Contraception & Sterilization Flashcards
Hormonal contraceptives provide the most reversible contraception. What are the options?
OCPs
Injectables (DepoProvera)
Implantable (Nexplanon)
Hormone-containing IUDs (Mirena, Skyla, Liletta, Kyleena)
Contraceptive patches (OrthoEvra)
Contraceptive rings (Nuvaring)
MOA of combination OCPs
Suppression of hypothalamic GnRH with subsequent suppression of pituitary production of FSH and LH
The progesterone component is the major player — suppresses LH and therefore ovulation, as well as thickening cervical mucous
The estrogen component mainly improves cycle control by stabilizing the endometrium and allowing less breakthrough bleeding
MOA of progestin-only OCP
Primarily makes cervical mucous thick and impermeable
Ovulation continues in about 40% of users
In what pt populations are progestin-only OCPs used?
Breastfeeding women
Women with a contraindication to estrogen
Why must progestin-only OCPs be taken at the same time every day?
Because of the low dose — if pt is more than 3 hours late taking the pil then they should use a backup method for 48 hrs
Benefits of hormonal oral contraceptives
Menstrual cycle regularity
Improve dysmenorrhea
Decrease risk of iron deficiency anemia
Lower incidence of endometrial and ovarian cancers, benign breast, and ovarian disease (cysts)
Adverse effects of OCPs
Breakthrough bleeding (more likely in first 3 months, then it usually gets better)
Amenorrhea
Mild AEs include bloating, weight gain, breast tenderness, nausea, fatigue, headache
Serious AEs include venous thrombosis, pulmonary embolism, cholestasis and gallbladder disease, stroke and myocardial infarction, hepatic tumors
MOA of the OrthoEvra patch
Transdermal patch containing estrogen and progesterone — same effect as combination OCPs
In what pt populations should the patch be used with caution?
Women > 198 lbs
Those at risk of thrombosis
The patch as the same side effects and precautions as OCPs, except a greater risk of ______
Thrombosis
MOA of vaginal ring (nuvaring)
Combination estrogen and progesterone in ring inserted in vagina for 3 weeks, then removed for 1 week (greater compliance)
Can be removed for up to 3 hours without affecting efficacy
Why is the vaginal ring considered better tolerated than OCPs?
Not systemically absorbed through GI tract; also less breakthrough bleeding
What patient populations CANNOT use combination contraceptives?
Women >35 y/o who smoke cigarettes
Women with personal hx of thromboembolic event (pts with family hx need to be evaluated for inherited thrombophilia)
Women with hx of CAD, cerebral vascular disease, CHF, migraine with aura, uncontrolled HTN
Women with moderate to severe liver disease or liver tumors
Women with POORLY CONTROLLED diabetes, chronic HTN, systemic lupus erythematosus [may use if good control and adequate f/u]
The primary injectable hormonal contraceptive is an IM injection of depot medroxyprogesterone acetate every 11-13 weeks. This maintains contraceptive level of progestin for about 14 weeks. What is the MOA and efficacy?
Thickens cervical mucous, decidualization of the endometrium, blocks the LH surge and ovulation
Efficacy is roughly equivalent to that of sterilization and is not altered by weight
Black box warning associated with depo-provera
Alterations of bone metabolism d/t decreased estrogen levels — of particular concern in adolescents
If used for more than 2 years, should consider alternative method
AEs of depo-provera
Irregular bleeding (decreases with use, often become amenorrheic with time; can improve bleeding profile with short term use of estrogen add-on)
Menses can take up to a year to regulate after discontinuation (important consideration if pt wants to be able to get pregnant right away)
Weight gain
Exacerbation of depression
Indications for use of 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 (decreased number of crisis)
Anemia secondary to menorrhagia
Endometriosis
Decreased risk of endometrial hyperplasia
Contraindications to use of depo-provera
Known or suspected pregnancy
Unevaluated vaginal bleeding
Known or suspected malignancy of breast
Active thrombophlebitis, or current/past hx of thromboembolic events or cerebral vascular disease
Liver dysfunction/dz
Nexplanon is an etonogestrel-containing implant used for 3 years, preferred to be inserted in first 5 days of menses and if not, using back up contraception for 7 days after insertion. What is its MOA?
