Contraception and Sterilization Flashcards
What are the two general contraceptive mechanisms?
- Inhibit the formation and release of the egg
- Imposing a mechanical, chemical, or temporal barrier between the sperm and the egg
What is looked at when comparing the different methods?
- Method failure rate or the rate inherent in method if used correctly
- Typical failure rate or the rate when the method is actually used by the patient
What are the five basic things you have to think about when choosing a birth control?
- Efficacy
- Safety
- Availability
- Cost
- Acceptability
What are the most effective reversible contraception?
- Hormonal contraceptives
What are the different types of hormonal contracetpives?
- Oral contraceptive pills
- Injectable: Depo medroxyprogesterone acetate
- Implantable: etonogestrel rod implant
- Hormone containing IUD: levonorgestrel
- Contraceptive patches
- Contraceptive rings
How do oral contraceptive pills work?
- Suppress the hypothalamic gonadotropin releasing factors with subsequent suppression of pituitary production of FSH and LH
What does progesterone do in OCP?
- Major player
- Suppresses LH and therefore ovulation as well as thickens the mucosa, inhibiting sperm migration and creating unfavorable atrophic endometrium for implantation
What does estrogen do in OCP?
- Improves cycle control by stabilizing the endometrium and allows less breakthrough bleeding
What are the different ways OCPs are packaged?
- Phasic formations: monophasic and triphasic
- Classic packaging is 21 days of hormones with 7 days of placebo; now could see 24 days of hormones and 4 days of placebo
- Also have continuous regimens versus every 3 month cycling
What is the use of progestin only OCPs?
- Primarily used for making cervical mucous thick and impermeable
- Ovulation continues in 40%
- Mainly used in breastfeeding women and women who have a contraindication to estrogen
What must be done in progestin only OCPs due to the low dose?
- Taken at the same time every day starting on the first day of menses (if late for more than 3 hours, then should use backup method for 48 hours)
What are the benefits of OCPs?
- Menstrual cycle regularity
- Improve dysmenorrhea
- Decrease risk of iron deficiency anemia
- Lower incidence of endometrial and ovarian cancers, benign breast and ovarian disease
What are some mild/moderate side effects of OCPs?
- Breakthrough bleeding
- Amenorrhea
- Bloating
- Weight gain
- Breast tenderness
- Nausea
- Fatigue
- Headache
What severe side effects of OCPs?
- Venous thrombosis
- PE
- Cholestasis and gallbladder disease
- Stroke and MI
- Hepatic tumors
What are some details about the patch?
- Apply one patch weekly for 3 weeks
- Can apply anywhere but breasts
- Caution in use in women over 198 lbs
- Side effects are similar to OCPs but greater risk to thrombosis
What is the ring associated with?
- Greater compliance due to once a month use
- Better tolerance since not going through GI tract and less breakthrough bleeding
Who can’t use hormonal contraceptives?
- Women who smoke and are over 35
- Women with personal history of DVT/PE
- Women with history of CAD, cerebral vascular disease, CHF, or migraine with aura, uncontrolled HTN
- Diabetes, chronic HTN, lupus get individualized prescribing
- Women with moderate to severe liver disease or tumors
How often is depo provera injected?
- Every 11-13 weeks
How long are the levels of progestin maintained after a depo provera injection?
- About 14 weeks
When is the depo provera injected?
- Within first 5 days of menses and if not, use a back up method for 2 weeks
What is the MOA for depo provera injection?
- Thickening of cervical mucosa
- Decidualization of the endometrium
- Blocks LH surge and ovulation
What is the efficacy of depo provera?
- Equivalent to sterilization and not altered by weight
What is the relationship between depo provera and bone density?
- Alterations of bone metabolism associated with decreased estrogen levels
- Particular concern in adolescents
- Reversible after discontinuation
What are some side effects with depo provera?
- Irregular bleeding
- Weight gain
- Exacerbation of depression
How does depo provera affect bleeding?
- Decreases bleeding with use and 80% are amenorrheic after 5 years
- Can improve bleeding profile with short term use of estrogen
- Menses can take up to a year to regulate
What are some indications for depo provera?
- Desire for effective contraception
- Need a method with better compliance
- Breastfeeding
- Can use when estrogen is contraindicated
- Women with seizure disorders
- Sickle cell anemia
- Anemia secondary to menorrhagia
- Endometriosis
- Decrease risk of endometrial hyperplasia
What are some contraindications to depo provera?
- Known or suspected pregnancy
- Unevaluated vaginal bleeding
- Know or suspected malignancy of breast
- Active thrombophlebitis, or current/past history of thromboembolic events or cerebral vascular disease
- Liver dysfunction/disease
What is nexplanon?
- Single, radiopaque, rod-shaped implant containing 68 mg etonogestrel, 4 cm long and 2mm in diameter
How long is nexplanon used?
- For 3 years
- Preferred to be inserted in first 5 days of menses and if not then use backup for 7 days after insertion
What is the MOA of nexplanon?
- Thickens cervical mucous
- Inhibits ovulation
What are some side effects of nexplanon?
- Irregularly irregular vaginal bleeding
- Headache
- Vaginitis
- Weight increase
- Acne
- Breast pain
What are the indications of nexplanon?
