Contraception Flashcards
Contraception
61 million women in US of reproductive age, 43 million are sexually active and need or want to prevent pregnancy
What is the Average # of years ppl at risk for pregnancy spend trying to prevent pregnancy?
30 years!
Learning Objectives
- Utilize the PATH questions for shared decision making in contraceptive counseling
- Discuss the efficacy, MOA, advantage/disadvantages, and key patient education points for hormonal contraceptive options currently available in the US, including emergency contraception
- Utilize the CDC US Medical Eligibility Criteria fro Contraceptive Use and Selected Practice Recomendations for evidence based contraceptive care
- Accurately communicate risks and Benefits associated with contraceptive use
Women’s Contraceptive Choices and Options are Changing
List variety of options
Pills
Sterilization
Condoms
IUD
Implant
Contraceptive Ring or Patch
Injectiable
Withdrawal
Shared Decision Making
“…clinicians provide patients with information about ___ the (relevant) _____ and help them to identify their _____ in the context of their _____”
all, options, preferences, values
Shared Decision Making
-
Patient Contribution
- Their v____, p_____, g____, and ____ experiences
-
Clinician Contribution
- Assist in ______ patients goals and preferences
- Provide _____/medical information that is: r_____, assimilated/int_____ by the patient
- Patient Contribution
- Values, Preferences, Goals, Past
- Clinician Contribution
- clarifying
- scientific, relevant, integrated
PATH Questions
PA:
T:
H:
Parenting/Pregnancy Attitudes: Do you think you might like to have (more) children at some point?
Timing: When do you think that might be?
How Important: How important is it to you to prevent pregnancy (until then)?
Follow up to PATH Questions
Do you have a sense of what is important to you about your?
Birth control method?
How Well Does Birth Control Work?
- Really Really Well (3)
- <__/100 pregnancies
- Okay (4)
- __-__/100 pregnancies
- Not so Well (4)
- __-__/100 pregnancies
- The Implant, IUD, Sterilization (men and women)
- <1
- The Pill, Patch, Ring, The Shot (Depo-Provera)
- 6-9
- Withdarawal, Diaphragm, Fertility Awareness, Condoms
- 12-24
Birth Control Effectiveness
_____ in 10,000 women in 1 year for No method?
8,500
US Medical Eligibility Criteria: Categories
1 =
2 =
3 =
4 =
No restriction
Advantages outweigh the risks
RIsks outweigh the advantage - or no other methods available
Unacceptable
Summary Chart of US Medical Eligibility Criteria
Overall, very few __ - the point is?
Some 4’s include
i vs. C (Initiating vs. Continuing)
4’s Mass Majority of women can use mass variety of BCM
Distorted uterine cavity, Breast/Endometrial CA, <21 days postpartum, Cirrhosis, GI disease, DVT/PE
US Selected Practice Recommendations for Contraceptive Use, 2016 (SPR)
- When to _____/_____ methods
- _____ pills
- B______ problems
- E___ and tests
- F____ -up
- How to be reasonably certain that a woman is?
- initiate/changing
- Missed
- Bleeding
- Exams
- Follow-up
- Not pregnant
How to Be Reasobly Certain That a Woman is Not Pregnant
Once you are reasonably certain that a client is not pregnant?: YOU CAN?
- Is < 7 days after the ___ of menses
- Has not had sexual intercourse since?
- Has been c_____ and c____ using a reliable method of contraception
- Is < 7 days after spontaneous or induced ______
- Is within __ weeks postpartum
- Is fully or nearly fully _______ , A____orrheic, and <6 months postpartum
QUICK START ANY METHOD
- start
- since start of normal menses
- correctly and consisting
- abortion
- 4
- breastfeeding, amenhorrheic
When to Start Using Specific Contraceptive Methods
The only thing that really requires an exam is?
IUD
How long until protection from pregnancy after initiation?
Immediately =
If >___d since 1st day of cycle
1 week = (4)
Copper-T IUD
5 day
LNG IUS, Implant, Pills/Patch/Ring, Injectable
Pretty much Copper IUD’s work immediately, everything else >5 days
Hormonal Methods
COMBINED HORMONAL METHODS
- Combined _____ (Ethinyl ____ + 1 of several _____)
- ______ (Ethinyl ____ + et_____)
- _____ (Ethinyl ____ + nor_____)
PROGESTIN ONLY METHODS
- Progestin only _____ (norethindrone)
- In_____ (DMPA)
- Im_____ (etonorgestrel)
- LNG _ _ _ (levonorgestrel)
- Pills (estradiol, progestins)
- Ring (estradiol + etonogestrel)
- Patch (estradiol + norelgestromin)
- pills
- Injection
- Implant
- IUS
Etonogestrel, Norelgestromin is progesterone
Situations that you would want progestin only (clots, don’t want estrogen)
First line is combined hormonal methods
Combined Hormonal Contraception (first line)
(3)
How frequently?
