Contraception - Pearson Flashcards
Method effectiveness
theoretical effectiveness if used perfectly
User effectiveness
actual effectiveness when studied in a non-perfect world
Categories of Contraceptive Options
Natural methods
Barrier methods
Hormonal methods
Emergency contraception
IUD’s
Sterilization
Natural Methods Goal
Avoid intercourse and/or ejaculation around time of ovulation to prevent conception from occurring
***Requires female with regular, predictable cycles
***Both partners dedicated = There may be long periods of abstinence
Timing is everything!
Natural Method Strategies
Withdrawal method
Calendar Method: abstinence from intercourse from 5 days prior to 3 days after ovulation
Basal body temperature
Cervical consistency
Other ovulation predictors
When would a women with a 32 day cycle ovulate?
14 days before day 32
Day: 18
Natural Methods: Ovulation Timing
Ovulation generally 14 days “prior to” 1st day menses
Avoid intercourse 5 days prior and 3 days after ovulation
Determine cycle variability
To determine fertile period:
Subtract 18 days from length of shortest cycle
Subtract 11 days from length of longest cycle
Abstinence during this fertile window
Natural Methods: Basal body temps + Cervical Mucous
Take temp before getting out of bed
Increased temp after LH Surge (follows progesterone level)
Avoid intercourse 5 days prior and 5 days after temp increase
At time of ovulation cervical mucous is: Most abundant, Watery, Has consistency of “egg whites”
Barrier Methods Goal
Prevent sperm from fertilizing egg by use of physical and/or pharmacological barrier
Barrier Methods Strategies
Female condom Male condom Spermicide Diaphragm Cervical cap Sponge
Condoms
BEST STI PROTECTION!
Male condom more effective and more commonly used than female condom
Effectiveness is highly user dependent
Most effective if used with spermicide (nonoxynol-9)
Diaphragm
Requires fitting by a trained physician (bi-manual exam to measure cervical os)
Decreases (but does NOT prevent) STI’s
Use with spermicide
Insert up to two hours before sex
***Must leave in at least 6 hours after (not more than 24 hours total)
Increased rate of UTI’s (puts pressure on urethra)
Latex
Must be re-fit if: more than 10# weight change; pregancy since last fitting; pelvic surgery
Patient must be comfortable doing self exam
Cervical Cap (“bouncer to your uterus”)
Fem Cap – silicone rubber
Must be fit by a trained provider
Comfort with self exam
Must leave in minimum of 6 hours after coitus (max of 48 hours total)
Harder to fit and to use
Option if patient is having problems with increased UTI’s from diaphragm
Question of increased risk cervical dysplasia
Increased risk for toxic shock
Sponge
Discontinued in 1995, re-introduced in 2005
“Today” sponge (also Protectaid and Pharmatex)
Circular disc with 1000 mg nonoxynol-9
Moisten with tap water, insert deep into vagina and leave in place for up to 24 hours
Less effective than other methods
Increased rate of yeast infections, UTI’s and toxic shock syndrome if left in place for extended period
Hormonal Methods Mechanism
Primary mechanism is estrogen-progesterone induced inhibition of the midcycle surge of gonadotropin secretion (as well as FSH/LH), so that ovulation does not occur.
Also makes cervical mucous inhospitable to sperm transit and makes endometrium less hospitable to conceptus (see supplemental slides included for physiology review).
