Contraceptive Options Flashcards
generally- what is contraception
Method, procedure, device, behavior, or medication that allows for the prevention of pregnancy and for planning the timing of pregnancy
describe actual vs theoretical effectiveness
- actual: efficacy when forgetfulness or improper use occurs; conditions of typical use
- theoretical: efficacy when consistent and reliable use occurs; conditions of perfect use
Hormonal Contraceptives (HCs)
generally describe
- contain synthetic analogs of the reproductive hormones (estrogen +/- progesterone)
- Act synergistically to produce anti-ovulatory effects (uppression of GnRH)
- Affect the endometrial lining (↓ bleeding and pain associated with menstruation)
Hormonal Contraceptives (HCs)
available types
- Oral contraceptive pills (combined and progestin-only)
- Transdermal patches
- Vaginal rings
- Progestin injections
- Subdermal implants
- Intrauterine devices
factors when choosing contraceptives
- Ease of access and use (dosing regimen, required procedures)
- Affordability
- Efficacy rate
- Reversibility or permanence
- Prevention of STIs
- Adverse effects
- Medical contraindications
- Ethical and moral beliefs
least to most effective BC methods
Least
- spemicide, fertility tracking based methods
- diaphragm, condoms, pull out, sponge, cervical cap
- breastfeeding, shot, pill, ring, patch
- vasectomy, sterilization, IUD, implant
Most
Hormonal Contraceptives
chemistry review- general
Both estrogens and progestins are steroidhormones, making them fat-soluble and highly protein-bound
Hormonal Contraceptives
chemistry review- ethinyl estradiol (EE)
- Very similar in structure to natural estradiol
- Addition of an ethynyl group (C2H) makes it significantly more stable than estradiol
- ↑bioavailability as compared with estradiol when taken orally
- ~50% (natural estradiolis only ~5%)
- Only estrogen used in hormonal contraception (variable doses)
Hormonal Contraceptives
Chemistry Review- Progestins
- Similar in structure to progesterone
- Addition of a triple bond in most cases makes the molecules more stable
Androgenic effects:
* Most are derived from testosterone → have stronger androgenic effects than natural progesterone
* Less androgenic: norgestimate, etonogestrel, and desogestrel
* Antiandrogenic activity: drospirenone (spironolactone analog)
* Multiple different progestins are used in HCs → different properties of the progestins are responsible for different side-effect profiles of various HCs
Hormonal Contraceptives
MOA- Estrogen
- Both estrogens and progestins cause an antiovulatory effect (Used together, this effect is SYNERGISTIC)
- Inhibits FSH release → prevents the selection and maturation of the dominant follicle = No ovulation
- Stimulates endometrial proliferation if given without progestin (↑ a patient’s risk for certain cancers) → ethinyl estradiol is NOT given alone
Hormonal Contraceptives
MOA- Progestin
- Inhibits LH surge that is necessary for ovulation by decreasing the pulse frequency of the GnRH
- ↑ Cervical mucus viscosity → inhibits sperm transport into the uterus
- ↓ Cilia motility in the fallopian tube
Effects on the endometrium:
* Natural progesterone is required to make the endometrium healthy forpregnancy
* Androgenic nature of synthetic progestins thins the endometrial lining, making it unsuitable for implantation
* All hormonal contraceptives are “progestin-dominant” → overall endometrial effect of hormonal contraceptives is endometrial atrophy
PREVENTS PREGNANCY
Hormonal Contraceptives
how does progesterone prevent pregnancy?
