Exam 1 Flashcards
ovarian cycle consists of
follicular phase, ovulation, luteal phase
dev/release of oocyte in ovary and follicular maturation
uterine/endometrial cycle consists of
menstrual phase
proliferative phase
secretory phase
preps the endometrium for implantation of fertilized ovum and shedding of lining when implementation does not occur
follicular phase
Day 1-7
starts last few days of last period until release of mature follicle; produce ovum in prep for fertilization
ESTROGEN DOMINANCE
ovulatory phase
Day 14
LH surge, ovulation happens 10-12 hrs afterwards
progesterone lvls increase = suppress new follicles
luteal phase
Day 15-28
if no conception = follicle luteinization; corpus lute forms then regresses and levels rapidly fall, allowing FSH/LH rise again for new cycle
PROGESTERONE DOMINANCE
menstrual phase
Day 1-5
Menses
proliferative phase
Day 6-14
rising lvls of estrogen & endometrial tissue develops
secretory phase
Day 14-28
rising progesterone shifts to secretory tissue
gland tortuous, thicker,
Day 21-27 prep uterus to accept fertilized ovum
estrogen function
proliferates and thickens endometrium which stimulates progesterone receptors & increases blood flow to endometrium
causes + feedback to make LH surge and FSH
progesterone function
causes endometrium to differentiate and secrete proteins that aid in survival and implantation of early embryo
decreases proliferative effects of estrogen on endometrium
what happens to endometrium when estrogen and progesterone w/drawal
sloughing / menstrual cycle
estrogen side effects
gall bladder dz
bone growth / density
reduced vascular tone
blood clot
progesterone benefits
protects fibrocystic breasts, prevent breast cancer, maintain secretory phase of endometrium / prevent cancer
abnormal uterine bleeding
Issue of timing, amount, or volume of bleeding
Variations of bleeding is from higher or lower lvls of prog or estrogen in body
Single variations in bleeding can be __ and due to ___
normal
exercise, activity, travel, time zones, emo stress, unknown
Reassurance!
frequent cycle days
occurs < 24 days between cycles
normal cycle days
24-38 days
hallmark of luteal phase is shift from
estrogen dominant in follicular phase to progesterone dominance in luteal phase
once corpus lute regresses from no pregnancy, these hormones decline
estrogen and progesterone
In menstrual phase, there is a phase called
ischemic phase which is destruction of functional zone
uterus sheds lining = drop in estrogen and progesterone
in mid to late follicular phase, estradiol levels increases causing the cervical mucus to become
clear, thin, profuse
cervix swells, softens, os dilates
after ovulation, progesterone causes the cervix to become
firm, os closes, mucus scant and thick
infrequent cycle
> 38 days
prolonged bleeding in days
> 8 days
typical bleeding in days
4.5 - 8 days
shortened bleeding in days
< 4.5 days
women of reproductive age with amenorrhea or AUB is…
pregnant until proven otherwise!!
post menopausal women (no period for 1 year) that bleeds is..
NEVER NORMAL!
think endometrial hyperplasia or endometrial cancer until proven otherwise
menorrhagia
heavy prolonged menstrual flow
aka heavy menstrual bleeding
oligomenorrhea, hypomenorrhea
oligo = infrequent cycles hypo = light/scant flow
polymenorrhea, hypermenorrhea
frequent cycles or profuse or prolonged bleeding
metrorrhagia
metro = irregular
irregular bleeding
metromenorrhagia
irregular, heavy bleeding
IMB/intermenstrual bleeding
intermenstrual bleeding
bleeding in between periods
post coital bleeding
bleeding after intercourse
PALM-COEIN is abbreviation for evaluating what?
PALM is for what etiologies?
COEIN is for what etiologies?
