Contraceptives in primary care Flashcards
LARC=
Long-acting reversible contraception
IUDs and Implants
Standard days method
- Must have regular cycles between 26-32 days long
- Avoid intercourse on days 8-19
- 5% failure rate for perfect use (approx. 15% typical)
Basal temperature method
- Measure temp immediately upon
waking up - Ovulation correlated with 0.6 increase
in temp - Avoid intercourse for 3 days after rise
- 10% typical failure rate
2- day method
- Avoid intercourse if had secretions on current day OR previous day
- 4% failure rate for perfect use (approx. 15% typical)
- Woman must be a secretion master
Lactational Amenorrhea
- Highly effective for women exclusively
breastfeeding during the first 6 months after
childbirth - The infant MUST be eating every 4 hrs during the day and every 6 hrs at night
- Failure rate of 0.9 -1.2% during the first 6 months; Failure rate of 7.4% at 12 months postpartum
- Another method of contraception must be used:
-as soon as menstruation resumes
-the frequency or duration of breastfeeds is
reduced
-bottle feeds are introduced
-baby reaches age 6 months
Condoms failure rates
- Failure rate perfect use= 2 %
- Failure rate typical use= 13%
- Hormone free; no side effects
- Available, inexpensive
- No prescription required
- Recommend for STI prevention (even if on a better contraceptive method)
Cervical Cap
o Small, cuplike diaphragm held in place by suction
o Must be refit each year, postpartum, and with +/- 10lbs
o Wash with mild soap and warm water
o Check it regularly by holding it up to the light
o Must tightly cover the cervix
o Each cervix is different making cervical cap fitting difficult
o Advocates recommend leaving the cap in place for 1-2 days
o However, a foul discharge often occurs after 1
day
o The cap must be left in place for 8-48 hrs
o Failure is most often due to dislodgment of the cap
Diaphragm contraceptive
o Contraceptive jelly or cream should be applied to the rim prior to insertion
o Diaphragm can be inserted up to 6 hrs prior to intercourse
o Diaphragm should be left in place for at least 6-24 hrs post coitus
o Must be refit each year, post partum, and +/- 10lbs
o Typical failure rate is 15-20%
When might a diaphragm cause vaginal wall irritation?
▪ With initial use
▪ With a device that is too tight fitting
▪ Increased risk of UTI from increased urethral
pressure
▪ May alter the composition of the vaginal flora
Combined Hormonal Contraceptives: MOA
- Exogenous estrogen & progesterone
- Suppresses GnRH from hypothalamus
- No FSH and LH release
- No follicle development
- No ovulation
- Thickening of cervical mucus, which becomes
less permeable to penetration by sperm - Thins endometrium- less suitable for implantation
- Impairment of normal tubal motility and peristalsis
CHC Contraindications
- Think estrogen → clot risk
- Contraindcated in
- <21 days postpartum
- Over 35 yo + smoking >15 cig/day (<15 cig/day is level 3)
- Previous hx of clotting disorders, angina, stroke, DVT, PE
- Migraine with aura
- Breast CA
- High 160/100+ hypertension
- Less common: Ischemic heart disease, liver cirrhosis, DM >20 yrs,
nephropathy/retinopathy/neuropathy
CHC Side Effects
o Breast tenderness, nausea, headache- <10% of patients, improve
after 1 mo.
o Weight neutral
o Mood neutral
o Libido neutral
o Breakthrough bleeding
o Blood clots/DVT
Oral Contraceptive types
- Progesterone Only (POP)/Minipill (best for breastfeeding woman)
- Combined Estrogen and Progesterone (COC)
COC Adverse Effects
- Breakthrough bleeding, which typically resolves within three months
- Mood: (likely no effect); libido: (likely no effect)
- Weight gain: no effect
- Increased risk of VTE: varies with estrogen dose and patient factors such as
age, obesity, and smoking status - COC use may slightly delay time to conception; effect is limited to the first
several months after COC discontinuation: Median time to return to menses
= 32 days - “Little to no increased risk of breast cancer” based on observational data.
