Family planning and contraceptive Flashcards
what are the family planning services (5)
- Fertility counselling
- Reproductive life plan and preconception counselling
- STI counselling
- Preventive health counselling
- Pregnancy testing and counselling
what are important points in counselling for contraceptives (4)
- The most effective methods
- Contraceptives do not prevent STIs
- Correct use of contraceptive
- Side effects
what are the goals of family planning (3)
- Improve pregnancy planning and child spacing
- Prevent unwanted pregnancies
- STI prevention
what are the 3 most popular methods of contraception in malawi
- Injectables: 33.9%
- Combined oral contraceptives (COCS): 9.7%
- Male condoms: 8.6%
what important things should you ask in obstetric history
Any pregnancies and deliveries
what things should you ask in gynecological hx (6)
- Characteristics of her menses (regularity, how heavy, how long)
- Last menstrual period
- History of STIs or abnormal vaginal discharge
- Past contraceptive use (if any)
- Current condom use
- history of AUB
what things should you ask in medical history (6)
- HIV
- Hypertension
- Stroke
- breast cancer
- Venous Thromboembolism
- Liver disease
what drug hx would you ask (3)
- ART
- TB medication
- Allergies
what social/ sexual hx should you ask (3)
- How many lifetime sexual partners
- How many current partners
- Future fertility intentions
how can you classify contraceptives (4)
- permanent methods
- long term hormonal methods
- short term hormonal methods
- non-hormonal methods
examples of permanent methods (2)
- Female sterilization (tubal ligation)
- Male sterilization (vasectomy)
examples of long term hormonal methods (2)
- Contraceptive implants containing the progestin hormone
- Intrauterine contraceptive devices (IUCD)
examples of other hormonal methods (3)
- Injectable contraceptives
- Oral contraceptives (pills): can be COCS or POPS
- Emergency contraceptive pills (ECP)
examples of non hormonal contraceptive (4)
- Barrier methods
- Lactational amenorrhea method (LAM) for breastfeeding women
- Fertility awareness methods (FAM)
- Withdrawal
how is a vasectomy performed (3)
- It can be performed under local anesthesia
- Excision of a small section of both vas deferens
- Followed by sealing of the proximal and distal cut ends
what are possible complications of a vasectomy (4)
- hematoma
- surgical site infection
- sperm granulomas (collection of sperm due to leakage from the vas deferens into surrounding interstitium)
- post vasectomy pain syndrome (PPS) (chronic, dull, aching pain in testicles)
how do you ensure sterility after a vasectomy
one must use contraception for 12 weeks or 20 ejaculations and then have two consecutive negative sperm counts because sperm can still be found proximal to the surgical site
what is the failure risk of vasectomies
0.15%
what is tubal ligation
surgical blocking of the fallopian tubes that disrupts the transit of ovum from the ovaries to the uterus
when can tubal ligation be performed (2)
- Postpartum -during c/s or right after vaginal delivery
- interval (remote from a pregnancy) however should be performed in the follicular phase of the menstrual cycle (in order to avoid the time of ovulation and possible pregnancy)
what is the failure risk of tubal ligation
0.5%
what are methods of BTL (4)
- laparoscopic tubal ligation (cut and tied ) ( 80-90%)
- electrocautery (most effective and most difficult to reverse)
- clipping (highest failure risk)
- banding
what are techniques of BTL and what do we use at QUEENS (3)
- pomeroy method (a segment of isthmus is lifted and a suture is tied around the approximated base, the loop is then excised leaving a gap between the proximal and distal segments)
- parkland method
- madlener method
- irving method
- kroener method
- partial or total salpingectomy
we use the modified pomeroy method
what are complications of a BTL (5)
- Surgical infections
- Fistula formation 9between uterus and peritonium)
- Failure of the procedure
- Post sterility syndrome (post tubal ligation syndrome)
- increased risk of ectopic pregnancy
what are implants
small plastic rods that are inserted underneath the skin and produces progestin which has the same effect as the natural progesterone
how do implants work (3)
- Prevents ovulation (by inhibiting release of GnRH hence suppressing LH surge)
- Thickens cervical mucus
- Makes the endometrium thin
implants might have reduced effectiveness in which situations (2)
among women taking Rifampicin or Efavirenz-based ART
what are the types of implants (3)
- jadelle
- levoplant
- implanon
what is the failure rate of implants
0.05%
how many rods are inserted for jadelle
2
what active ingredient is in jadelle
levonorgestrel 150mg (each rode 75mg)
levoplant contains how many rods
2
what is the active ingredient in levoplant
levonorgestrel 150mg (75 mg each rod)
how long does jadelle last for
5 years
how long does levoplant last for
4 years
how many rods are inserted for implanon
1
what is the active ingredient in implanon
etonogestrel 68mg
what is another name for implanon
nexplanon
how long does implanon last
3 years
on removal of implants when do serum levels become undetectable and when does ovulation resume by
- undetectable by 1 week
- ovulation resumes within 6 weeks
what pre insertion counselling do you do for implants (3)
- explain procedure, potential side effects, ensure patient understands contraceptive method
- make sure patient is pregnant
- confirm timing of insertion ( best time is usually first 5 days of the menstrual cycle or immediately postpartum)
how does the insertion process of an implant go (4)
- ask patient to lie down , with non dominant arm flexed at the elbow, externally rotated to expose the inner aspect of the upper arm
- clean the skin on the medial aspect of the upper arm, about proximal to the medial epicondyle of the humerus 8-10cm above the elbow
- apply local anesthesia (lidocaine)
- pinch the skin at insertion site, inserts applicator at about 15 degrees angle and release rod into the subdermal space
what is the post insertion care for implants (6)
- check to see that it is properly inserted by palpating the skin to feel it
- apply a sterile bandage to the insertion site for about 24 hours
- patient is advised to avoid:
- heavy lifting with the arm for a few days
- water exposure924-48hrs)
- direct pressure - if it was inserted 5 days after menstrual cycle the patient is advised to use additional contraceptive like condoms for 7 days
- advised on danger signs
- infection (redness, swelling, warmth, pus discharge, fever)
- severe pain/ tenderness that doesnt improve with pain medication - nerve or vascular issues
- numbness
-tingling
- bleeding
what are side effects of implants 94)
- Changes in normal menstrual cycle – Irregular unpredictable bleeding (heavy/ prolonged/intermenstrual bleeding/ spotting) is the main side effect
- Abdominal pains
- hormonal symptoms:
- Headaches
- Breast tenderness
- mood changes
- acne - weight gain
whats a complication of implants (2)
- insertion site infection
- risk of ectopic pregnancy
what is an intrauterine contraceptive device (2)
- A T-shaped implant made of plastic and copper that is placed in the uterine cavity to prevent pregnancy
- Two threads are attached to the IUCD and pass out through the cervix to lie in the vagina
what are the 2 types of IUCD
- Copper T380A (Paragard) IUCD: has 380mm^2 of copper surface area and a monofilament thread
- Levonogestrel intrauterine device
how long does a copper T-380A IUCD last
10-12 years
what is the MOA of a copper T-380A IUCD
It has chemical (copper ions) which cause significant endometrial changes making the uterine environment hostile for the survival of sperms and ovum (sperm migration, quality and viability (spermicidal) at the level of the endometrium is hindered)
1. spermicidal effect
2. prevents implantation- altering endometrial lining
what is the failure risk of copper T IUCD
0.8%
what are complications of copper IUCD (3)
- Uterine perforation – at the time of insertion
- Ectopic pregnancy
- