonal Methods

Transdermal patch

A

Ortho Evra (20ug EE, 150ug norelgestromin); apply q1wk; decrease efficacy in pts >90kg

FDA warning: increased systemic estrogen exposure w/patch tan from OCP (w/35 ug EE), may cause increase risk VTE

27
Q

Combination oral contraceptive pills (OCPs)

General Approach

A

After review of medical hx and CI
1. Select estrogen and progesterone formulations
2, Set initiation plan (quick vs 1st day vs sunday start)
3. Decide on planned patter of use (cyclic vs extended vs continuous)
4. Discuss indications for backup methods
5. counsel (side effects)

28
Q

Combination oral contraceptive pills (OCPs)

Estrogen formulations

A

Low-dose (10-20ug) to high dose (50ug) formuations; standard 20-35 ug; breakthrough bleeding may increase w/ less than or equal to 20ug dose

29
Q

Combination oral contraceptive pills (OCPs)

Progestin formulations

A

Vary in androgenic activity

2nd gen: lveoneorgestrel (increase androgenic), norethindrone ( decrease androgenic)

3rd gen: norgestimate, desogestrol (least androgenic)

4th gen: drosperinone, (antiandrogenic + antimineralocorticoid activity)

30
Q

Combination oral contraceptive pills (OCPs)

Initiation

A

Can be safely provided after careful medical hx and BP

Quick start: (preferred) take 1st pill as soon as prescription is filled; increase compliance w/o increase side effects; need backup contraception for 7 days

1st day start: take 1st pill on 1st day of period; backup contraception not needed

Sunday start: Take 1st pill on sunday after period begins; backup needed X 7 days

31
Q

Combination oral contraceptive pills (OCPs)

Pattern of use

A

Can be given cyclically (21 active pills -> 7 hormone free pills), on extended cycle regimen (84 active pills -> 7 hormone free pills), or continuously. extended/continuous options may be preferred in women with premenstrual sx or for lifestyle; efficacy and safety equivalent to cyclic use

32
Q

Combination oral contraceptive pills (OCPs)

backup method indications

A

Missed pill: use backup contraception x 7 days after 2 or more missed pills

medication interactions: efficacy decreased by meds that increase liver microsomal enzyme activity ( anticonvulsants, griseofulvin, rifampin, St johns wort); no clinical evidence on other antibiotics although some case reports w/PCN and tetracyclines

33
Q

Combination oral contraceptive pills (OCPs)

Side effects

A

Counsel pts in advance of side effects, these typically resolve in 2-3 months; also discuss risk/benefits of combined hormonal tx

34
Q

Combination oral contraceptive pills (OCPs)

Follow-up

A

Consider f/u 3 mos to check BP, evaluate for tolerance and side effects; can switch pill to adjust amount of EE or type of progestin per s/e

35
Q

Combination oral contraceptive pills (OCPs)

pregnancy

A

if pregnancy occurs while on OCPs. d/c upon dx, but reassure pts no adverse outcome a/w using OCPs at time of conception

36
Q

OCP side effects

estrogen excess

A

HA, nausea, mastalgia

Try dosing QHS vs low estrogen pill (increase risk breackthrough bleeding)

37
Q

OCP side effects

Progestin and/or androgen excess

A

Hirsutism, acne, wt gain

change to 3rd generation progestin

38
Q

OCP side effects

Progestin excess

A

Mood changes, decrease libido

change 3rd generation progestin

39
Q

OCP side effects

Pregnancy; nonpathologic suppression of endometrial shedding

A

amenorrhea

Pregnancy test; if + d/c OCP; if - reassurance; if pt desired menses -> increase EE or choose progestin w/increase endometrial activity (eg 1mg norethindrone -> 5mg) triphasic pill may be effective.