Any effect appears to be temporary and limited to current or recent (within
five to seven years) COC use - Decrease effect on ovarian and endometrial CA
COC Dosing types
- Monophasic- same dose throughout all active pills
- Triphasic- dose varies throughout active pills
- Continuous- skip placebos; withdrawal bleed at 3, 6, or 12 mos.
per pt preference - Cyclic use- 21 active/7 placebo; 24 active/4 placebo
- Estrogen dose ranges- most are 20 mcg or 35 mcg per pill
COC Interactions: antibiotics
- Antibiotics: rifampin
- In spite of anecdotal reports of COC failure, other antibiotics have not been proven to affect the pharmacokinetics of ethinyl estradiol
COC Interactions: antifungals
griseofulvin
* COC failure
COC Interactions: Antiseizure medications
phenytoin, carbamazepine, barbiturates, primidone, topiramate, felbamate, or oxcarbazepine
* may reduce the efficacy of the hormonal contraceptive
* COCs decrease lamotrigine levels
Vaginal Ring
- Combined estrogen + progesterone (CHC)
- Nuvaring
- Insert for 3 weeks
- Remove for 1 week
- **Insert new ring
- To begin a new cycle, a new ring should be inserted on the same day of the week that the old ring was removed the previous week (ie, if the ring was removed on a Monday, a new ring should be inserted on the following Monday).
- Not removed during intercourse
- Can’t be out for >3 hours
Vaginal Ring Contraindications
- Same contraindications as all CHC
Vaginal Ring Adverse Effects
- vaginitis, vaginal wetness, and leukorrhea
- Same as CHC
Patch
- Combined estrogen + progesterone
(CHC) - Brand names Xulane and Twirla
- Absorbs through skin
- Place patch on buttock, abdomen,
upper outer arm or upper torso - Change patch every week for 3
weeks - Patch free for 1 week
Patch Contraindications
- BMI ≥30 kg/m2
- Due to increased risk for thromboembolism or lower efficacy
(depending on which patch is being used) - Pts on some treatments for Hep C
- Skin hypersensitivity to components of patch
- Same as for all CHCs
Patch Adverse Effects
- Irregular bleeding- improves by 6 months
- Same as all CHC
- Increased clot risk more than COCs- overall estrogen absorption
higher than that of a 35 mcg COC pill - Avoid continued usage method (i.e. skipping period) due to
increased clot risk
Studies show no medical reason to have a monthly _____
withdrawal bleed
Pts can omit placebo dadys
Progesterone Only Pill (POP)
o Great for pts that can’t take estrogen
o Bad for people that can’t remember
o Must take every day at the same time within 3 hr window!