abnormal bleeding
palm is for anatomical/structural etiologies
coein is for hormonal / functional abnormalities of AUB
P (PALM-COEIN)
polyps - overgrowth of endometrial glandular tissue
endocervical polyps
Fleshy, pedunculated lesion, often on a stalk
red/purplish in color (vascular)
Pear shaped
Seen in speculum exam
May cause post-coital
if > 3cm/ irregular shape = bx
endometrial polyps
Overgrowth of endometrial tissue
Benign
Smaller polyps, resolve spontaneously
seen only on US
A (PALM)
Adenomyosis
Endometrial tissue from uterus burrows deep in uterine muscle in wall
knifelike stabbing pain, dysparunia
from multiple pregnancies, spontanous abortions, uterine surgery, c section, or DNC
L (PALM)
Leiomyoma or uterine fibroids
Fibro-muscular tumors that are benign
Arise from smooth muscle in uterine wall
Estrogen and Progesterone promote growth
After menopause = degenerate and resolves
Leading indicator of hysterectomy
“pelvic fullness”
firm, nontender and irregular on bimanual exam
can contribute to: infertility, preterm labor, spontaneous abortion, abn labor, rectal pressure
dx with US
M (PALM)
Malignancy and hyperplasia
Overgrowth of endometrial glands = precancerous atypical adenomatous hyperplasia and into endometrial cancer
> 50 yrs, average dx is 61
C (COEIN)
coagulopathy
Any family hx of bleeding sx’s
Clotting disorders that explain abnormal bleeding, r/t clotting deficiencies (thrombocytopenia, liver dz, platelet deficiencies)
Von Willebrand disease
Von Willebrand disease
congenital acquired clotting factor def
Always r/o if young women with heavy bleeding w/ cycles since they began period/menarche
a/s with easy bruising, prolonged bleeding after dental procedures, surgery, PP hemorrhage
Work-up: PT, PTT, platelet count
Treatment: anticoagulation therapy may also be considered in abnormal uterine bleeding
Diagnosis: hematologic testing; referral to hematology
3 things seen with von willebrand dz
O (COEIN)
Ovulatory dysfunction
age (peri - menopause; amenorrhea)
dx after r/o everything else
causes: endocrine, luteal defects, adrenal hyperplasia, renal/liver dz, PCOS, excessive exercise, acute stress
E (COEIN)
endometrial
increasingly longer and heavier menses in predictive cyclical patterns
Pelvic inflamm dz and PP bleeding
a/s with placental fragments after delivery or endometritis or post abortal issues
I (COEIN)
Iatrogenic Conditions
medications (anticonvulsants, dilantin, digoxin, progestin in contraceptives), IUD, PID, complications with IUD (perforation and expulsions), chronic steroid use, opiates
N (COEIN)
Not classified
Other chronic conditions that are not infectious
Do not fit in any other categories
For ex, AV malformations
hwo do you evaluate AUB?
first R/O pregnancy
determine where bleedig is coming from: cervix, uterus, vagina, sore, rectum?
anovulatory?
regular/irreg? other sx’s?
AUB: physical exam
BMI >30
Skin: acne, hirsutism, acanthosis nigricans, bruising
Breast: galactorrhea (nipple discharge)
Abdomen: abdominal pain, masses
Pelvic/speculum exam: lesions, S/S infection, foreign body
Can determine if uterine blood by looking at blood exiting thru cervical os into vaginal
Source of bleeding: cervical, vaginal, anal?
Bimanual exam: uterine ovarian enlargement, masses
Can be perianal bleeding
AUB: labs
Urine HCG (r/o preg)
CBC to check H&H and platelet count
TSH and prolactin if amenorrhea or any anovulatory bleeding is suspected
PT, PTT fibrinogen if coagulopathy is suspected
endometrial biopsy only tells us
if it’s uterine hyperplasia or endometrial cancer
when is endometrial biopsy warranted
in premenopausal women with prolonged irregular bleeding, unexplained post-coital bleeding, or intermenstrual bleeding, or those with endometrial cells noted on pap smear, premenopausal with anovulatory abnormal bleeding or glandular cells on their pap smear
required for post-menop with abnormal uterine bleeding and those on hormone therapy with abnormal bleeding
Any unscheduled bleeding on hormone therapy that lasts > 3 months after starting combined OC or with endometrial stripe that > 5mL on US
when to do a pelvic ultrasound
anovulatory and no response to tx
or any anatomic defect suspected (saline infusion sonogram, helps identify polyps and fibroids)
when is amenorrhea abnormal
PCOS, anatomic, abnormalities in HPO axis/hormones
primary amenorrhea
no menses by 14 yrs + no secondary sex characteristics ( pubic)
OR
no menses by 16 regardless of characteristics
secondary amenorrhea
No menses in previously normal menstruating for at least 3 cycles or 6 months after being normal
ashmeran syndrome
disorder of genital outflow tract
development of scar tissue from surgical instrumentation (c section) of uterus, vagina, or cervix
No pain, no buildup
Uterine lining obliterated bc of scar tissue, no endometrial buildup, no bleeding
cervical stenosis
disorder of genital outflow tract
scar tissue that develops in cervix and plugs = no bleeding allowed to drain
Scar tissue from cone bx of cervix, LEEP procedure, cryotherapy of cervix, dilation and curettage, congenital absence of uterus/vagina
Amenorrhea: disorder of ovary
autoimmune: thyroid, addisons, diabetes, lupus, RA
other: ovarian, chemo, tubo-ovarian abscess, surgery
4 causes of amenorrhea
disorders of:
genital outflow tract
ovary
anterior pituitary
hypothalamus or CNS
sheehan syndrome
significant postpartum hemorrhage causes vascular infarction and deprives pitutary gland
anovulatory amenorrhea
alteration in menses; irregularity; unpredictable
NO mittelschmerz or PMS
caused by: PCOS
common cause of infertility
chronic anovulation
amenorrhea: disorder of hypothalamic/CNS
causes
lifestyle!
