Family Planning

Question 1

Abstinence

Answer 1

o Cost- zero
o Advantages – inexpensive, intimacy
o Disadvantages – not followed

Question 2

Coitus interuptus

Answer 2

o Cost – zero
o Failure rate – Typical 27%, Perfect 4%
o Advantages – free, no side effects, no chemicals, backup for any other method
o Disadvantages – decrease pleasure, pregnancy and no protection for STD/HIV

Question 3

Male condoms

Answer 3

o Cost – $0.5-1
o Failure rate – Typical %6-30, Perfect %2
o Advantages – inexpensive, accessible, hygienic, STD/HIV prevention, sperm allergies, erectile enhancement
o Disadvantages – latex allergy, decrease sensation, interrupt erection, breakage
o SE – irritation to spermicide, latex
o CI – latex allergy
• Yeast, BV, and oil based products breakdown condom integrity
• Sheepskin more mpermeable to HIV/STDs but equally effective in preventing pregnancy

Question 4

Female condoms

Answer 4

o Cost – $2.50-3
o Failure rate – Typical 21%, Perfect 5%
o Advantages – no allergy, accessible, packaged with lube
o Disadvantages – need to learn correct insertion, cost
o SE – none
o CI – allergy to polyurethrane
• Can be placed 8 hours before intercourse

Question 5

Diaphragm

Answer 5

o Cost – $25-30
o Failure rate – Typical 16%, Perfect 6%
o Advantages – good for 3 years, can use w/ condoms, no hormones, decrease cervical neoplasia
o Disadvantages – increase UTI, BV, VVC, decrease spontaneity, TSS
o SE – none
o CI – allergy to latex, rubber, spermicide, abnormal anatomy, inability to insert and remove, Hx of TSS or recurrent UTIs
• Insert 6 hours b4 sex, leave in 6 hrs post sex
• Refit for weight change >10lbs, post partum, post abortion or SAB

Question 6

Cervical cap

Answer 6

o Cost – $24-30
o Failure rate – N: Typical 20%, Perfect 9% M: Typical 40%, Perfect 26%
o Advantages – use w/ condoms, no hormones, long term
o Disadvantages – TSS, increased BV, VVC, decrease spontaneity, abnormal paps, only few sizes
o SE – none
o CI – latex, rubber, spermicide allergy, hx abnormal pap, cervical infection, vaginal bleeding (inc menses)
• Must leave in place for 6 hrs post sex, up to 48 hours

Question 7

Spermicide

Answer 7

o Cost – $12/canister or tube, suppositories or sheets more exp
o Failure rate – Typical %21-40, Perfect %4
o Advantages – good back up method, accessible, OTV, inexpensive, STD/HIV protection, lubrication
o Disadvantages – irritation, increase VVC, must use w/I time frame, messy
o SE – irritation
o CI –allergy, sensitivity, inability to insert, abnormal anatomy
• Foam – alone or w/ condom or diaphragm, effective 1 hour after insertion
• Creams/gels – alone, diaphragm, cap, condom, effective 1 hour after insertion
• Suppositories – alone or w/ condom, wait 15 min before sex, effective 1 hour, posterior vagina
• Film – wait 15 min b4 sex, one hour effective, dry fingers to insert into posterior vagina

Question 8

Progesterone Only

Answer 8

inhibits ovulation, increases cervical mucus, premature luteolysis gets rid of corpus luteum, atrophic endometrium so egg cant implant
o Advantages – no estrogen side effects, decrease menses, amenorrhea, decrease anemia, ok in lactatin mothers, decreases PID, endometriosis, ovarian ca, okay when estrogen CI (hx dvts, >35, smoker, inactive, overweight
o Disadvantages – irregular menses, amenorrhea, weight gain, breast tenderness, mood changes, HA, same time daily

Question 9

Depo-Provera

Answer 9

o Cost – $35-50/injection
o Failure rate – Typical/Perfect 0.3%
o Advantages – easy, immediate efficacy, post partum, spontaneity, amenorrhea
o Disadvantages – weight gain, decreased bone density, not immediately reversible, apt q3 mo, increase in breast ca, menstrual changes
o SE – menstrual changes, HA, weight gain
o CI – suspected pregnancy, undiagnosed irregular vaginal bleeding, contemplating pregnancy, concern for weight/mood changes
• Given within first 5 days of mesnies, repeat q12w, 150mg IM
• Black label warning after 2 years – bone density → Ca+vitD daily
• Can take 12-18 months to get out of system – not good if want pregnancy soon

Question 10

Progesterone only pills

Answer 10

• Progesterone only pills
  o Cost – $25
  o Failure rate – Typical %5, Perfect %0.5
  o Advantages – immediately reversible, no weight gain, amenorrhea (maybe after a year)
  o Disadvantages – irregular bleeding, ovarian cysts, ectopic pregnancies
  • One pill daily, no placebos, use backup for first month
  • Can use w/ breast ca patients

