Contraception Flashcards
1
Q
Extremely Effective Contraception (>99%)
A
- Sterilization
- IUD/IUS
- Implants
2
Q
Very Effective Contraception (>92%)
A
- Pills
- Injectables
- Patch
- Ring
3
Q
Moderately Effective Contraception (~80%)
A
- Condom
- Withdrawal
- Sponge
- Diaphragm
4
Q
Effective Contraception (Up to 75%)
A
- Fertility awareness
- Cervical cap
- Spermicide
5
Q
Contraception chosen most often by women 35+ yo
A
Female Sterilization
6
Q
Male Sterilization
A
- No scalpel vasectomy is standard of care
- Low rate of failure
- Cheaper, safer, and more effective than female sterilization
- Must have 2 negative sperm counts after procedure for confirmation of success
7
Q
Female Sterilization (Surgical)
A
- Surgical procedure by laparoscopy
- Ligate, clip, cauterize tubes
8
Q
Female Sterilization (Non-Surgical)
A
- Essure:
- Micro-inserts expand and occlude fallopian tubes
- No reported failures to date
- Adiana:
- Low-level radio frequency delivered to fallopian tubes
- Micro-inserts placed into fallopian tubes
- 98% effective after 3 years
- Must use back-up method for 3mo
- Permanent
9
Q
Levonorgestrel IUS (Mirena)
A
- Approved for 5 years (effective for 7)
- 20mcg/day
- Progestin only IUD
- Amenorrhea in 20-30% by 1yr
- CANNOT be used for EC
- Trim strings to about 2-3cm
10
Q
Copper IUD (ParaGard)
A
- Copper ions
- Approved for 10 years (effective for 12)
- CAN be used for EC (98% if within 5d)
- Main MOA = Prevents fertilization; reduce motility and viability of egg
- Decreased risk for endometrial CA
- DOES NOT reduce menstrual bleeding (can increase); can increase cramping
11
Q
Indications for IUD
A
- Desire for long-term contraception
- Don’t want to use OC’s
- Desire quickly reversible method
- CI: Fibroids, sepsis, bleeding, PID, STI, TB, etc.
12
Q
Characteristics of IUDs
A
- One of highest pt satisfaction
- rapid return of fertility
- Safe; starts protecting immediately
- Long-term protection
- Highly effective
- May be inserted after delivery or abortion
13
Q
Copper vs. LNG IUD
A
- Copper:
- Wants regular menses
- Does not want to use hormones
- No history of dysmenorrhea/menorrhagia
- LNG IUD
- Amenorrhea acceptable
- Irregular bleeding tolerable
- Hx of dysmenorrhea/menorrhagia
14
Q
Dispelling myths about IUD
A
- Can be used with multiple partners
- Women with Hx of STD or PID (risk only increased in 1mo after insertion)
- Nulliparous women
- Teens
- Immediately post-partum/post-abortion
- Hx w/Hx of ectopic pregnancy
15
Q
Contraindications for IUDs
A
- Current purulent cervicitis, gonorrhea, or chlamydia
16
Q
Implanon
A
- Subdermal implant
- Contains etonogestrel (progestin-type hormone)
- Effective for 3 years
- Effectiveness in morbidly obese not yet determined
- Rapidly reversible (ovulation within 3wk-3mo)
- Can be used during breast feeding after 6wk
- Can improve dysmenorrhea and acne
17
Q
Contraindications for implanon
A
- Pregnancy
- Hx of blood clots, liver Dz
- Abnormal genital bleeding
- Known or suspected breast Ca or Hx of
18
Q
Disadvantages of implanon
A
- Infrequent bleeding
- Prolonged bleeding
- Weight gain (~5lbs)
19
Q
Timing of placing IUD or Implanon
A
- Anytime during menstrual cycle when pregnancy can be excluded
- Confirmed by negative pregnancy test and no unprotected sex in last 2wk
20
Q
Combined Oral Contraceptives (COCs)
A
- 20-35mcg ethinyl estradiol + 1 of 8 available progestins (21 pills, 7 placebos)
- By 3rd month, typical users miss 3+ days/cycle
- Progestin is main ingredient; suppresses gonadotropins, leutenizing hormone (Pituitary)
- Estrogen inhibits FSH secretion
- Both work synergistically to affect uterine lining and mucus
21
Q
Who can use COC’s
A
- Menstrual cramps
- Desire to regulate periods
- High compliance
22
Q
Advantages COC
A
- Reduce risk of ovarian cancer (15-20yr after use)
- regulate menses
- Protects against endometrial cancer
- Protects against ectopic pregnancy, acne, benign breast disease, IDA, bone density, and PID
23
Q
Contraindications COCs
A
- Risk factors for CV disease (Smoking, DM, HTN)
- Known thrombogenic mutations