o Typical use failure rate 7%+
POP Mechanism of Action
o thickening cervical mucus to inhibit sperm migration
o suppress ovulation (1/2 still ovulate)
o lowering the midcycle peaks of FSH and LH
o slowing movement of an egg through the fallopian tubes
o thinning the endometrium
o Slynd (drospirenone) inhibits ovulation
POP Contraindications
- Known or suspected pregnancy (pregnancies conceived in individuals taking POPs have not been associated with adverse effects)
- Known or suspected breast cancer
- Undiagnosed abnormal uterine bleeding
- Benign or malignant liver tumors, severe cirrhosis, or acute liver disease
Depo Provera shot
- Progesterone only
- Lasts for 13 weeks
- Patient returns every 12 weeks for
injection - Can cause irregular bleeding
- Most women stop having a period
after their 2nd injection
Depo Provera Adverse Effects
- Risk for decreased bone density
with prolonged use - Weight gain
- Can delay onset of ovulation and
menstruation for 1 yr after
stopping
IUD: Mechanism of Action
- Local inflammatory response- cytotoxic to sperm and ova
- Reduced sperm motility
- Reduced sperm capacitation- last step needed to be able to fertilize egg
- Sperm phagocytosis
- Not an abortifacient
- Progesterone: cervical mucous thickening, endometrial thinning
- Copper: copper increases inflammatory response
Progesterone IUD types
- LNG 52 mg: Mirena, Lilleta; 8 yrs
- LNG 19.5 mg: Kyleena; 5 yrs Skyla
- LNG 13.5 mg: Skyla; 3 yrs
Copper IUD
- Paraguard
- No hormone
- Lasts 10 years (studies show 12+)
- May cause heavier menses
- Contraindications- uterine abnormalities
- Women with current purulent cervicitis or
chlamydial infection or gonorrhea should
not undergo IUD insertion
Women with current ______ should
not undergo IUD insertion
purulent cervicitis or
chlamydial infection or gonorrhea
IUD Advantages: general
- Highly effective (>99 percent), few side effects
- Long acting without regular compliance
- Rapidly reversible
- Reduced costs with long-term use
- Few medical contraindications for most women, including teens and
nulliparous women
IUD Advantages: copper vs. progesterone
- Copper: Avoidance of exogenous estrogen (both IUD types) and hormones, maintain cycle
- Progesterone: reduction in heavy menstrual bleeding, anemia, dysmenorrhea, endometriosis-related pain, endometrial hyperplasia, pelvic
inflammatory disease, and reduction in the risk of endometrial cancer and ovarian cancer; amenorrhea (some women like)
IUD Adverse Effects: copper vs. progesterone
- Partner may feel strings- can trim strings, too short may be pokey
- Copper: may make bleeding volume/frequency and cramping heavier
- worse in first few cycles: improve by 6 mos.
- NSAIDs help
- Progesterone: prolonged bleeding (59 percent), unscheduled bleeding (up to 52 percent), amenorrhea (6 to 20 percent), and spotting (30 percent
IUD Complications
- Expulsion (3 to 6 percent in the first year)- <25 yo, immediately postpartum
- Pelvic inflammatory disease (PID) (1 percent in first 20 days, and 0.5 percent in first 3
to 6 months) - Contraceptive failure (0.1 to 0.6 percent in first year)- <25 yo increased fertility
- Increased risk of ectopic pregnancy if failure does occur
- Perforation (0.01 percent)- post-partum, lactating
Implant contraception
- Nexplanon
- Progesterone only
- Thin, flexible rod
- Inserted in subcutaneous tissue of bicep,
right under skin - Lasts for 3 years
- Contraindicated: current breast cancer,
active liver disease
Implant MOA
- Increase cervical mucus
- Decreases tubal motility – inhibit sperm
migration, inhibiting fertilization - At high doses, progestins also inhibit
gonadotropin secretion, thereby inhibiting
follicular maturation and ovulation
Emergency Contraception
- UPI (unprotected intercourse) from non-use or nonperfect use,
assault - “EC does not interrupt an existing pregnancy; thus, it does not cause
abortion.” - uptodate - Options:
- IUD
- oral pills to ovulation: ulipristal acetate (UPA), levonorgestrel (LNG), and
combined oral contraceptives (COCs)
MOAs of Oral Emergency Contraception
- Ulipristal acetate (UPA)- delays ovulation in pre-ovulatory period and after the LH surge
has started - Levonorgestrel (LNG)- block LH surge and stop ovulation
- Combined oral contraceptives (COCs)
Utah law on abortion
o Currently legal up to 18 wks
o Mandates pt counseling and education module
o Waiting period of 72 hrs after education
o Offer ultrasound at no cost
Abortion types
o Medication: Indicated for up to 70 days of gestation (10 weeks)
o Mifepristone- progesterone receptor antagonist- blocks progesterone
o Misoprostol- prostaglandin- cervical ripener/dilator, causescontractions
o Surgical: In office- suction ( up 14-16 wks) or D & E (16 wks+)
o RH neg pt- Rh immune globulin (per ACOG)
