EXAM - Reproductive Health Flashcards
Sam is a 19 year old women who presents to your care concerned about pregnancy. She states the “condom broke” 3 nights ago. Her last menstrual cycle started 7 days ago.
She has heard of Plan B but wants to know if it’s too late for emergency contraception?
It’s not too late for ECP!
Rx files p. 169 emergency contraception
-Oral options can be taken up to 5 days after unprotected sex
- Can use copper IUD as emergency contraception option too! (And Mirena coming up quick here…) - insert within 5-7 days
Sam is concerned that this medication will cause abortion if she’s already pregnant. What education can you provide about the MOA of these medications?
- MOA: can delay/inhibit ovulation & therefore prevent fertilization (NOT implantation….so less effective if ovulation as already ocurred)
This will NOT terminate a pregnancy if she’s already pregnant
Sam would like to try oral ECP. What do you prescribe?
3 options in right hand box on page 169 rx files… Plan B is considered “drug of choice for most”
If Sam is a curvy lady with a BMI of 33 and/or if she thinks she has already ovulated, what would her best option be for emergency contraception?
Copper IUD (first line for BMI >30 and has pregnancy rate of <0.1% even after ovulation).
Rx files p. 169
If I remember correctly, ELLA (Ulipristal) can also be a better PO option for people who think they have ovulated? I think Susan may have mentioned that in her lecture
New case:
Amanda is a 16 year old who comes to your clinic requesting contraception. She is anticipating becoming sexually active soon.
She wants to start “the pill”.
You discuss her medical history to determine if she is a good candidate for a combined hormonal contraceptive.
What contraindications are you screening for?
Rx files table 2a on p. 169
From class slides:
Unacceptable Health Risk of method used
(Category 4):
* Breast Cancer
* DVT or PE
* Hypertension < 160/100 mmHg
* Ischemic Heart Disease
* Known thrombogenic mutations
* Liver disease (severe cirrhosis, etc.)
* Major surgery with prolonged immobilization
* Migraine with Aura
* Smoking, age > 35 years
* Solid organ transplantation
* Stroke
* Systemic Lupus erythematosus
* Valvular heart disease
* Vascular disease
uProven Risks usually outweigh the advantages
(Category 3):
*Acute Viral hepatitis
* Bariatric surgery
* Diabetes with complications or > 20 years duration
* Hypertension (systolic 140-149/ diastolic 90-99 mmHg)
* Inflammatory bowel disease
*Medication Interactions
* Specific Anticonvulsants
* Specific Antiretrovirals
(If you haven’t already explored it, I also highly recommend the Medical Eligibility Criteria [MEC] from the CDC that outlines relative/absolute contraindications for all birth control types at:
https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf)
Amanda has no contraindications for starting a CHC. You take her blood pressure and it’s 115/75.
What do you prescribe?
Lots of options p. 170 in Rx Files
I would choose Alesse 28. Take 1 tab daily.
What important teaching will you need to provide Amanda with her new rx?
- Take at same time each day
- First 21 pills contain hormones. Last 7 pills are “sugar pills” when period-like bleeding with occur (this is called withdrawal bleeding and is not a true period)
- Requires back up contraceptive x 7 days as will not be protective of pregnancy before until then
- Does not protect against STIs
- Risks of smoking while on the pill
- If misses pills, should follow instructions in package but may need backup contraception
- Common side effects include nausea, bloating, headache, and breast tenderness but these should decline within first couple of months. May experience menstrual irregularities x first few months as well (such as spotting) but this also tends to normalize within that time. If it doesn’t may need to try another pill.
- Review ACHES (see table 3 on p. 169 of rx files)
- Can start taking pills any day (does not need to wait for start of cycle).
Amanda returns after 6 months and reports she is happy with the pill except she is still experiencing spotting regularly, especially in the first week of taking the hormonal pills (after her withdrawal bleed). What do you do now?
Rx files p. 170
See Table 8 and 9.
- Breakthrough bleeding expected in first 3-6 months. Want to investigate another possible cause (such as Chlamydia if has become sexually active).
- Can relate to poor adherence, smoking, and drug interactions.
BUT may also just need to increase hormone levels in birth control. Early bleeding/spotting (days 1-9 of cycle) is more suggestive of estrogen deficiency.
I would change her pill, such as to Marvelon (which has higher estrogen as well as progestin)
New case: Nancy is 40 years old and smokes a 20 cigarettes a day. She wants to start birth control. Which options are NOT suitable for her based on these details alone?
All combined hormonal contraceptives (oral, patch, nuvaring) would be contraindicated for her. Would want to explore progestin-only options such as oral pill, depo-provera, implant or IUD (hormonal or copper)
(see table on p. 171 of rx files)
New case:
Frankie wants to start on the Nuvaring. She says “you leave this in for a month, right?!”
How do you reply?
No, It is kept in the vagina for 3 weeks and then removed for
one week (when withdrawal bleeding will occur)
Frankie returns a month later and tells you she doesn’t like the ring and wants something less “fussy”. You learn she wants long-term birth control because she doesn’t expect to want to get pregnant for at least 5 years. What do you think good options are for her?
A LARC: IUD or implant.
- Could also consider depo-provera shot but needs to be aware return to fertility can be very delayed (up to 18 months as per rx files on p. 171) and will still need to come for short every 3 months.
New case: you are providing contraceptive counselling to someone who is exploring their options. How do you explain the mechanism of action of combined hormonal contraceptives?
Principle effect is inhibition of ovulation
* Thickening of cervical mucus
* Modify uterine lining
(as per susan’s slides)
CPS “patient medication information” page under Alysena states: “Birth control pills work by inhibiting the monthly release of an egg(s) by the ovaries. Some studies have demonstrated changes in the endometrium (lining of the womb) and mucus produced by the cervix (opening of the uterus) with the use of birth control pills.”
New case:
Jan presents to your clinic seeking birth control that can also help with her acne. What options are good for her?
- All CHCs can be beneficial
- Progestin-only methods can increase acne
(p. 171 rx files)
Jan decides her acne problem isn’t important now that she’s heard how great the hormonal IUDs are. Before insertion, what 3 checks will need to be done on Jan?
(from Susan’s slides #30)
Bimanual and cervical exam
Pregnancy test
STI test (will still insert while waiting on results)
New case:
Pamela presents to your clinic because she has been using the pull-out method and her period is “a few weeks” late. You take a pregnancy test and it’s positive. After considering all options, Pamela decides she wants to terminate the pregnancy.
It is determined that she is 8 weeks pregnant. Can you provide a medical abortion option to Pamela or is surgical her only option?
Rx files p. 169 lower right hand side:
- can offer medical abortion up to 10 weeks (surgical options beyond this)