it provides negative feedback at the hypothalamus to decrease the pulse frequency of the GnRH; this in turn reduces the secretion of FSH and decreases the secretion of LH
Combined Oral Contraceptive Pills (OCPs)
describe how these are classified
number of phases
- Monophasic: Each pill contains fixed amounts of ethinyl estradiol and progestin
- Biphasic: Variable amounts of ethinyl estradiol and a form progestin
- Triphasic: Variable amounts of ethinyl estradiol and a form progestin
By Progestin
* 1st generation (estranes): EE/norethindroneacetate
* 2nd generation (gonanes): EE/norgestrel, EE/levonorgestrel
* 3rd generation: EE/desogestrel, EE/norgestimate
* 4th generation/unclassified: EE/drospirenone (Yaz)
OCPs
describe use/meds
- Low-dose ethinyl estradiol (10-35 mcg) preferred to high-dose (50 mcg)
- must take daily
- initiation on the first day of the menstrual cycle or first Sunday after the onset of the cycle
- NOTE: Patients using the first Sunday start are not protected from pregnancy in the first 7 days and an additional form of birth control will be needed
Pregnancy rate
* 0.3% with perfect use
* 8% with typical use
Contraindications
* SBP > 130 or DBP > 80
* pregnancy
* thorough family/soc/personal hx
OCPs
non-contraceptive benefits
- More regular, lighter, shorter menses
- Improvement of dysmenorrhea symptoms (cramping)
- Decreased risk of ovarian, endometrial, and colon cancers
- Improvement of acne and unwanted hair growth
- Functional ovarian cysts are less likely
- Lower frequency of uterine myomas with taking COCPs > 4 years
- Reduce the frequency of migraines associated with menstruation (NOT for use in patients with migraines with aura
Transdermal Patch
describe use of
- Small, square adhesive patch worn on the skin (Buttocks, chest (not the breasts), upper back or arm, or abdomen); should rotate application sites
- Releases ethinyl estradiol and norelgestromin or levonorgestrel daily which is absorbed through the skin
- Hormone blood levels are more constant with the patch than with OCs
- Weekly administration: 1 patch applied per week for 3 weeks in a row, no patch for 1 wk then menses occurs
Less effective in women > 90 kg
Vaginal Ring
describe use of
- Flexible, transparent, plastic ring that is placed in the upper vagina
- Releases ethinyl estradiol and a progestin (etonorgestrel = NuvaRing; segesterone = Annovera) that is absorbed through the vaginal tissues
- adverse: increased vag discharge
Ring types
* Month-long (NuvaRing): 1 ring inserted for 3 weeks/21 days; removed for 7 days…menses occurs, replaced each month
* Year-long (Annovera): 1 ring inserted for 3 weeks/21 days; removed for 7 days…menses occurs, replaced once a year
Efficacy and adverse effects are similar to those of OCs, but adherence is better with rings because they are inserted monthly rather than daily
Hormonal Contraceptives
methods of administration
Cyclic Administration
* Pills/patches/rings containinghormonesare typically used for 21–24 days in a row (ovulation and endometrial growth are suppressed during this time)
* Hormone-free interval (HFI): Typically 4–7 days in length, Pill packs include placebo pills, Patch/ring is withheld during this time, Withdrawal bleeding during this time
Prolonged Cyclic Administration
* Hormones taken for up to 84 days (12 weeks) followed by a 4–7-day HFI
* Withdrawal bleeding typically 4 times per year
* Hormone use can be extended beyond 12 weeks if tolerated by the patient
Continuous Administration