Question 11

Nexplanon

Answer 11

o Cost – $400-800/insertion, $75-100 removal
o Failure rate – Typical/perfect % 0.5
o Advantages – 3 years, no estrogen, breast feeding ok, immediately reversible, amenorrhea 2%
o Disadvantages – irregular bleeding 6-12mo, cost, pain/scarring at insertion site, small weight gain, HA, acne, ovarian cysts, mood changes
o SE – N, breast tenderness, bloating, decreased libido
o CI – pregnancy, allergy to etonogestrel, breast cancer, liver tumors, undiagnosed vaginal bleeding, severe liver dx, NOT before 6 wk postpartum
• No age restriction
• Local anesthetic to inner upper arm between bicep and tricep, insertion into subdermal tissue w/ needle like applicator, bandage for 24hrs, removal after 3 years w/ small incision and forceps

Question 12

• IUD

Answer 12

o Cost – $200/IUD, $200-300/insertion
o Types – copper v progesterone vs. levonorgestrel
o Mechanism of action – immobilizes sperm, interferes with migration, speeds ovum transport, endometrial effects
o Advantages – safe, highly effective, Rx ashermans (increased scarring in uterine lining which thins)
o Disadvantages – PID, dysmenorrhea, menorrhagia, expulsion, pregnancy complications, uterine rupture
o SE –
o CI – multiple partners, hx PID, ectopic endometriosis, post abortion sepsis, pregnancy, anatomical abnormalities, heart/valve dx

Question 13

• Copper IUD

Answer 13

– Copper T 380A Paraguard – copper T w/ single filament string
o Failure rate – Typical 0.8%, Perfect 0.6%
o Efficacy 10 years
o Advantage – long term, immediately reversible

Question 14

• Levonorgestrel 20mg – Mirena– releases 20mcg levo daily

Answer 14

– releases 20mcg levo daily
o Failure rate – Typical/Perfect 0.1%
o Efficacy 5 years
o Advantages – decrease flow and pain, ease of use, amenorrhea
o Disadvantages – increase ectopic, PID, perforation, sepsis
• Good w/ transitioning into menopause and need bleeding control

Question 15

• Levonogestrel 13.5mg – Skyla – releases 13.5mcg levo daily

Answer 15

• Levonogestrel 13.5mg – Skyla – releases 13.5mcg levo daily
  o Failure: Typical/perfect 0.1%
  o Efficacy 3 years
  o Adv/disadv same as mirena

Question 16

• Combined estrogen/progesterol products –

Answer 16

• Combined estrogen/progesterol products – screen out if smoker +35, CV risk, bleeding, migraines w/ aura, diabetes, liver, smoke

Question 17

Combined oral contraceptives

Answer 17

o Cost – $24-30
o Failure rate – Typical %5, Perfect 0.1%
o Advantages – safe, effective, cycle control, dysmenorrhea, ovarian cysts, acne, mittelschmerz (painful ovulation), PID, anemia, reversible, prevents ovarian and endometrial ca, BMD, lipid profile, PMDD
o Disadvantages – expensive, daily, BTB, glucose intolerance, gall bladder dx
o SE – BTB, N, V, HA, breast tenderness, mood changes
o CI – pregnancy, undx irregular bleeding, vag bleeding, breast ca, >1ppd, >35 and smoker, hx PE, CVD, thrombophlebitis, CVA, liver dx, >50yo
o Inhibits ovulation, decrease ovum transport, early lutelysis, thickens cervical mucus, alters capacitation, alters endometrium
o Complications – thrombophlebitis, PE, CVD, cancer, hepatocellular adenoma
o Drug to drug: rifampin, vit C, anticonvulsants, antibiotics

Question 18

Combined oral contraceptives- types

Answer 18

Types – monophasic (good for ovarian cysts), biphasic, triphasic (orthotricyclen good for acne)
• Seasonale, loestrin 24 – good for migraines – 4 menses/yr

Question 19

Combined oral contraceptives- Education

Answer 19

Education – first day or Sunday start
• Missed pills – miss one take 2 next day, miss 2, take 2 next 2 days, miss 3
• Fu 3-6 months at least w/ call
o BTB – 1st half of cycle, change estrogen, 2nd half, change progesterone
o ACHES – abd pain, chest pain, HA, eye visual changes, swelling

Question 20

Combined injection– lunelle – medroxyprogesterone and estradiol cypionate

Answer 20

o Cost – $30-35
o Failure rate – Typical/Perfect 0-0.2%
o Advantages – immediate coverage, given q 28-33 days, as effective as pill, no daily pill, less BP elevation, return of ovulation in 2-4mo
o Disadvantages – monthly apt, monthly menses, pill SE
o SE – same as pill

Question 21

Combined transdermal patch – Ortho evra – Norelgestomin/norgestimate 150ug and EE 20ug

Answer 21

Failure rate – 0.8%
o CI – >198lbs
• Apply 2 week for 3 weeks, off for 1 wk, constant serum concentration – abd, butt, uppoer outer arm, torso, not near breast – 1st day or Sunday start
• Blackbox – higher estrogen dose compared to pill – higher risk stroke, MI, DVT – ONLY in young, active, healthy ppl

Question 22

Combined Vaginal Ring – nuvaring – etonogestrel 120ug, EE15ug, 2” flexible ring, in for 3 weeks, out for 1

