Contraception and sterilization Flashcards
Why is lactational amenorrhea a bad idea? When is it an ok-ish idea?
Ovulation occurs before the return of menstruation
Most effective when it’s the baby’s ONLY source of nutrition and even then, use for 6 months tops.
Condoms advantages?
The ONLY contraceptive protection against HIV
85-90% effective
How does the diaphragm work?
Spermicidal jelly then leave in place for 6-8 hours AFTER intercourse. If you wanna go again before that window, put more spermicide in the vagina WITHOUT removing the diaphragm.
Must be fitted by doctor.
Replace every 2 years OR if your body weight changes by 20%.
Side effects of diaphragm?
Bladder irritation–> UTIs
Toxic shock syndrome
How does cervical cap work?
Held in place by suction and need to use spermicidal jelly.
Fitted by doctor.
NOT POPULAR IN USA.
Dislogement is way it fails.
Can be inserted up to 6 hours before intercourse and left in place for 1-2 days…but foul discharge often develops after first day EW OMG EW.
Spermicides?
Nonoxynol-9 and octoxynol-9; both disrupt cell membranes of sperm and act as a mechanical barrier to cervical canal.
- 30 min before sex at least so it can disperse thru vagina
- Irritates
- When used alone efficacy is 70-75%; with condoms its 95%
- MORE SUSCEPTIBLE TO STI’s due to the irritation
IUD factoid?
Most widely used method of reversible contraception in the world!
Hormonal contraceptives are #1 in the USA
How do IUDs work?
Kill sperm, prevent fertilization.
- Elicit a sterile inflammatory response.
- Reduce tubal motility
- Progesterone in Mirena thickens the cervical mucus and atrophies the endometrium to prevent implantation
- Copper in Paragard hampers sperm motility
Contraindications for IUD use?
- Known or suspected pregnancy
- Abnormal vaginal bleeding (undiagnosed)
- Acute cervical, uterine, salpingal infection
- Copper allergy or Wilson’s disease (Paragard)
- Current breast cancer (Mirena)
Relative contraindications:
- Prior ectopic (though we place it anyway)
- History of STIs in past 3 months
- Uterine anomaly or fibroid distorting cavity
- Current menorrhagia or dysmenorrhea (ParaGard)
Do you need antibiotic prophylaxis for IUD insertion? What needs to be done before?
NO!
Screening for GC
There is a slight risk of insertion-related PID. This is controversial bc supposedly it could be from contamination of endometrial cavity at the time of INSERTION.
Basically, IUDs do not CAUSE PID.
How long do you have to wait after a spontaneous or induced first trimester abortion?
You DON’T!
How long do you have to wait until placement after pregnancy?
6 wks
How do OCPs work?
SUPPRESS OVULATION
Put the body in a pseudo-pregnancy state by interfering with pulsatile release of FSH and LH.
“Period” bleeding is withdrawal bleeding
Secondary mechs: thicken cervical mucus; change endometrium to make it unsuitable for implantation
Monophasic (Fixed-dose) combination pills
Fixed doses of E and P
Which monophasics are 3 months? 1 year?
Seasonique is 3 months. Lybrel is one year.
Multiphasic (dose varying combination pills?
Vary the dosage of E&P to mimic the menstrual cycle.
Progestin-only OCPs aka “the minipill”
Small daily dose of progestin.
Thicken the cervical mucus
TAKE AT THE SAME TIME EACH DAY.
NO HORMONE-FREE DAYS (take them every day, no iron pills)
Side effects of the progestin-only OCP?
Irregular cycles!
Breakthrough bleeding, follicular cysts form more often, acne.
Who should get a progestin-only OCP?
Women who can’t take estrogens like over 35 year old smoker, htn, CAD, collagen vascular disorder, lupus, migraines, thromboembolism history.
What are the absolute contraindications to COCs?
- Thromboembolism/pulm embolism
- CAD
- CVA
- Smokers over 35
- Breast/endometrial cancer
- Unexplained vaginal bleeding
- Abnormal liver function
- Severe hypercholesterolemia
- Severe hypertriglyceridemia
What are the RELATIVE contraindications to COCs?
- Uterine fibroids
- Lactation
- Diabetes
- Sickle cell disease
- Kidney disease
- Htn
- Lupus
- Age over 40 and high risk for vascular disease
- Migraine headaches
- Seizure disorders
- Elective surgery
What are all the combined estrogen and progesterone contraceptive methods?
- Combined OCPs
- Transdermal patch aka. Ortho Evra
- NuvaRing
What are all the progestin only contraceptives?