- Hx of heart Dz, Stroke, PE, Valve Dz, PVD
- BP >160/100
- Age >35 and smoker (>15cigs/day)
- Migraine WITH aura
- Current Breast Ca
24
Q
Obesity and COCs
A
- Obesity decreases effectiveness of COC’s
25
Bleeding and COCs
- May experience irregular bleeding, N/V, breast tenderness for first 3mo
26
Progestin-Only Contraceptives (POPs)
- "Mini-pill"
- 2 Formulations: norethindrone (Micro-Nor) & Norgestrel (Norvrette)
- Consistent timing is IMPERATIVE
* Being late by 4hr can cause ovulation breakthrough
27
MOA POPs
- Suppress ovulation
- Suppress midcycle LH, gonadotropin peaks
- Alter cervical mucus (thickens)***
- Alter endometrium and fallopian tubes
28
Who to use POPs
- Want immediately reversible contraception, but estrogen is contraindicated
- Breastfeeding, cardiovascular Dz, Migraines
29
Advantages POPs
- Used to correct dysfunctional uterine bleeding
- No estrogen related side effects
- Protect against cancer of breasts and ovaries, PID, & benign breast Dz
30
Contraindications of POPs
- Current Breast Ca
31
Disadvantages POPs
- Need backup if not taken on time or EC
- Backup for 48hrs after late dose
- Do not suppress ovulation as well as COCs
32
Side effects of POPs
- Irregular bleeding and Spotting
* Usually clears up after 3-6mo
- Amenorrhea
33
Extended Hormonal Contraceptions
- Continuous use of COC's, transdermal patch, or vaginal ring
- For pills, 63 on pills, 7 off pill (vs. 21on and 7off)
- Delays or eliminates menstruation
- Menstrual and non-menstrual benefits
- Do NOT need bleeding week as previously thought
34
Extended Hormonal Contraception Methods
- Continuous use of COC's
- Transdermal patch
- Vaginal ring
- Seasonale, Seasonique, and Lybrel
35
EHC Benefits
- Remove menstrual related complaints
| - Treats heavy menstrual bleeding, dysmenorrhea, endometriosis, chronic pelvic pain, & anemia
36
EHC Disadvantages
- Increase in breakthrough bleeding in first few cycles after start of pill
37
Transdermal Patch/Ring Application
- Quick start: apply first patch on day prescribed
* If the patch is applied within 24hr after start of menstrual cycle -> No back-up needed
* If it is not begun within 1st 24hrs or not quick start method, need backup for 1wk
- Sunday Start Method: good to help remembering when period weeks begin
38
Transdermal Patch
- "Ortho-Evra"
- Applied to ABD, buttock, upper outer arm, or torso
- Patch applied 1x/wk (3wk on, 1wk off)
- May deliver med for 10d
- 150mcg norelgestromin/20mcg ethinyl estradiol
39
Ortho-Evra Advantages
- weekly
| - Rapidly reversible
40
Ortho-Evra Disadvantages
- similar to oral COC's
- More breast discomfort, dysmenorrhea, and N/V
- Avoid placing it on the breast
- Do NOT place under high friction areas to prevent excess release of medicine
41
Ortho-Evra Side Effects
- Breast tenderness (fades)
- Decreased effectiveness in >198lbs.
- 2x risk for Thromboembolism as compared to COC's (risk for VTE is still greater in pregnancy)
42
NuvaRing Facts
- One size fits most
- Etenorgestrol/Ethinyl Estradiol
- Contraception achieved in ~1wk
- Insert on or before day 5 of cycle. Backup for 7d
- If switching from COC, do not need to use backup.
43
NuvaRing Advantages
- Helps to regulate periods
- 3 week cycle
- Improves vaginal flora (decrease in BV)
- Privacy
44
NuvaRing Disadvantages
- Doesn't work w/significant vaginal relaxation
- Fibroids decrease
- increased leukorrhea
- HA, Nausea
- Risk of expulsion (rinse off and replace if within 3 hours, if >3hr new ring)
45
Rationale for Ring
- Easily inserted by pt.
- Monthly, NOT daily
- Continuous release w/constant serum hormones
- Lowest EE dose
- Avoids GI interference w/absorption
- Avoids hepatic 1st pass metabolism
46
What to do if ring is not replaced on time
- Consider EC
- R/O pregnancy
- Insert new ring
- Backup for 1wk
- NuvaTimer
47
Health Benefits: COC's
- Decreased dysmenorrhea, menstrual loss, anemia
- May reduce PMS symptoms
- Decreased risk of ectopic pregnancy, endometrial/ovarian Ca, benign breast Dz, & PID
48
Side effects hormonal contraception: Progestin
- Bloating, anxiety, irritability, depression, menstrual irreg.