excessive exercise, issues a/s with excess exercise (catechol estrogens are produced and endorphins, which inhibit GnRH, LH, FSH)
Dramatic life events
Grieving process = amenorrhea
Anorexia
Hypothalamic lesions, tuberculosis, sarcoid, and encephalitis = dec secretion of GNRH and reduced levels of FSH and estrogen
what meds / conditions can cause amenorrhea
meds that affect prolactin levels: antihypertensives, psychotropics, H2 blockers, oral contraceptives
chronic dz: diabetes, crohns, CF, celiac dz
amenorrhea: disorders of anterior pituitary
causes
from hyperprolactinema; a prolactinoma (secretes prolactin) tumor! most common cause
hypothyroidism can lead to hyperprolactinemia
increasing dopamine from hypothalamus inhibits GnRH = inhibits steroidogenesis
amenorrhea work up
- Rule out pregnancy and peri-menopause
- overall health: malnutrition, Exercise, recent weight changes, disorders of eating (anorexia, crash dieting, rapid weight loss), Obesity
Meds, herbs, Emotional state, chronic illness
- Physical exam, BMI, Gynecological and breast examination (galactorrhea)
- Assess TSH and prolactin levels (hyperprolactinemia common with anovulation)
- Administer provera challenge test
- Assess FSH & LH levels
ovarian failure dx if FSH high and low estrogen
provera challenge test
7-10 day course of provera making high levels of progestin then stop taking that to create withdrawal bleeding
Positive if get period = it’s not due to obstruction & has estrogen but not ovulating/anovulation
Negative if no period = adhesions/ashermans or not enough estrogen making endometrium not thick enough
If fails, give exogenous estrogen to determine if that’s part of problem
If responds, we know its limited endogenous estrogen or inadequate estrogen
Draw gonadotropin levels
ovarian amenorrhea most common cause
ovarian fxn abnormalitiies
ovary resistant to FSH or LH stimulation (PCSO) or lacks egg to ovulate
hypothalamic or pituitary amenorrhea r/t to
deficiency of FSH and LH
assess what for heavy menstrual bleeding
duration, color, presence of clots, character of bleeding
look for anemia
heavy bleeding assessment
- r/o pregnancy
- Manual exam
- Pelvic exam
Masses (ovarian, uterine) = pap smear
CBC, TSH, liver fxn, coagulation
r/o infections with cervical cultures, endometrial bx if indicated
- Pelvic sonogram = assess fibroids, polyps, measure endometrial stripe
During follicular phase, endometrial thickness is 1-2mm
During preovulation, layer 3-5 mm
Endometrial stripe > 5 mm = suspicious! Eval
heavy bleeding tx
single epsidoe vs chronic/cyclic
single is prob due to pregnancy or infection
chronic/cyclic: manage with IUD, monophasic OCP, patch/ring, Progestin (limits growth), depo, GnRH agonist (Lupron), NSAIDs, Danocrine (Danazol) but weight gain
non pharm: acupuncture, chinese med, herbs, aromatherapy
acute vaginal bleeding tx
estrogen and progestern 3x the dose but NAUSEAAAAA
metrorrhagia etiology
Possibly of preg
Threatened spontaneous abortion
Ectopic pregnancy
Gestational trophoblastic neoplasm
Mid-cycle spotting might signal ovulatory bleeding with heavy bleeding.
An STI can be a source of the problem, including cervicitis, vaginitis, or pelvic inflammatory disease.
