Contraception Options Flashcards
When you think of risks vs benefits on contraception. What is the big complication to consider?
The woman’s risk for cardioembolic events.
They are: HTN, age>35, and smoker
What are some excessive estrogenic effects that may result from taking contraception?
Dysmenorrhea Nausea Cholasma CVA DVTR Thromboembolic disease PE Telangiectasias Hepatic adenoma/adenocarcinoma Cervical changes Breast tenderness (secondary to increased size)
What are some excessive progestational effects?
Breast tenderness Transient HTN Depression Fatigue Decreased libido Decreased duration in menstrual bleeding Increased appetite
What are some excessive androgenic effects?
Hirsutism Acne Oily skin Edema Increased libido
If you had a patient deficient in estrogen, when would you expect them to have?
What about if she was deficient in progesterone?
Deficient ESTROGEN: continuous spotting/bleeding, atrophic vaginitis, no withdrawal bleeding, decreased duration in menstrual bleeding, breakthrough bleeding on days 1-9 of cycle
vs.
Deficient PROGESTERONE: Breakthrough bleeding on days 10-21 of cycle and delayed menses
You have a patient who is on a combination pill and she comes to see you complaining of menorrhagia, N/V, headache, bloating, and irritability. What do you do?
You know these symptoms indicate she is getting too much estrogen and too little progesterone so you lower her dose of estrogen and increase her dose of progesterone.
Who are the best candidates for progestine-only OCPs?
Those with migraine headaches and who are breastfeeding… or who have some contraindication for combined OCPs
True or False. It is okay for women with a family history of breast CA to take a combination OCP?
FALSE!
What should you know about OCPs and antibiotics, anticonvulsants, warfarin, and certain oral hypoglycemic agents?
Antibiotics and anticonvulsants decrease the efficacy of OCPs
OCPs decrease the efficacy of warfarin and hypoglycemic agents (oral and insulin)
True or False. OrthoEvra releases 60% more estrogren than OCPs?
True.
**Increased risk of serious cardioembolic events
Ortho Evra Patch Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines?
**<1-2%
**Prevents ovulation, similar to OCPs
**Once per week for 3 weeks, easily reversible
**Site reactions, prog/estrog S/Ss, no STI protection
**Reduced effectiveness in women >198 lbs/90 kg
**Same contraindications as OCPs
**If off for >24 hrs, need to restart 4-week cycle and use
back up method
When would you instruct your patient to start/place the OrthoEvra patch?
On the first day of her menstrual cycle or the Sunday after the first day of her menstrual cycle
What do you tell the patient if she patch falls off/or is off for more than 24 hours?
Put on a new patch (start the 4 week calendar over again) and use a backup method
Which contraceptive method decreases HDL, has the potential to reduce bone density with long-term use, when discontinued may have a delayed return of fertility of up to 1 year, and may be helpful in reducing pain from endometriosis?
Depo-Provera (long-acting reversible contraceptive/LARC)
If pregnancy planned within a year, should not be given
There is a 2 week grace period for injections. If longer than 2 weeks, pregnancy test needs to be done.
Which contraceptive methods require informed consent?
Implanon and IUDs
Which IUD can remain in the uterus for 10 years?
ParaGard/Copper IUD
Which IUD can remain in the uterus for 5 years?
Mirena/Progestin-only IUD
What are the two absolute contraindications to use of an IUD
Pregnancy
Active, recurrent, or recent PID including gonorrhea and
chlamydia
*An IUD can be inserted 4-8 weeks postpartum
What do you do if a patient tells you she can’t find her string?
Abdominal US to ensure IUD is still in place
How long must a diaphragm/cervical cap be left in place after intercourse?
6 hours
After how much weight loss or weight gain must a cervical cap/diaphragm be refitted?
20 lbs
What are the top 3 least effective contraceptive methods (with the greatest failure rate)?
Spermicides (21%)
Diaphragm (18%)
Male condoms (12%) vs female condoms (21%)
If using an IUD as emergency contraception, when should it be inserted?
Within 5-6 days of having intercourse
*It is 99% effective vs Plan B which is 85% effective
What is the most common side effect of Plan B?
N/V… so prescribe or advise anti-emetic use
If using the basal body temperature method for contraception, when should you avoid intercourse?
2-3 days before the expected drop in temperature (indicates ovulation) to approximately 3 days following the rise (rises after ovulation d/t progestin)
What are combined pills?
Alter the dosage of estrogen and progestin throughout the cycle and contain:
Estradiol - Most common estrogen preparation
What is a mini pill?
Progestin only, not as effective as combination pills
What is effectiveness of the pill?
Typical 1st year failure rate is 3%
Typical 1st year failure rate in age <22 yrs is 4.7%
MOA of the pill
Estrogenic effects:
*Ovulation inhibited by suppression of FSH/LH
*Implantation inhibited by alteration of endometrium
*Ovum transport is accelerated
*Luteolysis may occur as estrogen causes progesterone
levels to fall
Progestational effects:
*Thick cervical mucus interfers with sperm transport
*Capacitation may be inhibited
*Ovum transport may be slowed
*Implantation is hampered by suppression of
endometrium
*Ovulation inhibited by hypothalmic-pituitary-ovarian
disturbances
Advantages of the pill include…
Excellent protection against unwanted pregnancy Safe for most women Decreased menstrual cramps and pain Less menstrual blood flow Improvement in facial acne Woman controls own fertility Excellent reversibility and easy to use
Non-contraceptive benefits of the pill include…
- Decreased menstrual cramps and pain
- Less menstrual blood flow
- Improvement in facial acne
S/S of combination of estrogen excess and progesterone deficient
Dysmenorrhea Menorrhagia N/V Headache Irritability Bloating/edema Syncope
Absolute contraindications for OCP use.