40
Q

Progestin-only Methods

progestin only mini pills

A

Option for pts w/ contraindicationto estrogen (including lactation); increase risk breakthrough bleeding; must take at the same time every day

41
Q

Progestin-only Methods

Injectable

A

Depot medroxyprogesterone acetate (DMPA); IM/SC injection q 3months

benefits: no need for daily pt adherence, amenorrhea w/ongoing use, decrease endometrial cancer

s/e: irregular bleeding, increase weight, HA

FDA black box warning: can decrease BMD (esp in adolescents)

42
Q

Progestin-only Methods

Subdermal contraceptive implant

A

implanon

very effective up to 3 years; fertility returns soon after removal; risk of irregular bleeding (primary reason for d/c)

43
Q

Condoms

A

Consistent, correct use protects from STI acquisition/transmission; latex condoms decrease HIV risk by 80-95%

Latex allergy in 1-6% of US population; synthetic and natural membrane condoms exist but decrease efficacy

Female condomes: polyurethane sheath; option if cannot use male condome

Spermicides: do not protect against STI’s, irritation may increase risk of infection

44
Q

Diaphragm, cervical cap

A

Require fitting by trained clinician; only effective when used with spermicide; do not prevent transmission of STI’s

45
Q

Intrauterine Contraception

Benefits

A

Very effective, no maintenance; good option for women who desire to avoid pregnancy for >3 years, avoids estrogen exposure

46
Q

Intrauterine Contraception

Risk of ectopic pregnancy

A

Decrease overall risk c/w pts who do not use contraceptives but increase risk if pregnancy occurs

47
Q

Intrauterine Contraception

contraindications

A

Uterine distortion, active pelvic infection (wait 3 mos before insertion), women w/increase risk for STI’s, pregnancy, unexplained uterine bleeding, active cervical/endometrial CA

Not contraindicated in adolescents/young adults or nulliparous women

48
Q

Intrauterine Contraception

Levonorgestrel IUD (mirena/Skyla)

A

Inhibits sperm transport and ova fertilization; partially inhibits ovulation; decrease blood loss, decrease dysmenorrhea; effective for 5 y (mirena) or 3 y (Skyla)

49
Q

Intrauterine Contraception

Copper IUD

A

Releases copper continuously into uterine cavity; interferes with sperm transport, prevents fertilization; effective for at least 10 years

50
Q

Tubal ligation

A

Prevents pregnancy by occluding or disrupting tubal patency; laprascopic (general anesthesia) vs hysteroscopic (often local anesthesia)

51
Q

Vasectomy

A

interruption or occlusion of vas deferens; can br performed in outpt setting w/ local anesthesia; safest, least costly method of surgical sterilization

52
Q

Emergency contraception

Indications

A

Pts who have had unprotected intercourse, indluding failure of another method w/in previous 120 hours; improved access does not increase sexual risk taking or STI acquisition

53
Q

Emergency contraception

Access:

A

plan b one step available w/o prescription regardless of age; other options available to women aged 17 and over w/o Rx; and to younger women w/RX

Contraindication to daily OCPs (VTE, liver disease) do not apply to EC

54
Q

Emergency contraception

Efficacy

A

Decreases pregnancy risk up to 88% (levonorgestrel EX); does not interrupt established pregnancy

55
Q

Emergency contraception

Options

A

Levonorgestrel EC
Yuzpe regimen
Ulipristal acetate
Copper IUD

56
Q

Emergency contraception

Levonorgestrel EC

A

1 (1.5mg) dose (plan b 1 step) or 2 X0.75 mg taken 12 h apart; single dose as effective ; safer and more effective than yuzpe regimen w/ decrease rates of N/V, however, minimally effective for women >154 lb (70kg)

57
Q

Emergency contraception

Yuzpe regimen

A

(EE+progestin): 2 X (100ug EE + 0.5 mg levonorgestrel). Many OCPS can be sued; less effective than progestin-only, increase N/V

58
Q

Emergency contraception

Ulipristal acetate

A

Ella: Rx only; most effective oral option; pregnancy rate = 1.3% vs 2.2% for levonorgestrel (use 0-120 hrs after intercourse)

59
Q

Emergency contraception

Copper IUD

A

Most effective form of EC (10X efficacy of pills); insert w/in 5 days of intercourse; provides continuous contraception; avoid w/active gonorrhea/chlamydia infection

60
Q

Emergency contraception

counseling

A

Emphasize regular contraception use (can start OCPs the day after EC) consider screening for STIs: check pregnancy test if no menses in 3-4 weeks.

Pocket Primary Care (18 decks)

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