Combined Estrogen / Progesterone Absolute Contraindications
Previous thromboembolic event or stroke
Hx of CAD
Hx of estrogen dependent tumor
Liver disease
Pregnancy
Undiagnosed abnormal uterine bleeding
Smoker over age 35
Migraine headaches w/ neurologic symptoms
Combined Estrogen / Progesterone Relative Contraindications
Obesity
Inherited thrombophilias
Anticonvulsant therapy
Migraine headaches
Hypertension
Depression
Lactation (prefer progesterone only)
Non-contraceptive Benefits of Combined Estrogen / Progesterone
Reduction in dysmenorrea
Reduction in menorrhagia
Reduction of ovarian, endometrial, and colorectal cancers
Improves acne
Improves benign breast disease
Improves osteopenia or osteoporosis
Decreases functional ovarian cysts
Decreases ectopic pregnancy rates
Medications interactions of Combined Estrogen / Progesterone
Antimicrobials (Rifampin)
Anticonvulsants
Anti-HIV
Herbal products (St. John’s Wort)
Medical concerns of Combined Estrogen / Progesterone
Increase in thromboembolic events
Breast cancer risks – controversial and unproven
Cervical cancer risks
Medication interactions
Formulations of Combined Estrogen / Progesterone
Estrogen: Ethinyl estradiol with doses from 10-50 mcg
Progestin:
First Generation: norethindrone, norethindrone acetate, ethynodiol diacetate
Second Generation: levonorgestel, norgestrel
Third Generation: norgestimate, desogestrel
Spironolactone analogue: drospirenone
Latest iteration: dienogest
Side effects of Combined Estrogen / Progesterone
Androgenic side effects: Increased LDL and/or decreased HDL, Acne, Hirsutism
General side effects: Breast tenderness Nausea Headaches Mood changes- anxiety, irritability, depression Irregular bleeding/spotting Weight changes/fluid retention
First and second generation progestins:
Norethindrone- least androgenic 1st/2nd generation progestin. Slight improvement in lipid profile which is different than other 1st/2nd gen. pills. More androgenic than newer progestins
Levonorgestrel is the most widely perscribed. In many formulations including Plan B and extended cycle pills as well.
Third generation progestins:
Norgestimate and desogestrel:
Less androgenic effect = good choice for patients with dyslipidemia, acne or other possible androgenic SE’s
Higher thromboembolic potential = 2-3 X higher than first or second generation progestins
Drospirenone
A spironolactone analogue
Both anti-mineralocorticoid & lower androgenic effects
Potential benefits: Improves weight stability/water retention, Improves other possible androgenic SE’s
May increase serum potassium: Thus contraindicated in certain patients
***New warning regarding VTE (venous thromboembolic) risk
Dienogest
Latest addition
FDA approved 2010
4 phase
Marketed for metromennorhagia
Monophasic
Same fixed dose for three weeks, then placebo week
Biphasic, Triphasic, +
Varying doses through first three weeks then placebo week
Similar SE profile to monophasics
Extended cycle (i.e. Seasonale / Lybrel)
Seasonale & Seasonique: 84 days fixed dose hormones then placebo week
Lybrel (Amethyst): Fixed dose of estrogen/progestin 365 days/yr
Breakthrough bleeding more common, but decreases over time
? Whether increased amount of hormone exposure over time will lead to greater long term side effects
How to prescribe “The Right” pill
Start with low to moderate dose estrogen with most appropriate progestin considering co-morbid conditions
Allow at least 2-3 cycles to assess
Adjust based on side effects
Follow-up based on side effects and co-morbid conditions
Common side effects and what to adjust
Breakthrough bleeding: In first 10 days - increase estrogen, After 10 days - increase progestin
No withdrawal bleed: Do pregnancy test, Continue pills, If patient wants menses to return, can increase estrogen
Typical “hormone related side effects”: Adjust appropriate hormone component
NuvaRing
15 mcg ethinyl estradiol and 120 mcg of etonogestrel daily
Worn intravaginally for three weeks, then out for one
When to start
Transdermal Patch
Ortho Evra - 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily
Change once a week for 3 weeks then one week patch free
How to start
Apply to buttock, abdomen, upper arm or torso (not breast)
Indications for Progesterone Only
Patients who want effective contraception but want or need to avoid estrogen:
- Medical contraidications to combination contraception
- Side effects to combo options that are prohibitory to using
- Lactation/Nursing
- Prefer prescribing schedule
What is the biggest issue to consider when starting patient on Progesterone only methods?
***Irregular bleeding
Non-contraceptive benefits of Progesterone only methods
Eventual reduction of menstrual flow
LITTLE risk of stroke, MI or thromboembolic event
Reduced risk of endometrial cancer and PID (with medroxyprogesterone acetate/Depo-Provera)
What is the most important patient instruction with the Minipill?