* Hormones are taken continuously, with no HFI
* Monophasic pills, the patch, and vaginal ring can all be administered this way
* Higher risk of breakthrough bleeding owing to prolonged endometrial atrophy
Progestin Only Pills (POPs)
describe use of
- Daily administration at the same time every day
- Packs: 28 active pills or 24 active/4 inactive
- Can be inconsistent in preventing ovulation
- Hormone: norethindrone or drospirenone
- often called mini pills
- recommend to start on day 1 of meses
Pregnancy rate
0.3% with perfect use
9% with typical use
Progestin Injections
describe us of
- Sightly more effective than progestin-only pills
- 1 injection (IM or SC) every 3 months or 13 weeks; Can be given up to 2 weeks late (15 weeks from the last injection)
- Hormone: depot medroxyprogesterone acetate (DMPA)
- Takes an average of 10 months to conceive following discontinuation of the injections
- adverse effect: bone loss (reversible
In the 3 months after the first injection
* 30% have amenorrhea
* 30% have spotting or irregular bleeding
* After 2 years, ~70% have amenorrhea
Pregnancy rate
* 0.2% with perfect use
* 6% with typical use
Subdermal Contraceptive Implant
Generally describe
- 4 cm, single-rod implant inserted through a trocar subdermally in the upper arm
- Releases etonogestrel at a rate of 50 mcg/day to prevent ovulation, thicken cervical mucus, and thin the uterine lining
- Lasts 3 years
Nexplanon
Intrauterine Device
describe use of + types
- T-shaped, plastic device that is inserted into and left inside the uterus
- Works to prevent fertilization by thickening cervical mucus and thinning the uterine lining
- adverse: pelvic pain, endometritis, uterine perf, device expulsion (> risk in copper), ectopic pregnancy if pregnancy occurs
Types:
* Copper IUD (ParaGard): Lasts 10 years
* Hormonal IUDs contain levonorgestrel
* Mirena & Liletta(52 mg of levonorgestrel): last 7 years - Mirena and 6 years - Liletta
* Kyleena(19.5 mg of levonorgestrel): lasts 5 years
* Skyla(13.5 mg of levonorgestrel): lasts 3 years
Emergency Contraception
describe use of
- Contraception administered after unprotected intercourse (UPI) or if birth control fails
- regular menses and a single act of intercourse → 5% risk of pregnancy
- irregular menses and a single act of intercourse → 12-20% risk of pregnancy
- Acts to preventfertilizationand/or implantation; if pregnancy test is positive, cannot end the pregnancy
Commonly used emergency contraception regimens:
* Insertion of a copper IUD
* Insertion of a levonorgestrel 52 mcg IUD
* Oral regimens (plan B)
Emergency Contraception
use of IUD as EC
- provide ongoing contraception
- Not impacted by body mass index or risk ofpregnancy(UPI midcycle, multiple episodes of UPI)
Options:
* Copper IUD (more effective than oral methods, pregnancy rate is 0.1%)
* Levonorgestrel 52-mg IUD
Emergency Contraceptives
oral methods
- Less effective in individuals with BMI > 30 and individuals at higher risk ofpregnancy (when UPI occurs)
Options:
* Taken as a single course as soon as possible after UPI
* Ulipristal acetate 30 mg PO once (can be used up to 5 days after UPI) (preg rate 1.5%)
* Oral levonorgestrel 1.5 mg PO once (can be used up to 3 days after UPI) (preg rate 2-3%)
* combined EC pills taken at higher doses than normal as soon as possible after UPI (often causes nausea and vomiting)
Time in the menstrual cycle that EC is administered and the patient’s BMI are major factors in the likelihood of pregnancy!