- Desires a convenient effective method of contraception
- May be used in breastfeeding patients
What are some contraindications of nexplanon?
- Known or suspected pregnancy
- Current or past history of thrombosis or thromboembolic disorders
- Liver tumors or active liver disease
- Undiagnosed abnormal uterine bleeding
- Known or suspected breast cancer
What are some complications with insertion?
- Infection
- Bruising
- Deep insertion
- Migration
- Persistent pain or paraesthesia at insertion site
What are the different types of IUDs?
- Copper T (paragard)
- Levonorgestrel releasing (Mirena/Liletta, Skyla/Kyleena)
What are some risks of an IUD?
- Increased risk of infection within first 20 days post-insertion
- Increased risk of ectopic pregnancy if pregnancy would occur
- If becomes pregnant, should be offered removal if the strings are visible
- Risk of uterine perforation at time of insertion requiring laparoscopy for removal
- Risk of malposition and necessitating hysteroscopy for removal
What are some contraindications of IUDs?
- Breast cancer (levonorgestrel containing only)
- Recent puerperal sepsis or chorioamnionitis
- Recent septic abortion
- Acute cervical infection
- Wilsons disease (Copper T only)
- Uterine malformations
How long is mirena/kyleena used?
- 5 years
How long is liletta used?
- 3 years
What is skyla used for?
- Used for 3 years
- Originally used for nulliparous women
What are the benefits of hormonal IUDs?
- Decrease in menstrual blood loss
- Less dysmenorrhea
- Protection of the endometrial lining from unopposed estrogen
- Convenient and long term
How long can the copper IUD be used?
- 10 years
What is the MOA for the copper IUD?
- Copper interferes with sperm transport or fertilization and prevention of implantation
What are some details about barrier methods?
- Depend on the proper use before, or at the time of intercourse
- Higher failure rate
- Inexpensive
- Require little to no medical consultation
What is special about condoms when compared to all barrier methods?
- Only method with protection against STI
What are condoms made out of?
- Latex
- Non-latex
- Animal membrane
What may decrease risk of condom breakage?
- Reservoir tip
What is a female condom?
- Vaginal liner
- Slippage and breakage rate of 3%
- Recommended to be left in for 6-8 hours after intercourse
What is a diaphragm?
- Small latex covered dome shaped device
- Must be used with a spermicide
- May be inserted up to 6 hours before intercourse and must be left in for 6 to 8 hours after
- Several sizes and must be fitted to the individual by a healthcare professional
What are women more at risk for when they use diaphragms?
- UTI
What is a cervical cap?
- Smaller version of a diaphragm
- Applied to the cervix itself
- High risk of displacement and toxic shock syndrome
- Used with a spermicide
- Left in place for 6 hours after intercourse
What is a sponge?
- Small, pillow shaped sponge containing spermicide
- Dimple in sponge fits over the cervix/opposite side has a loop for removal
- Only one size
- More effective in nulliparous women
- Left in place for 6 hours after
What is the calendar method?
- Calculation of fertile period and avoid sex during that time
- Cycle beads
What is the basal body temperature method?
- Check temperature daily before getting out of bed and will not a 1/2 or 1 degree change at time of ovulation and avoid sex 3 days after
What is the cervical mucus method?
- Women assesses her cervical mucus and notes changes around ovulation and avoid sex for 4 days after peak
- Stretchier it is, the closer to ovulation
What is the symptothermal method?
- Combines cervical mucus and basal body temperature
- Awareness of other signs of ovulation –> cramping, breast tenderness, changes in position or firmness of cervix
What is the use of emergency contraception?
- Woman who have unprotected sex
What are the two types of emergency contraception?
- Plan B
- Ella
What is plan B?
- Progestin only –> 2 pills taken 12 hours apart
- Over the counter for women older than 17
- Must be used within 120 hours after unprotected intercourse
- Failure rate 1.1%
What is ella?
- Ulipristal acetate 30mg
- Indicated for up to 5 days after unprotected intercourse
- Postpones follicular rupture/inhibits or delays ovulation
What is sterilization?
- Highly effective birth control without ongoing expense
- Most frequently used method in US
- All methods prevent sperm from meeting egg
- Should be considered permanent
What do you talk about when counseling patients?
- Permanent
- Address all other options
- Reasons for choosing sterilization
- Discuss procedure
- Screen for indicator of regret
- Possibility of failure and increase risk of ectopic pregnancy
- Need to use condoms for STI protection
What is a vasectomy?
- Occlusion of the vas deferens
- Safer
- Not immediately effective –> complete azoospermia complete within 10 weeks
What are some post operative complications of a vasectomy?
- Bleeding
- Hematomas
- Acute/chronic pain
- Local skin infections
How can a female be sterilized?
- Done by laparoscopy, mini-laparotomy and at time of C section
How is a laparoscopy sterilization done?>
- Small incisions, low rate of complications
- Occlude the fallopian tubes with electrocautery, clips,, bands, or a salpingectomy
What sterilization method has the highest fail rate but the best chance for reversibility?
- Hulka clips
What is a mini-laparotomy?
- Most common approach in the world
- Use small infraumbilical incision in postpartum period or suprapubic incision as an interval procedure