Thickens cervical mucous
Inhibits ovulation
Side effects of nexplanon implant
Irregularly irregular vaginal bleeding
Headache
Vaginitis
Weight increase (3-5 lbs, which is less than that seen with depo provera injection)
Acne
Breast pain
Indications for nexplanon implant
Desires convenient effective method of contraception
May be used in breastfeeding pts
Contraindications of nexplanon implant
Known or suspected pregnancy
Current or past hx of thrombosis or thromboembolic disorders
Liver tumors or active liver disease (poorly metabolized)
Undiagnosed abnormal uterine bleeding
Known or suspected breast cancer (only absolute)
Complications with nexplanon implant insertion
Infection, bruising, deep insertion (may lead to migration), persistent pain or paresthesia at insertion site
Risks with IUDs
Increased risk of infection within first 20 days post-insertion
Increased risk of ectopic pregnancy
Risk of uterine perforation at time of insertion requiring laparoscopy for removal (more common in postpartum period)
Risk of malposition and necessitating hysteroscopy for removal
If pregnancy does occur, removal within first trimester to decrease risk of spontaneous abortion
Contraindications to IUDs
Breast cancer (contraindication to levonorgestrel-containing only)
Recent infection — including puerperal sepsis, septic abortion, and/or cervical infection
Wilson’s disease (contraindication to copper T only)
Uterine malformations (uterine septums, fibroids, significant enlargement, etc.)
What are the levonorgestrel IUDs and their overall efficacy?
Mirena/Kyleena may be used for 5 years
Liletta is used for 3 years
Skyla is used for 3 years and was designed originally for nulliparous women (smaller diameter)
Highly effective — pregnancy rate of 0.2%
Benefits of hormonal IUDs
Decrease in menstrual blood loss (up to 50%)
Less dysmenorrhea
Protection of endometrial lining from unopposed estrogen
Convenient and long-term
The Copper T IUD (paragard) can be used for up to 10 years. What is its MOA?
Copper interferes with sperm transport or fertilization and prevention of implantation
Diaphragms are small latex covered dome shaped devices that must be used with ________; may be inserted up to 6 hours before intercourse and must be left for 6-8 hrs after (no more than 24 hrs). There are several sizes and they must be fitted by a healthcare professional. Women who use diaphragms are more likely to get ________
Spermicide; UTIs
Smaller version of the diaphragm applied to the cervix itself, used with spermicide and left in place for 6 hours after intercourse; carries high risk of displacement and TSS
Cervical cap (Femcap)
Small, pillow-shaped barrier containing spermicide with only one size that is more effective in nulliparous women, left in place for 6 hours but no more than 30 hours (risk of TSS)
Sponge
What are the fertility awareness methods for contraception? (Natural family planning)
Calendar methods — calculation of fertile period and avoid sex during that time
Basal body temp method — check temp daily before getting out of bed and avoid sex for 3 days after 0.5 to 1 degree change
Cervical mucous method — avoid sex for 4 days after stringy changes noted
Symptothermal method — combines cervical mucous and basal body temp method
MOA of emergency contraceptive pills
Prevent ovulation and fertilization
Plan B is progestin-only (levonorgestrel); must be used w/i 120 hours after unprotected intercourse
Ella is ulipristal acetate; indicated for up to 5 days after unprotected intercourse — postpones follicular rupture/inhibits or delays ovulation
Method for male sterilization, including benefits and risks
Vasectomy - occlusion of the vas deferens
Benefits: safer, more easily performed, less expensive, and easier to reverse than female sterilization
Risks: postoperative complications like bleeding, hematomas, acute/chronic pain, local skin infection; also not immediately effective — complete azospermia typically obtained w/i 10 weeks
Methods of female sterilization
Done by laparoscopy, mini-laparotomy, or hysteroscopy at time of c-section
[the mini-laparotomy is the most common approach throughout the world, uses small infra-umbilical incision in postpartum period or suprapubic incision as an interval procedure]
Laparoscopic methods for female sterilization utilize small incisions and have a low rate of complications. They work by occluding the fallopian tubes — what are the different methods for doing this?
Electrocautery — fast, increase risk of thermal injury to surrounding tissues, poor reversibility, greater risk of ectopic if failure occurs
Clips — hulka clips are most reversible method but have greatest failure rate; filshie clips have lower failure rate d/t large diameter
Bands — intermediate reversibility and failure rate, higher incidence of postop pain, increased risk of bleeding
Salpingectomy — increasing in use d/t possibility of decreasing ovarian cancer risk
The essure system utilized a ______ approach to tubal ligation that is no longer recommended d/t ______
Transcervical; post-op pain