adverse effects of HC
Risk of venous thromboembolism (VTE):
* ↑ risk with ethinyl estradiol > progestins and is dose dependent
* Ethinylestradiolshould be avoided in people at risk for VTE
* Progestin-only methods are recommended
Abnormal bleeding (unscheduled bleeding (spotting), prolonged bleeding)
* More often associated with progestin-only methods
* Estrogen tends to stabilize bleeding patterns
* Worst with etonogestrel implant
Ovarian cysts
* Associated with progestin-only methods
* Ethinyl estradiol generally suppresses cyst formation
Hromonal Contraceptives
adverse effects
- breast sx: fibrocysticc breast changes, mestalgia (pain), decreased milk production during breast feeding (ethinyl estradiol only)
- wt gain: progestin injections (avg < 5 lbs); due to changes in appetite not metabolism
- other sx: n/v, HA, migraine, decreased libido, melasma
Hormonal Contraceptives
contraindications of ethinyl estradiol HCs
- pregnancy
- current, hx of, or risk factors for VTE (< 21d postpartum, coagulopathies, smoking if > 35 yrs, SLE)
- CV disease (HTN, ischemic heart disease, valvular disorders, peripartium CM)
- migraines w/ aura in women > 35 yrs
- undiagnosed abnormal uterine bleeding (AUB)
- current/past breast cancer
- liver disease (cirrhosis, hepatocellular adenoma, liver cancer)
- DM > 20 yrs or w/ -pathy (neuro, nephro, retino)
- solid organ transplantation w/ complication
- hyperTGs
Hormonal Contraceptives
contraindications of progestin only HCs
- pregnancy
- current/past breast cancer
- undiagnosed AUB
- liver disease
- IUDs: uterine anomalies, PID, endometritis, acute vaginitis
drug interactions
- Metabolism of COCPs and POPs is increased by any drugs that increaselivermicrosomal enzyme activity, resulting in reduced contraceptive efficacy
Meds
* Anti-Convulsants: penytoin, carbmazepine, barbiturates, topiramate, felbamate, oxcarbazepine, lamotrigine
* Anti-bx: rifampin, rifabutin
* anti-viral: NRTIs, protease inhibitors
non-hormonal contraceptives- describe
- Has no effect on the reproductive hormones
- Each method has a different mechanism and extent of efficiency in preventingpregnancy
Includes:
* Physiological methods - high failure rates
* Barrier methods
* Copper IUD
* Surgical methods (permanent) - highly effective
Physiologic Methods
withdrawal/coitus interruptus method
- A traditional method that has been in use for centuries
- Complete withdrawal of the penisfrom thevaginaprior to ejaculation
- Preventsfertilizationby preventing the sperm from reaching the egg, however, pre-ejaculate from the cowper gland may contains sperm
- High failure rate
Physiologic Methods
periodic abstinence- Rhythm method
- Based on the woman’smenstrual cycle
- The cycle has to be regular
- the greater the variance in cycle length, the longer the abstinence required
- High failure rate
Interval of abstinence:
* Subtract 18 from the shortest of the previous 12 cycles and 11 from the longest
* Example: cycle varies from 26 to 29 days…abstinence is required from day 8 through 18 of each cycle
Physiologic Methods
Symptothermal method
- Periodic abstinence determined by signs and symptoms that correlate with different hormone levels as indicators for an approximate timeframe when ovulation is likely to occur
- high failure rate
Basal Body Temperature (BBT)
* Based on an ↑ in body temperature at rest (by 0.5–1.0 degrees) during and after ovulation
Cervical Mucus
* End of the follicular phase/ovulation - the mucus is increased, thinner, clearer, and elastic (Peak levels of FSH and LH; ↑ estrogen at the end of the follicular phase)
* Luteal phase – mucus is thick and sticky (↓ FSH and LH; ↑ progesterone)
Physiologic Methods
lactation amenorrhea
- Mechanism: Infant’s suckling leads to increased prolactin production → increased milk production
Effects:
* ↓ Gonadotropin-releasing hormone
* Delay in ovulation
Only viable for women who are/have:
* Exclusivelybreastfeeding
* Within the 1st 6 months postpartum
* Not seen a return of their menstrual period (amenorrhea)
Barrier Methods
condoms
- Create a physical barrier between the male and female genitalia and secretions