Trauma related to sexual activity or abuse
Need sexual history and extensive assessment regarding interpartner violence or assault.
metrorrhagia tx
if from OC = change/review dosing, change
if not OC = stop OC to allow healthy buildup
progesterone therapy
Nuvaring, patch, progesterone IUD
primary dysmenorrhea
begins 6-12 months after menses (menarche)
d/t increased prostaglandin production = uterine contraction (use NSAID)
ischemic pain
recurrent sx’s with each cycle and stops after end of period
NOT from hx of anxiety/depression/psychosomatic dz
secondary dysmenorrhea causes
1 cause: endometriosis
adenomyosis (2nd common)
fibroids, polyps, cysts, cancer, PIDS: STI’s, pelvic floor weakness,
non GYN issues: IBS, interstitial cystitis or UTI
secondary dysmenorrhea assessment
GYN, obstretic, sexual hx
physical exam
US - pelvic pathology
r/o STI
if sus endometrial cancer, collect bx
if from IUD = remove and alt methods
when can secondary dysmenorrhea happen? is it related to prostaglandins?
before, during, or after period
NOT caused by prostaglandins
Primary dysmenorrhea Management:
Pharmacological vs Non Pharm
pharm: first line is NSAIDS (start 2-3d before menses + 2-3 d ibuprofen 400-800 mg q 6 hrs or naproxen 500 mg onset)
combined hormonal contraceptives
progestin only contraceptives (LNG IUD, Nexplanon), Depo BUT not immediate results (takes 3-12 mo)
non pharm: heat, no smoking/sugar, soda, exercise, belladonnna/camilla (herbal), acupuncture/relaxation aromatherapy
premenstrual disorder (PMD) sx’s appear ONLY during what phase
luteal phase (7 days or less before menses and RESOLVES with menses) day 4-13
moderate sx’s = PMS
severe sx’s = PMDD
PMDD sx’s in majority of cycles and have at least 1 of these sx’s:
1 or more: emotional lability, anger, feelings of hopelessness, anxious
1 or +, total 5 or +: poor concentration , appetite changes, decreased interest in activities, fatigue, overwhelmed, breast tenderness, bloating , weight gain, aching joints, insomnia or hypersomnia
how is PMDD thought to happen
neurologic hypersensitivity to normal hormone fluctations
NOT depression, NOT hormonoe changes
best tx for PMDD
stabilize hormones
suppressing ovulation with hormonal contraceptives, especially drospirenone, or Yasmine and Angeliq.
or SSRI antidepressants
PMDD management
pharm & nonpharm
stabilize hormones; suppress ovulation = COC drospirenone
SSRI #1 if sx is mostly emotional/PMS and taken only during luteal phase/day 14 [fluxoetine, sertraline, paroxetine]
anxiolytic last resort (Buspar, Ativan, lorazepam)
nonpharm:
healthy, exercise, stress, smoking, sleep
herbal: vitex agnus castus, curcumin (tumeric), Calcium supplements 500 mg, acupuncture, acupressure
what can worsen PMD symptoms
oral contraceptives
symptoms of toxic shock syndrome
fever, hypotension, sunburn rash
chills, malaise, h/a, sore throat, vomiting, diarrhea, desquamation of fingers/palms/feet (late)
TSS involves what organs
GI, MSK, mucus membranes, hepatic, hematologic, CNS
TSS Dx and tx
DO NOT WHAT
SEND TO ER!