MOA:
XULANE Patch - Weekly
Pill - Daily
Ring - Monthly
Ovulation suppression, progestational effects
On the inactive week, there is light bleeding but is not true period bc theres no ovulation
Pill, Patch, Ring MOA
The pill, patch, and ring all have hormones that prevent _____ from releasing ____
The hormones also _____ cervical mucus, _____ sperm from getting to the egg
ovaries from releasing egg
thicken mucus, block sperm
Variety of Pills
- Good Starter Pill =
- Monophasic; __d pill free interval
- __phasic
- ___phasic
- ______- Cycle
- __ pill free interval
- Monophasic 7d pill free interval
- Monophasic 4d
- Biphasic
- Triphasic
- Extended
- No
20mcg monophasic - less change of spotting and regularity
CHC: Contraindications
- Current/Past Hx ______ CA
- Severe C______, viral ____ (acute or flare)
- S_______ > 15/day and age >35
- Known th________ mutations (Factor V Ledien, Protein S deficiency)
- <____d Post partum (breast feeding or not)
- Hx of _ _ _, major _____ w prolonged imm______
- D_____ w/ vascular disease
- G________ disease (medically treated)
- M______ w aura
- Hx of ______ procedures (malabsorptive)
- H _ _, S_____
- _______ Heart Disease, complicaed v_____ heart disease
- Multiple risk factors of ______ disease (older, age, DM, low HDL)
- Some meds: anti_______, ARV, anti______, R______)
- Breast
- Cirrhosis, Hep
- Smoking
- Thrombogenic
- <42 postpartum
- DVT, surgery w immobilization
- Diabetes
- Gallbladder
- Migraine
- Bariatric
- HTN/Stroke
- Ischemic, Valvular
- Cardiovascular
- anticonvulsants, antiparasitics, Rifampin
Assessing for Migraine with Aura
Key Questions: Do the ______ symptoms start before the ___, last up to an ____, and resolve before the HA begins? Yes to ALL = positive for aura
- Most auras are ______ -(99%); duration? followed by HA
- At least one of the following:
- Visual symptoms: flickering _____, sp____, l____, or ____ of vision in ______ of visual field
- (NOT generalized spots, blurry vision, or light sensitivity)
- Sensory symptoms: “____ and _____” or n______
- D______ speech disturbance
- Visual symptoms: flickering _____, sp____, l____, or ____ of vision in ______ of visual field
Visual before HA, 1 hour
- Visual
- lights, spots, lines, loss MIDDLE
- pins and needles, numbness
- Dysphagic
Patient Education for CHC
ACHES: Danger Signs
A: Abdominal cramping (severe)
C: Chest pain (severe)
H: Headache (new onset, severe)
E: Eyes (visual disturbances)
S: Severe leg pain, severe mood change
Hormonal Contraception: Communicating Risk
-
____/____/____
- E and P: ______ levesl of procoagulant factors and f______; _____ anticoagulant levels
- Incidence is ____ in reproductive age women, with or without OC use
- _______ > OC use at all ages
- Post ______ > pregnancy > COC user
-
______ Cancer
- No link: ____ dose pills
- Possible link: ____ dose (50mcg), triphasic, some progestins (ethynodiol diacetate)
-
VTE/STROKE/MI
- increase, fibrinogen, decrease
- low
- Smoking
- Post partum
-
Breast CA
- low
- high
Progestin-Only Oral Contraceptives (POPs)
MOA:
- No ______ week
- Disadvantages (2)
- Advantage (1)
60% of women - ovulation suppression, progestational effects
- No placebo week
- Timing must be within 1hr qd, Bleeding irregularities
- Can be used when estrogen is contraindicated (ie PP and breastfeeding)
Possible SE of CHC
- Progestin Related:
- Estrogen Related:
- E or P:
- Increased appetite, breast tenderness, mood/depression, decreased libido, fatigue, hair growth/acne
- N/V, elevated BP, Chloasma
- HA, Bleeding irregularities
CHC Non-Contraceptive Benefits/Advantages
- Decreased Cancer Risk (C_____, O_____, E______)
-
Decreased
- Endo_____, Aden_____
- P _ _
- E______ Pregnancy
- Benign ______ Disease
- A____, H_______
- O______ Cysts
- ________ Symptoms or _______ Symptoms
- Colon, Ovarian, Endometrial
- Endometriosis, Adenomyisis
- PID
- Ectopic
- Breast
- Acne, Hirsuitism
- Ovarian
- Menstrual, Perimenopausal
DEPO Injection
- Generic Name:
- Brand Name:
- Route:
- Frequency:
-
MOA: ______ suppression 2/2 inhibition of _______ secretion and ______ effects
- ___ Folliculogenesis or FSH/LH surge
- ______ Cervical mucus, ______ of endometrium, _____ tubul motility
- Depot Medroxyprogesterone Acetate (DMPA, “DEPO”)
- Depo Provera
- IM or SQ
- Every 3 months
- Ovulation, gonadotropin, progestational
- NO
- Thickens, Thining, Slows
- Ovulation, gonadotropin, progestational
DEPO Provera
Advantages
- Non_____
- Use when ______ is CI
- Non-contraceptive _____: _____ disorders; _____ Cell
- Can use post-_____, b______
DisAdvantages/SE
- _____ gain
- Menstrual _______
- Delayed return of _____ (1-2 yrs)
- Requires office ______
- _____ density
- Nondaily
- estrogen
- benefits, seizure, sickle
- partum, breastfeeding
- Weight
- irregularities
- fertility
- visit
- Bone
Key Points About DMPA
- Structured _______ increases _______ rates
- What returns to baseline after cessation?