Timing critical (within 3 hours) or backup contraception needed
Injectable Progesterone Only
Medroxyprogesterone acetate (Depo-Provera)
IM every 3 months (4x per year)
Start within 5 days of first menstrual day
Irregular periods for year after stopping, variable return for fertility
*Concern with bone health: Evidence for bone resorption and reduction in BMD presumably due to induced estrogen deficiency, Will normalize in healthy subjects once off DMPA, Current labeling recommends limiting use to 2 yrs, If long term use necessary, BMD needs to be evaluated and followed, Calcium and weight bearing exercise recommended
Progesterone Only Implant
Rods implanted subcutaneously under skin- remove once no longer effective
*Implanon/Nexplanon (etonogestrel)
One rod system – effective for 3 yrs
FDA approved
Emergency Contraception Definition
The Prevention of pregnancy within 72-120 hours of unprotected intercourse or failure of a contraceptive method
Emergency Contraception Mechanism
Depending on timing within menstrual cycle, can inhibit ovulation or prevent fertilization
Greater possibility of a post-fertilization effect => Endometrial changes inhospitable to a fertilized ovum
Emergency Contraception: Plan B
Progestin only
Less nausea and vomiting
TWO STEP (originally, now generic)
Gained OTC approval in 2006
One tablet within 72 hours of unprotected intercourse, repeat with second tablet 12 hours late
ONE STEP: Take within 72 hours of unprotected intercourse
Available OTC to ALL AGES since June of 2013!
Emergency Contraception: Ella (Ulipristal Acetate)
The latest to hit the market (FDA approved in 2010)
Can use up to 120 hours or five days post un-protected intercourse
***Requires prescription!
Progesterone agonist/antagonist
SE’s: headache, nausea, abdominal discomfort, dysmenorrhea, fatigue, dizziness
Emergency Contraception: Using Combo pill packs (estrogen + progestin) “Yuzpe method”
Depending on estrogen/progestin dose, taking 2 or 4 pills initially within 72 hours of unprotected intercourse, and repeating dose in 12 hours.
May cause nausea therefore pre-medicate if necessary
Copper IUD (ParaGard)
Mechanism: Pre-fertilization effect; induces foreign body reaction in endometrium, with resulting inflammatory response preventing viable sperm from reaching fallopian tubes
Effective for 10 years
Slow release levonorgestrel (Mirena)
Non-contraceptive benefits: decreases menstrual blood loss and relieves dysmenorrhea
Effective for 5 years
Lower dose levonorgestrel (Skyla)
Effective for 3 years
Marketed & FDA approved in nulliparous women
Copper IUD (Paragard) vs. LNG IUD (Mirena, Skyla) for appropriate candidates
Copper IUD (Paragard) Want more regular periods Want no hormones No h/o dysmenorrhea No h/o menorrhagia
LNG IUD (Mirena, Skyla) OK w/ irregular bleeding OK w/ ammenorrhea H/o dysmenorrhea H/o menorrhagia
IUD Safety issues
IUDs DO NOT cause PID. Incidence is similar to that of the general population
Risk is increased only during the first month after insertion
Preexisting STI at time of insertion, not the IUD itself, increases risk
RULE OUT GC/Chlamydia prior to insertion
***IUDs DO NOT cause infertility
IUD Contraindications
Pregnancy
Congenital or acquired uterine cavity malformation
Acute STD, cervicitis, or vaginitis
Postpartum endometritis or infected abortion within 3 months
Known or suspected uterine or cervical neoplasia
Unresolved abnormal pap smear
Genital bleeding of unknown cause
Acute liver disease
Immunodeficiency states
Hx previously inserted IUD that has not been removed
Allergy to copper (for ParaGard)
Known or suspected breast carcinoma
Artificial heart valves
Wilson’s disease (for ParaGard)
Contraindications or sensitivity to levonorgestrel (for Mirena/Skyla)
Surgical Tubal Occlusion
Laparoscopic procedure
Ligation and section removal, clips, rings, coils, plugs, cauterization
Can do during Cesarean section or postpartum
Main adverse effects are surgery related
If pregnancy does occur, higher risk for ectopic
Post tubal ligation patients at decreased risk for ovarian cancer
Nonsurgical Sterilization Method(s)
Brand name: Essure = microinserts placed into proximal fallopian tubes
Brand name: Adiana = Silicon insert + radiofrequency ***NO LONGER AVAILABLE as of 2015
**Less invasive, but 3 months of backup contraception needed
How long after Vasectomy is sterilization effective?
MUST have semen analysis to assure no motile sperm**
Approx 20 ejaculations or 3 months following
Need to use other form of contraception until cleared