culture, IV hydration, infectious dz, broad spectrum antibiotics, corticosteroids, immune globulin, supportive therapy
DO NOT RESUME TAMPON USE/MENSTRUAL CUP/BARRIER CONTRACEPTIVES LIKE DIAPHRAGM/CAP/SPONGE
what is the most common org for TSS
staph aureus
what is the leading cause of infertility
PCOS
PCOS patho
ovaries make excess male hormone, either excess LH or excess insulin = stimulate androgen production in ovaries
androgen precursor to estrogen = hyperplasia risk
‘string of pearls’ bc no LH surge
insulin resistance could be leading cause
PCOS risks
anovulation/infertility
obesity
hirsutism
CVD
endometrial cancer
DM 2
diagnosis criteria for PCOS
according to PCOS consensus group:
need 2 of 3: oligo/anovulation, clinical/biochemical signs of hyperandrogenism, polycystic ovaries
according to androgen excess and PCOS society:
hyperandrogenism, ovarian dysfxn (anovulation and/or cysts), exclusion of aother androgen excess
PCOS diagnosis
PE: BMI, trunical obesity, virilization, moon face, buffalo hump, alopecia, amenorrhea, hirt, acan nigri
thyroid exam
breast: galactorrhea
pelvic: bimanual exam
screen for depreesion
screen PCOS for
if have menstrual dyxfunction + hyperandrogenisms, screen:
Pregnancy—urine hCG
Hypothyroidism—TSH
Hyperprolactinemia—prolactin level
Glucose intolerance—OGTT
Dyslipidemia—lipid profile
R/O other causes of hyperandrogenism with PCOS such as
Androgen-secreting tumor
Adrenal gland tumor
Adult-onset non-classical congenital adrenal hyperplasia CAH
Cushing’s syndrome
PCOS management
determine if wanna get preggos, life style mods (diet, sat fat, fiber), exercise
COC! suppress enlarged ovaries and inhibit LH/androgen secretion = helps normalize ovary function, protect endometrium, raises sex hrmone binding globuin = binds to testosterone (helps with hirtsusism)
Progesterone, Levonorgestrel (LNg) - Mirena
progestin only pills
DMPA (depo provera) or implant (DONT give if want preg soon)
if no contraception, medroxyprogesterone acetate QD x 14 days
PCOS tx for hirsutism
antiandrogens:
spironolactone (Aldactone)
finasteride (Propecia, Proscar)
PCOS managing metabolic abnormalities
metformin and oral antihyperglycemics
inhibits glucose production, decrease androgen lvls with PCOS (no weight loss)
dec insulin, BP, LDL cholesterol
regulate menses, induce ovulation with clomiphene
PCOS f/u
tx diabetes, dyslipidemia, and hypertension
Smoking cessation
Repeat lipid profiles every two years
HgA1c screening for diabetes annually
birth control
limitation of children conceived or via specific methods of contraceptives
contraception
preventing pregnancy via contraceptive methods
efficacy
likelihood conception occurs when evaluating birth control methods
“true method failure” from “perfect use”
effectiveness
measuring success of method preventing pregnancy when used
user error; what’s really happening
open adoption
birth mother + adoptive family know each other
closed adoption
birth records closed/sealed, all identities concealed
semi open adoption
identifying info is shared b/t parties
communicaiton occurs at a pre-arranged intervals via agency or attorney
medication abortion most often used up to?
surgical?
10 weeks
mifepristone + misoprostol or methotrexate
products of conception passes 2-4 hrs after misoprostol or 24 hrs later
surgerical: aspiration/manual vacuum < 14 weeks, D&C after 14 wks, D&Evacuation after 14-15 wks+
Mifepristone
indication and MOA
Mifepristone
blocks progesterone receptor sites (require for normal implantation) & prevents fertilization
can be used up to 10 weeks/70 days
prostaglandin analog
used with misoprostol
95-98% effective
methotrexate MOA / indic
inhibits enzymes required for DNA synthesis and stops normal mitosis of rapidly dividing cells
60-84% effective
takes up to 2 wks for expuslion (undesirable)
coitus interruptus
withdrawal method
12/100 get pregnant; no STI protection
pre-ejac fluid may have sperm
lactational amenorrhea (LAM)
criteria
using beginning of postpartum period as contraception
high levels of prolactin from BF inhibits gonadotropin releasinghormone = sets off HPO axis = prevents ovulatin
criteria: exclusive/near exc BF (4 hrs max b/t feedings, and 6 hrs max at night), amenorrhea, infant < 6 months
PUMPING reduce effectiveness
Fertility Awareness Based on Methods
Identify the fertile period during the menstrual cycle + abstinence and/or a barrier method to prevent conception during the time when the risk of pregnancy is at its highest
fertile period: 5 days before ovulation until 1 day after ovulation = need back up method during this time
least effective contraception
contranindications to FABM
anything that interrupts cycles, birth, menarche, BF, intermenstrual bleeding, infxns
calendar method
count/record 6-12 months to find longest and shortest cycle. Then find the 1st and last fertile days expected in her routine or menstrual cycle.
subtract 18 from shortest cycle and 11 from longest cycle
Calendar Method: Standard Days Method
MUST have cycles of 26-32 day cycle
barrier contr days 8 - 19
circle beads (32 beads)
Calendar Method: Billings Ovulation Method
changes in cervical mucus to determine the fertile window.
Pt observes the sensation of moisture around the vulva and the presence of mucus throughout the day and records observations daily.
Abstinence first cycle to record!
fertile window: when observe vulva wetness slick, slippery up to 4 days
estrogen causes spinnbarkeit (mucus increases, clear, stretchy egg white) before ovulation
Calendar method: Two-day method
Did I note secretions today? And did I note secretions yesterday?