- Best to use with a water-based or silicone lubricant to prevent tearing and breaking
Effects:
* Protects againstpregnancy
* ↓STIrisk (including HIV)
* Protects againstHPVinfections → ↓ risk of cervical neoplasia
Types:
* Male condoms
* Female condoms
barrier methods
male condoms
- Reversible male contraceptive method
- Use: A thin sheath with a reservoir at the tip and a base ring; Applied to an erectpenisbefore penetration
Advantages:
* Does not affect fertility
* Protection from STIs
* Easily accessible and inexpensive
* Minimal side effects
Disadvantages:
* Latex allergy is a contraindication
* Potential ↓ in sensitivity
* Slippage or breakage can occur
Pregnancy rate at 1 year:
* 2% with perfect use
* 18% with typical use
barrier methods
female condom
- Use: A pouch with an inner and an outer ring, The inner ring holds the condom in place, The outer ring remains outside and covers the perineum
- Should be used no more than 8 hours before intercourse
Advantages:
* Does not affect fertility
* Protection from STIs
* Does not require medical evaluation or special fitting
* Minimal side effects
* Offers protection to women whose partners refuse to use a male condom
Disadvantages:
* Allergy to nitrile is a contraindication
* Not as readily available as male condoms
* May be difficult to insert and remove properly
* Possibility of: Semen to spill when removing, Breakage
Pregnancy rate at 1 year:
* 5% with perfect use
* 21% with typical use
barrier methods
spermicides
Mechanism:
* Provide a chemical barrier by killing or immobilizing sperm
* Most spermicides contain nonoxynol-9
Use:
* Can be used alone or with other barrier methods
* Form: foams, creams, gels, films, and suppositories
* Should be placed in thevaginaclose to the cervix at least 10‒15 minutes (no more than 1 hour) before sexual intercourse
* Effective for 1 hour after insertion
* Reinsertion is required for each act of intercourse
Advantages:
* Does not affect fertility
* Does not require a prescription
* Easy to use
Disadvantages:
* Should be used with other barrier methods due to limited efficacy
* Does not protect against STIs
* Can cause vaginal irritation or dryness → ↑ risk of HIV transmission
Pregnancy rate:
* 18% with perfect use
* 20% with typical use
barrier methods
contraceptive sponge
Mechanism:
* Foam disk impregnated with nonoxynol-9
* Acts as both a barrier device and spermicidal agent
Use:
* Moisten with water before insertion into thevagina→ activates spermicide
* Should cover the cervix
* Can be inserted up to 24 hours before intercourse
* Should be left in place for ≥ 6 hours after intercourse
* Cannot be worn for longer than 30 hours
* No need to be replaced for additional acts of intercourse
Advantages:
* Available without a prescription or special fitting
* Does not affect fertility
Disadvantages:
* Less effective than other barrier methods
* Can cause vaginal irritation or dryness → ↑ risk of HIV transmission
* May be difficult to remove (can break apart during removal)
* Associated with ↑ risk oftoxic shock syndrome(rare)
Pregnancy rate:
* 12% for nulliparous women
* 24% for multiparous women
barrier methods
diaphragm
Mechanism:
* A reusable, dome-shaped rubber cup with a flexible rim that fits over the: Cervix, Upper and lateral wall of thevagina
* Provides a physical barrier to sperm
Use:
* Usually with a spermicide (applied before insertion)
* Ideally, placed < 1 hour before intercourse
* Should remain in place for 6‒8 hours (no more than 24 hours after intercourse)
Advantages:
* Does not affect fertility
* Can be placed at a convenient time before intercourse
* Durable and reusable (can last up to 2 years)
Disadvantages:
* Can be difficult to use properly
* Requires a prescription
* Does not prevent STIs
* Should be avoided during menses due to the risk of infection
* can become dislodged
Adverse Effects:
* vaginal discomfort/irritation
* UTIs
* increased risk UTIs
Pregnancy Rate
* 6% w/ perfect use
* 12% w/ typical use
barrier methods
cervical cap
Mechanism:
* Resembles a diaphragm but is smaller and more rigid
* Provides a barrier against sperm entering the cervix
Use:
* A spermicide should always be used
* Must be inserted before intercourse