Answer 22

o	Failure rate – 0.7%
o	Advantages – no daily pill
o	Disadvantages – backup for 1st month
o	CI – poor vaginal tone/hx vaginal prolapse, chronic constipation
•	Insert between 1st and 5th day of LMP
•	If falls out, rinse and put back in

Question 23

Emergency contraception

Answer 23

o Cost – $20-30
o Failure rate – 25%
o Advantages – effective, alternative to pregnancy and abortion, low cost, safe
o Disadvantages – failure, exposure to meds, N, V
o SE – N, V, breast tenderness, dizzy, abd pain
o CI – anyone where OCPs are contraindicated or if sex >72 hours ago, not for >35+smoker
• 1st dose w/I 72 hours sex, 2nd dose 12 hr later – cant take as one pill too – if N after 1st dose, retake
• Make sure not pregnant first
• Generally get period w/I 3 weeks of taking

Question 24

• Mefeprestone - (mifeprestone/misoprostone) RU486 – progesterone receptor antagonist

Answer 24

o Failure rate – 8%
o SE – N, V, D, HAs
o CI – allergy to med, hemorrhagic d/o, adnexal mass, chronic adrenal failure, suspected ectopic, unk vag bleed
• 600 mifeprestone followed by 400mg misoprostol 2 days later
• f/u 14 days after 1st dose to confirm termination and evaluate bleeding
• Give w/I 49 days of LMP

Question 25

Abortion

Answer 25

o Legalized in 1970, 73 w/ Roe v Wade
o 1st tri – decision up to woman and md
o 2nd tri – state can choose to regulate procedure r/t womens health – hard to find place to perform
o risks – infection, hemorrhage, blood clot, cervical/uterine damage, continuation of pregnancy and death
o Eval support system, during and after procedure
o f/u 2 weeks post abortion for check, teaching, birth control, support, psych

Question 26

Natural family planning

Answer 26

o Cost – $0-10
o Failure rate – Typical 25%
o Advantages – increased reproductive awareness, no SE, help detect impaired fertility, plan and prevent pregnancy
o Disadvantages – no protection for STD/HIV, difficult with long, irregular cycles, approaching menopause or recent menarche

o Sympto-thermal – Perfect 2% - use billings and BBT – abstain or condoms from beginning of cycle until 3rd day after peak temp and 4th day after peak in mucus

Question 27

basal body temperature

Answer 27

BBT – Perfect 1% - record resting temp qd, resting temp will rise 0.4-0.8 right before, during or after ovulation and remain elevated for the rest of cycle
• Contraception or abstain from beginning of cycle until 3 days after rise in temp

Question 28

Ovulation/billings

Answer 28

Ovulation/billings – Perfect 3% - monitor mucus qd – mucus will increase in amt and become very clear, stringy, slippery as ovulation approaches – ovulation occurs the day before to the day after peak mucus production
• Contraception or abstain from beginning of cycle until 4th day after peak

Question 29

Calendar

Answer 29

– Perfect 9% - subtract 10 from longest cycle and 20 from shortest cycle, abstain during those days in next cycle or sex qod if attempting pregnancy

Question 30

Sympto-thermal

Answer 30

Perfect 2% - use billings and BBT – abstain or condoms from beginning of cycle until 3rd day after peak temp and 4th day after peak in mucus

Question 31

Bilat tubal ligation

Answer 31

o Cost – $1200-2500
o Failure rate – 0.5%
o Advantages – permanent, effective, spontaneity, no SE, no partner compliance, private
o Disadvantages – permanent, no STD/HIV, reversal difficult, risk of surgery and anesthesia, mortality/morbidity higher than vasectomy, increase ectopic
o Reversal 43-80% depending on type and amt of damage

Question 32

Essure – transcervical sterilization – spring like coils inserted into fallopian tubes, cause scarring and block tubes

Answer 32

o Advantages – incision free, local anesthesia, in office or hospital, quick recovery 24hrs
o Disadvantages – not immediate, use backup for 6 months, cant use IUD or IUS at same time, may need multiple insertions

Question 33

• Vasectomy

Answer 33

o Cost – $250-1000
o Failure rate – Typical 0.15%, Perfect 0.1%
o Advantages – safe, effective, permanent, less expensive, short recovery
o Disadvantages – bleeding, infection, permanent, no STD/HIV, inconclusive prostate ca assoc
o Reversal 16-79%, avg 50%

Question 34

• New technologies

Answer 34

• New technologies
  o Implants – Norplant 2, implanon in diff doses
  o Barrier – leahs shield OTC, fem cap
  o Injectables – levonorgestrel diff dosages and types of prog, combined E/P, subQ prep of DMPA for self admin
  o Progesterone only vaginal rings
  o Hormone – male – increase testosterone/prog inj for men
  o IUD – new copper, combined
  o Vaccine – male and female – prevent hcg production
  o Transcervical methods
  o Male – US (consistent US can lower sperm count), contraceptive gel that suppresses testosterone, gamendazole pill that slows speed of sperm, RISUG (reversible inhibition of sperm under guidance- office procedure), clean sheets pill suppresses ejaculation, orgasm still present