- What to encourage in the meantime?
- ACOG and WHO support ____ term use
- Weight _____: Diet/Exercise
- ______ irregularities can be medically managed
- counseling, continuation
- Bone mineral density
- Calcium, Exercise
- long
- Gain
- Bleeding
Progestrone Only Injection: Managing Bleeding Irregularities
- Irregularities could be?
- Frequent/Heavy Bleeding Management:
- R/O _______, In_____, Neo_____, An_____
- _______ (Ibuprofen, mefanamic acid)
- Add _____ 1-2 mos
- Amenorrhea, Infrequent, Frequent, Heavy
- Management
- Pregnancy, Infection, Neoplasia, Anemia
- NSAIDS
- CHC’s
Lactational Amenorrhea (LAM)
MOA: Increased _______ ______ the HPO Axis
-
3 conditions MUST be met
- Exclusive _______
- A_______
- < ___ mos post partum
- Advantages: No ___, No ____, No ___ resource poor areas
- Disadvantages: Limited use per _____ for use and ____ 6 mos _____
Prolactin inhibits HPO Axis
-
3 conditions
- Breastfeeding
- Amenorrhea
- <6 mos
- Cis, Cost, SES
- conditions limit use, max 6m
Barrier Methods
(5)
- Pt Counseling
- _____ for use
- Opportunity to practice in _____
- ***______ _______***
Condoms/Insertive Condoms
Diaphragm (requires filling)
Contraceptive Gel
Sponge
Cervicle Cap (3 sizes)
- Counseling
- Instructions
- Office
- EMERGENCY CONTRACEPTION
If only using barrier methods, we want pts to have emergency contraception on hand
Fertility Awareness Methods: APPs Available
-
OPTIONS
- _______ (Rhythm) method
- Cervical ______ Monitoring
- Basal Body ________
- S____-Th_____
-
ADVANTAGES/DISADVANTAGES
- __In______, no pro_____, supp____
- No ____ effects, No ____indications
- Acceptable for those who prefer no _____; adherence to ______ ideologies
- Cumber____, in_____
- Comm_____
- Have to use other method during _____ days or ab_____
-
OPTIONS
- Calendar: predicts ovulation based on when occurred in past cycles
- Mucous: fertile mucous: wet, slippery/2day method: secretions today or yesterday? yes to either = fertile
- Temperature: daily T, rise indicates ovulation occurred
- Sympto-Thermal: combines mucous, T, and other sx
-
ADVANTAGES/DISADVANTAGES
- __Inexpensive, procedure, supplies
- SE, CI
- hormones, religious
- Cumbersome, inaccurate
- Committment
- fertile, abstain
Spermicide
MOA: ______ and ______ sperm ______
- Advantages:
- L______, ____ to use
- Disadvantages:
- Films and suppositories require ___ min for activation
- M____
- Potential _____
- Pt ED:
- Place close to ___/___
- Follow package ______
- Use with _____ method
- _____ ______!*
Barrier and Slows sperm motility
- Advantages:
- Lubricant, easy
- Disadvantages
- 15
- Messy
- Irritant
- Pt ed
- cervix/os
- instructions
- barrier
- Emergency Contraceptions!* on hand
Emergency Contraception
Primarily progesterone -> when brain gets this message -> ovulation is not going to occur bc brain thinks it already did
Key Points: Contraceptive Counseling is Primary Care
Dual Protection =
CONDOMS are the only thing that protect from STDs -> so whatever they are using for contraception also need condom!