- Minipill (an OCP)
- Depo-Provera (injected intramuscularly every 3 months) aka DMPA
- Nexplanon (implanted for 3 years)
What’s in Ortho Evra?
The patch releases 150mg progestin, norelgestromin and 20 mg ethinyl estradiol every day
Major risk of Ortho Evra?
DVT AND PE RISK IS EVEN HIGHER THAN FOR COCs!
Same mech as OCPs
Besides the contraindications for E&P contraceptives, who ELSE should NOT get Ortho Evra?
> 198 lb women aka 90kg
How does the NuvaRing work?
Placed in vagina for 3 weeks, removed for 1 (can also continuously use to not get a period)
Advantage of NuvaRing?
One size fits all
Can leave in place for sex
LOWER TOTAL HORMONES
Note: if removed for intercourse (which is ok), replace within 3 hours.
In what 3 ways does Depo-provera work?
1) Suppresses ovulation
2) Thickens cervical mucus (can’t implant)
3) Reduces tubal motility
Side effects of Depo Provera?
- Irregular menstrual bleeding (main reason women stop it)
- Higher rates of amenorrhea compared to Mirena (50% within first year)
- Reversible decrease in bone mineralization when used >2 years
Advantages of Depo?
- Highly effective
- Injection every 3 months
- Reduces risk of endometrial cancer and PID
- Treatment for menorrhagia, dysmenorrhea, endometriosis, endometrial hyperplasia
- GREAT FOR PPL WITH OTHER MEDICAL ILLNESS (like E&P contraindication ones)
Depo should be used with caution in…
Depression
Mood disorders
PMS and PMDD
Disadvantage of Depo?
Delay in return to ovulation (6-18 months)
DON’T GIVE TO SOMEONE WHO WANTS TO GET PREGNANT IN LIKE A YEAR.
Nexplanon
Effective 24 hours after placement.
Suppresses ovulation, thickens cervical mucus.
Does NOT affect patient’s bone density, weight, or mood!
(Good for depression)
Side effects of nexplanon?
Irregular and unpredictable light bleeding
Emergency contraceptive types?
- Pill
- Copper IUD
- Progesterone receptor modulators (Ulipristol)
Which types of ECP’s are preferred?
Levonorgestrel methods (THIS IS A PROGESTIN, not an E&P)
Plan B one step is first line for the pills, but Paragard IUD is the most effective overall.
Like, Plan B is PROGESTIN ONLY.
When to take ECP
First dose within 72 hours after.
Some are 2 doses, others are one.
Mech of action of ECP?
Depends on point in the cycle!!
Inhibits ovulation, interferes with fertilization and tubal transport, prevents implantation, or causes corpus luteum to regress
Side effects of ECP?
Nausea 50%
Vomiting 20%
Headaches, dizziness, breast tenderness.
GOOD THING IS THAT THE CONTRAINDICATIONS FOR OCPS DON’T APPLY FOR ECPs!
How do the selective progesterone receptor modulator ECPs work?
Delay ovulation (follicular rupture) and inhibit endometrial implantation
Mifepristone is closely related drug but it is NOT for emergency contraception!
Who can’t take Ulipristal?
Breastfeeing and pregnant (obvi) bc it’s abortifacent.
Disadvantages of Ulipristal?
It’s prescription only; need a pregnancy test first.
But mild side effects, yay.
Tubal sterilization methods (3)
1) Postpartum
2) Laparoscopic tubal ligation
3) Hysteroscopic tubal occlusion (Essure)
How does Essure work? Advantage?
Microinserts are introduced into the UTERINE portion of the fallopian tubes.
Outer spring coil molds to the shape of the fallopian tube to anchor the micro insert.
Sterilization is complete over ~12 wks.
OFFICE PROCEDURE.
Need backup BC for 3 months after
Follow up for Essure?
Do an HSG at 3 months to confirm coil location and complete tubal occlusion.
Which tubal sterilization method is best?
Essure most effective; ligation immediately following birth also.
Risk of regret highest in who for tubal sterilization?
Women under 30, REGARDLESS of parity.
Which methods are most effective if interval procedure is done?
Falopie rings best in women under 28; Electrocautery and Falopie rings have equal efficacy in women over 28.
What is vasectomy?
Ligation of the vas deferens
Why is vasectomy good?
Safer, simpler, more effective than females sterilization
When is vasectomy fully effective?
In 6-8 wks.
50% of patients develop anti sperm antibodies