* Should remain in place for ≥ 6 hours after intercourse (no more than 48 hours)
Advantages:
* Does not affect fertility
* Can be placed at a convenient time before intercourse
* Durable and reusable (can last up to a year)
Disadvantages:
* Can be difficult to use properly
* Requires a medical visit and fitting
* Refitting required after childbirth, weight gain, and weight loss
* Does not prevent STIs
* May cause vaginal irritation
* Associated with urinary tract infections
Pregnancy rate:
* 12% for nulliparous women
* 24% for multiparous women
barrier methods
vaginal pH regualtor gel
Mechanism:
* Gel that lowers the vaginalpHto 3.5‒4.5 (even in the presence of alkaline semen) → immobilizes sperm
Use:
* Used as an alternative to spermicide
* Comes in single-dose, prefilled vaginal applicators
* Should be applied within one hour of intercourse
Advantage:
* Lower risk of vulvovaginal and penile irritation compared to spermicide
Disadvantages:
* Requires a prescription
* Typically used in conjunction with other products (condoms, diaphragms)
* FDA approved, but newerproduct with less data regarding efficacy
barrier methods
copper IUD
Mechanism:
* T-shaped polyethylene device with a fine copper wire wound around the stem (and often the horizontal arms) and inserted into the endometrial cavity
* Causes local, sterileinflammationand releases small amounts of copper → affects sperm mobility and egg implantation
Use:
* Inserted by a clinician
* STItesting is done just prior to insertion
* Can remain in place for 10 years
* Can be used foremergency contraceptionif placed within 5 days of unprotected intercourse
Advantages:
* Highly effective
* Provides long-term efficacy
* Convenient
* Does not affect fertility
* Minimal systemic effects
* Can be used as emergency contraception
* May be removed at any time
Disadvantages:
* Requires a medical visit for placement and removal
* Does not protect against STIs
* Side effects: Heavy menstrual bleeding, Severe cramping
barrier methods
copper IUD
contraindications, complications, preg rate
Contraindications:
* Current STIs orpelvic inflammatory disease(PID)
* Anatomic abnormalities that distort the uterine cavity
* Unexplained vaginal bleeding
* Knowncervical cancerorendometrial cancer
* Pregnancy
* Wilson disease or copper allergy
Complications:
* Expulsion rates are < 5% within the 1st year after insertion
* Uterine perforation
* Ectopic pregnancy
* ↑ Risk of PID
Pregnancy rate:
* 0.5%‒0.8%
* Higher failure rate in younger women
Surgical Methods
tubal ligation
Mechanism:
* Disrupts the patency of the fallopian tubes
Can be accomplished surgically by:
* Cutting and excising a segment of the fallopian tubes
* Complete removal of the fallopian tubes (salpingectomy)
* Fallopian tube closure via: Ligation, Fulguration, Various mechanical devices (plastic bands or rings, spring-loaded clips)
Indications and contraindications:
* Indicated for women with a desire for permanent contraception (should be given extensive counseling)
* No absolute contraindications
Risk factors for complications should be assessed:
* Severeobesity
* Prior abdominal surgery
* Previous PID or abdominal infections
* Comorbidities
Complications:
* Death: 1–2 per 100,000 women
* Hemorrhage or intestinal injuries: approximately 0.5% of women
* Failure of tubal occlusion: up to 2-3% of women
* Ectopic pregnancy: approximately 30% of pregnancies that occur after tubal occlusion
Surgical Methods
vasectomy
Mechanism:
* Disrupts the patency of the vas deferens
* Sterility requires about 20 ejaculations after the procedure and should be documented by 2 sperm-free ejaculations
Can be accomplished surgically by:
* Transection of the vas deferens
* Ligation or fulguration of the ends
Indications:
* Indicated for men with a desire for permanent contraception (should be given extensive counseling)
Contraindications:
* Scrotal hematoma
* Infections
Complications:
* Hematoma (≤ 5%)
* Sperm granulomas (inflammatory response to sperm leakage)
* Epididymitis
* Post-vasectomypainsyndrome
* Spontaneous re-anastomosis (usually occurs shortly after the procedure)
preg rate 1.1% at 5 yrs