49
Side Effects hormonal contraception: Estrogens
- Breast tenderness
- N/V
- HA
- HTN (rare)
50
Contraindications: COC's
- Clotting disorders
- Hx of DVT or PE
- Migraine w/aura or focal neurologic deficit
- Uncontrolled HTN
- <21d post-partum, gallbladder Dz, breast feeing,
51
Quick Start Method
- Start contraceptive in presence of clinician or on the day of visit
- Time during the menstrual cycle not a factor
- Back-up for 7d
52
Missed or late hormonal contraception: COC's
- Take missed pill ASAP and next pill at regular time
| - Use back-up method for 1wk if missed 1-2 pills at the start of pack or 3+ pills in the first 3wk
53
Missed or late hormonal contraception: POP's
- Take missed pill ASAP and next pill at regular time
| - Use back-up method if pill is taken more than 3hr past regular time
54
Transdermal patch
- Use back up method for 1wk if patch has been on more than 9d, off more than 7d, or falls off and is not reaffixed w/in 24hr
55
- Vaginal Ring
- Use back-up method for 1wk if ring has been in more than 5wk, out more than 7d, or falls out and is not reinserted within 3hr
56
Dose Regimens
- 21/7: Based on large doses of progestin in 1960's
- 24/4: Also produces menses
- Extended use: Prevents menses
- Ring: Can be used 365d in a row (must change ring q3wk); about 80% estrogen as oral dose
- Patch not studied for extended use; 3 in a row only
57
Starting Pills
- Quick Start: (25% who do not start pill at office got pregnant)
* Can use any time in cycle
* If she has had unprotected sex and it is on day 17+, give Plan B and 7d of backup
58
Depot Medroxyprogesterone Acetate (DMPA)
- Depo-Provera
- IM or SQ injection q3mo
- Not Immediately reversible
- 1cc, 150mg
- Progestin only; prevents ovulation and prevents ovarian production of estradiol
- Can be used immediately post-partum
59
Contraindications for Estrogen
- Complicated migraine
- Complicated DM
- Smokers >35yo
- Immediately post-partum
60
Advantages of Depo-Provera
- may improve menorrhagia, dysmenorrhea, and IDA due to amenorrhea
- Amenorrhea develops within 12mo
- May improve dysfunctional bleeding in obese women
- Decreasing risk of endometrial Ca, PID, uterine fibroids, and sickle cell crisis
61
Disadvantages of Depo-Provera
- CI in Breast CA
- Weight gain (~5lb/yr)
- Menstrual irregularities for first 3mo
- Median time to pregnancy after last injection is 10mo
62
Protection from pregnancy
- Immediately: Copper IUD
| - After 7d: LNG IUS, Implant, pills, patch, ring, or injection
63
Male Condoms
- Protects against STD's
| - Perfect use 98%; typical use 83%
64
Withdrawal
- Almost effect as condom
- Perfect use 96%; typical 82%
- Does not protect against STD
65
Female Condom
- Coated with silicone based lubricant
- Made from nitrile material, quieter (2nd gen); polyurethane, louder (1st gen)
- Can be inserted up to 8hr prior to intercourse
- Should not be used w/male condom
- Perfect use 95%; Typical use 80%
- Protects against STDs
66
Sponge
- Contains 1g minoxyl 9
- Barrier protection
- Can be left in for 24hr
- May cause yeast infection if left in place too long
67
Diaphragm
- Used with spermicide
- Barrier method
- Requires prescription
- Must be fitted (and refitted if have pregnancy or gain 10lbs)
- May be placed 20min-6hr prior to intercourse, but MUST be left in place for 6-8 hours after intercourse
- If intercourse within 6hr after the 1st act, then add more spermicide (do NOT remove)
68
Fertility Awareness
- Uses physical S/S and data to determine when ovulation occurs
- "Cycle-Beads"
- Avoid unprotected intercourse b/n days 8-19
- 1st day of cycle is red bead; brown beads are infertile days; white days are fertile days
- Can add or remove beads
- If cycle is not in 26-32d, then this is not appropriate method
69
Cervical Cap
- "FemCap"
- More effective for nulliparous women
- reusable; conforms to anatomy
- Comes in 3 sizes (Small for nullips; medium for women with no vaginal deliveries; large for women with vaginal deliveries
70
Leah's Shield
- Can be purchased online, get from planned parenthood, from provider, or from YAMA
- Reusable
- One-size
- Not held in place by cervix
- Can be used by highly motivated women, breast feeding women, or as back-up method
71
Spermicide (Nonoxynol-9)
- Damages vaginal flora, may increase risk for HIV transmission
- Can protect against STI's
72
Lubricants: Safe w/condoms
- Astroglide, Water/Saliva, Glycerin, I-D lubes, Aloe 9, H-R lube jelly, KY jelly, Prepair, Probe, Aqualube, ForPlay, Gynol, Wet, Cornhuskers lotion, silicone lube, deLube, Spermicide
73
Lubricants: Not safe w/condoms
- Aldara cream, baby oils, cold creams, Eddie oils (olive, Peanut, corn, Sunflower), Massage oils, Mineral oils, head and body lotions, petroleum jelly
74
Emergency Contraception
- Prevents pregnancy after sex
- Not an abortifacient (not same as abortion pill {RU-486/mifepristone})
- No effect on future fertility
75
Emergency Contraception: Methods
- Brand: Plan B One-Step - behind counter >16yo; Rx for 16yo; Rx s (Ella is most efficient oral EC)
- Copper IUD
76
EC: Plan B and Next Choice
- Most effective when taken sooner
- Can be taken up to 5d after unprotected intercourse or contraceptive failure
- Works with progesterone to change chemistry in cervical mucous to prevent fertilization
77
EC: Copper IUD
- Blocks or prevents implantation (Does not prevent fertilization)
- Creates hostile environment in uterus