If yes, NO SEX
Typically, this results in 10 to 14 days of abstinence during her menstrual cycle.
check daily for secretions
Basal body temperature (BBT) Method
Measures basal body temperature daily BEFORE GETTING OUT OF BED
progesterone (corpus luteum) causes rise in temp = ovulation
rise of 0.4F or more = ovulation
fertile days: sharp temp rise and continue for 3 days until 5 day progressive increase
symptothermal method
BBtemp AND cervical mucus/observations
self-examines the cervix, os is dilated slightly and cervix is higher in the vagina and softer. After ovulation, the cervix becomes more firm and lower in the vaginal canal and closed.
pros and cons to FAB
Pros:
Min cost
User control
Culture acceptance
Cons:
Abstinence or barrier BC needed (10-12 days monthly if not longer)
Complicated
No protection from STI
male condoms
Natural rubber latex
Made of polyurethane = synthetic material for latex allergy.
Prevent STIs
Latex condoms are effective in preventing HIV and STI transmission (Non latex = not as effective)
18% will have unintended pregnancy.
condom failures = breakage or slippage during intercourse or while removing the condom.
female condom
2 flexible rings; larger ring remains outside of the vagina and covers the introitus.
1 size only
Can use lubricants and spermicides
In for up to 8 hours before sex but must be in place before the penis enters the vagina
Effectiveness: 79% during the 1st year of typical use.
Spermicidal agents with condoms
agent? don’t what?
chemical agents that are available as creams, aerosol, foam, supposed, gels, and tablets, vaginal film and sponges = kill sperm.
Agent: nonoxynol-9 (N-9): surfactant that destroys the sperm cell membrane. The inert basin which the spermicide is compounded acts as a physical barrier to the cervical os.
Don’t use for HIV protection !!! actually causes irritation and can cause HIV
Don’t put in rectum = micro tears
Don’t lube condom with N-9
using spermacide alone is
MOST ineffective contraceptive methods, with failure rates as high as 28%.
Sponge
Polyurethane with spermicide
When moistened, releases 125-150 mg N-9 over 24 hrs
Leaves in at least 6 hours after sex
Irritation more common than diaphragm bc higher amt of N-9
toxic shock syndrome a/s with what BC and sx’s of TSS
sponge
an immunological, potentially fatal septic reaction to toxins from Staph aureus and Strep pyogenes.
involves recent childbirth, leaving the device in place longer than 24 hours, or difficulty removing or fragmenting the sponge.
presents as 2-3 day syndrome of mild symptoms including low backache or body aches, chills, and malaise.
Sx worsen and rapidly progress to include fever higher than 101.4 or 38C.
diffuse macular erythematous rash and hypotension occurs.
teach to remove the device within 24 hours of its insertion to avoid the risk of TSS
diaphragm and cervical cap both need what
spermacide to maximize eff!
diaphragm
Used with spermicidal gel or cream that’s spread around the rim and inside the dome for maximum effectiveness.
needs fitting/various sizes
Inserted for up to 6 hours before intercourse and should remain in place in the vagina at least 6 hours after intercourse, but no longer than 24 hours because TSS
If have sex again w/in the 6 hr window, add more gel, DON’T take the diaphragm out
if PP, wait 6 weeks
diaphragm SE’s
UTI due to pressure on the bladder or change in vaginal flora related to spermicide.
Local irritation from an improperly fitting diaphragm may result in abrasions of the vaginal wall.
potential for latex allergy.
TSS if leave in > 24 hrs
Need to be refitted if the woman experiences weight gain, more than 15 pounds, or has had a 2nd trimester abortion or a vaginal birth within the past 6 weeks.
cervical cap
Dome-shaped cervical silicone cap that has suctionUsed with spermicide applied inside the dome and around the brim.