Hx of thromboembolic disorders Hx of CVA CAD Known or suspected breast CA Pregnancy Liver tumor or impaired LFTs Previous cholelithiasis during pregnancy Undiagnosed, abnormal uterine bleeding
NuvaRing Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines?
**<1-2%
**Releases synthetic estrogen and progestin, prevents
ovulation, convenient, once a month, fewer mood
swings compated to OCP, possible shorter/lighter
periods
**Increased vaginal discharge/infection, may worsen
depression, no STI protection
**Age >35, smoker, uncontrolled HTN, hx of MI, CVA, DVT,
PE, etc.
**Inserted once a month, left for 21 days
**If it slides out, needs to be put back in within 3 hrs,
back up method needed if left out for more than 3 hrs
Depo-Provera Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines?
PROGESTIN ONLY
**<1%
**Suppresses FSH and LH, thickens cervical mucosa,
alters endometrium
**Highly effective, long acting, convenient, prolonged
amenorrhea possible, decreased anemia, decreased
cramps and ovulation pain/endometrial pain
**No estrogen related side effects
**Possible reduction in risk of PID and CA
**Delayed return of fertility (up to 1 year)
**Injection Q3 months -2 week grace period-
**Decrease in HDL
**Possible reduction in bone density with long-term use
Nexplanon Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines?
PROGESTIN ONLY
- *<0.01%
- *Same as other progestins
- *Good for 3 yrs
- *Same as other progestins
- *Requires informed consent
- *Implant may be slightly visible
- *Expensive
IUD Types? Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines?
**Copper-releasing (ParaGard) - 10 yrs
**Progestin-releasing (Mirena) - 5 yrs
**1-3%
**Immobilizes sperm and interferes with migration
**Local foreign body inflammatory response
**Same as other progestins
**Can prevent Asherman’s Syndrome
**Pain/cramping, up to 45% removals due to pain
**Increased menstrual bleeding
**Pregnancy - spontaneous abortion up to 50% if IUD
left in uterus and ectopic pregnancies occur in 5%
**Spotting/bleeding/hemorrhage/anemia
**Expulsion, up to 10% in first year
**Lost IUD string
**PID - highest risk in first 6 weeks after insertion
**Requires informed consent
Danger signs late menses, abdominal pain/dysparunia,
fever, chills
Diaphragm/Cervical Cap Typical failure rate? MOA? Advantages? Disadvantages? Management/Prescriptive guidelines?
- *18%
- *Barrier against sperm transport
- *Use with spermIcide cream or gel
- *May provide some STI protection when used with spermicide
- *Possible increased risk of UTI, vulvovaginitis
- *Allergy to rubber/latex/spermicide
- *Check for holes periodically
- *AVOID OIL-BASED LUBES
- *Leave in for 6 hrs following sex, instill spermicide in vagina for repeated intercourse
Spermicides
Typical failure rate?
Advantages?
Disadvantages?
- *21%
- *Purchased OTC
- *May cause skin irritation
Condoms
Typical failure rate?
Advantages?
Disadvantages?
- *male 12%
- *female 21%
- *protection against STIs
- *Allergy to rubber or spermicide
- *They break
- *Natural skin condoms have no protection against STIs
- *NO OIL BASED LUBES
Emergency Contraception
Types?
Effectiveness?
OTC levonorgestrel (Plan B) No prescription if over 17 yrs Should be taken within 72 hours NOT THE ABORTION PILL Only 85% effective
IUD - Copper releasing
Inserted within 5-6 days, almost 99% effective
Sterilization
Permanent Female 1:400 failure rate Male 1:600 failure rate Female tubal ligation Male vasectomy
Natural family planning
Typical failure rate?
First year failure rate 20%
Calendar Method
**Record serial cycles, identifying longest and shortest
cycles
**Determine fertile phase by subtracting 18 days from
shortest cycle (earliest day of fertility) and 11 days from
longest cycle (latest day of fertility)
**Abstain from sex during this time frame
Basal Body Temp Graph
BBT
**Record daily BBT prior to rising in AM over 3-4 month
period
**Temp drops 12-24 hrs prior to ovulation and rises
following ovulation due to production of progesterone
**Avoid intercourse from 2-3 days prior to expected drop
to approximately 3 days following the rise
Cervical Mucus Test
Billings Testy
**Record changes in cervical mucus (Spinnbarkeit) over 3-
4 month period
**Notice when mucus changes from scant and thick
amounts to thin, with increasing Spinnbarkeit
**Abstain from time of mucus change until approx 4 days
after change, mucus resumes thickness
Symptothermal Method
Method that uses both the basal body temp and cervical mucus techniques
Lactational/Amenorrhea Method
Pro-longed breast feeding
**Pt relies on breastfeeding for natural family planning as
breastfeeding often delays the onset of ovulation and
menstruation for approx 6 months