FemCap
3 sizes: 22 mm for a nulligravida, 26 mm for a nullipara, and 30 millimeters for full term vaginal delivery
Inserted up to 42-48 hours prior to intercourse and in place for at least 6 hours after intercourse
77% eff
what are some serious side effects with CHC
ACHES
abdominal pain (hepatic mass/tenderness)
chest pain (cough, SOB)
headache (migraines)
eye problems (visual changes/loss of vision/speech)
severe leg pain (DVT, hot leg/edema leg)
other side effects CHC
Breast Tenderness
Nausea
h/a
Altered bleeding pattern – spotting, breakthrough bleeding (not taking pill same day / time), increase/decrease bleeding, amenorrhea
Mood Alteration – Mood swings and depression
Libido changes
Skin Changes and acne
Acne gets worse before it gets better
health benefits of CHC; reduces risk of:
Reduce risk of:
Endometrial cancer
Ovarian Cancer
Colon cancer
Reduce anemia and blood loss with menses
May reduce PMS/PMDD
Reduce PID
Fewer ectopic pregnancies
Reduce benign breast conditions /Fibrocystic breast
May reduce ovarian cysts
Less dysmenorrhea
Some improve acne and hirsutism
Improve BMD
Long-Acting Reversible Contraceptives, or LARCs
IUDs, implant
Short-acting reversible contraceptives
Rings, patches, contraceptive pills, injectable agents, transdermal patches, and intravaginal rings contain estrogen and progesterone or only progestin.
cautions/contraindications to hormonal methods
contrain: Active breast cancer or pregnancy, history of cardiovascular disease or coagulopathies.
Caution tx for tuberculosis, seizure disorders, clotting disorder, HIV, or depression, including use of rifampin, Tegretol, Dilantin, antifungal agents, particularly Griseofulvin, St. John’s Wort, and over-the-counter antacids such as Maalox or Mylanta can decrease effectiveness due to impaired absorption.
management for hormonal contraceptives
1st: r/o preg (no recent unprotected sex for past 2 wks)
if started within first 5 days of period = protected; no need for back up
if start any other time = back up for 7 days
make sure no contraindications and know how to use correctly
if have photophobia, loss of vision, flashing nights, slurred speech, dizziness from CHC
STOP! til eval
could b ecerebrovascular accident = med emerg!
quick start method / same day
can start BC today and use backup method x 1 week
monophasic pill COC
same dose combo hormone eveery day
steady state
24 active pills + 4 placebo
multiphasic coc
vary in estrogen and/prog weekly
4-7 day of placebo pills
biphasic or triphasic
extended cycle coc
Seasonale
daily 3 months
84 active pills, 7 placebo
pseudomenstruation
from combined OC
endometrium doesn’t grow as thick
Transdermal Contraceptive (Patch) placements and contranindications
Xulane
exogenous estrogen transdermally with progestin
inhibit ovulation by suppressing gonadotroins in HPO axis and changes cervical mucus and endometrial lining
1 patch x 7 days over 3 weeks, 4th week patch free
sites: but, upper outer arm, abdomen, upper torso
NO: breast or legs
91% effective
Patch management
>198 pounds = decreased effectiveness
Discuss satisfaction and side effects
Use only if untouched and unstuck
If more than 9 days elapsed, NOT protected
Intravaginal Contraceptives
the Ring
flexible, vinyl ring about 4 mm thick and 54 mm in diameter
Body heat activated ; NOT A BARRIER METHOD
Not systematically absorbed
inhibits ovulation through suppressing the gonadotropins in the HPO access.
alters cervical mucus, and the endometrial lining
91% effective
keep in fridge x 4 months
last 21 days and then, it’s removed for seven days, to induce a withdrawal bleed.
if out > 3 hours= decrease in effectiveness
Progestin only pill (mini pill)
for those that are contraindicated using estrogen or lactating pts
only thickens cervical mucus which happens 2-4 hrs after taking pill and lasts 22 hrs
if 3 hrs late taking pill, use back up BC x 2 days (strict schedule)
Depomedroxyprogesterone DMPA
MOA
derivative of progesterone
inhibit HPO axis; thickens cervical mucus, endometrial atrophy = less likely implantation
shot every 13 weeks; suppresses ovulation q 14 weeks
shot anytime as long as not preg
don’t massage site!!!! dec efff
side effects of depo
menstrual changes
migraine with aura = STOP
report h/a’s
weight gain common
vag dryness
delayed feritity
BBW: bone density loss (take Ca + Vit D suppls)
DMPA benefits and pt education
Benefits:
Reduces seizures
Not affected by most meds
Reduction in sickle cell risks
Less menorrhagia and dysmenorrhea
Decrease in eptopci preg, PID and endometriosis
Educate:
BMD loss, changes in bleeding pattern then amennorhea after 12 months
Need ca vit D and weight bearing exercises
DO NOT ORDER DEXA / BMD testing in young women
if d/c, ovulation comes back 15-49 weeks after last injection
weight management (weight gain)
MEC for DMPA
3
BBW density d/t supp gonadotropin secretion suppressing ovarian estradiol production but reversible
Nexplanon Implant
MOST effective contraception
progesin analog x 7 yrs
start after 6 wks PP or during first 7 days of period or termination
barium sulfate = see on xray
once take out, return to fertilty 6 weeks
implant SE
1 unscheduled bleeding
mood changes
Weight gain
Acne
Breast tenderness
Bruising /irritation at insertion site
Small ovarian cysts
Migration
Infection at insertion site
Difficult removal
Damage to nerves and/or blood vessels
Scarring
IUD
Liletta, Mirena, Skyla, Kyleena
continuous release of levonorgesterl = absorbed locally by endometrium = changing mucus viscosity & diminished dev of endometrium
NOT systmically absorbed
insert any day but prefer during period (os more openand blood as lube)
can be placed after birth but caution of explusion, up to 4-8 wks PP (give nonsteroids 30 mins prior), misoprostol (cervical ripening) if cramping
do IUD’s cause ectopic pregnancy
NO. but if ferti with IUD, greater risk of ectopic implantation but risk of this still lower than no IUD and ectopic
if can’t feel IUD strings on speculum…
1: r/o pregnancy
uterus perforation
strings thru uterine wall
spontaneous expulsion
strings cut short andmigrate up cervix (can retract string and pull back out)
pains reported to provided using IUD
P.A.I.N.S.
period - irregular, late or spotting
Abdominal pain or dyspareunia
Infection or abn vag discharge
Not feeling well, flu, chills
strings missing
Copper IUD Paraguard MOA
NONhormonal; copper ions paralyze sperm and decrease motility
Foreign body effect toxic to sperm and ova
Local inflammatory response: creates spermicidal environment
barium = x ray = shows
Copper IUD not good for
heavy menstrual bleeding (better using levonorgestrel IUD) or copper allergy
worsens anemia, inc dysmenorrhea, and blood loss
Yuzpe method
Take 4-5 pills x 2, 12 hours apart
high doses of estrogen and progestin, combined oral contraceptive pills in a single dose = inhibit ovulation
Preg rate 2% to 3%
LOTS of nausea and vomiting, headache, breast tenderness, irregular bleeding, or spotting = unfav
Copper IUD/Paraguard as EC
insert w/in 120 hrs/5 days after unprotected sex
most effective EC AND in obese women and ongoing contraception (0.1%)
alters tubal transport. It’s toxic to the ovum and incapacitates sperm so that fertilization is prevented.
inhospitable uterine environment, preventing implantation.
which IUD NOT effective for emergency contraception?
The levonorgestrel-releasing IUDs, like the Mirena, the LILETTA, the Skyla, and the Kyleena are NOT effective for emergency contraception.
female sterilization/ tubal ligation
done after vaginal delivery, C-section, uncomplicated first-trimester abortion, or independent of pregnancy, or whenever
The fallopian tubes are surgically cut and ligated with or without a section of the tube being removed = salpingectomy
May be mechanically blocked using clips or rings or coagulated electronically.
blocked by a reaction induced by chemicals or micro-inserts.
>99% effective in preventing pregnancy. failure rate is about 0.5% in the first 12 months.
tubal ligation pros and cons
pros: decrease ovarian cancer and PID
cons: high risk of ectopic preg
won’t rec if unsure of future, unlikely to get preventative health services, not wear condoms -> STI, regrets
female transcervical sterilization
Essure
insert into fallopian tubes
new growth of tissue into a surrounding insert = forms scar tissue and occludes the tube.
Need follow-up hysterosalpingogram, or HSG, to ensure occlusion has occurred about 3 months following the procedure.
**Taken off market in 2018
NO allergy nickels
male sterilization
vasecetomy
The procedure involves cutting or occluding both of the vas deferens so that sperm can no longer traverse into the seminal fluid.
uses ligation, cautery, or excision of a segment, and then application of clips.
no-scalpel technique
where the scrotum is pierced, and the vas deferens are then exposed and occluded through this small opening.
no stitches and results in less bleeding, quicker recovery time, less issues with hematomas, infection, and pain.
no difference in effectiveness between the no-scalpel technique and traditional conventional vasectomy.
Male sterilization counseling
NOT immediately effective.
Sperm continually is produced and transported, so some sperm will continue to be present distal to the site of the procedure.
Take between 15 and 20 ejaculations to clear all the sperm; wait 3 months.
The failure rate is < 1%, similar to the female sterilization; some post-operative discomfort; infection; scrotal hematomas are possible.
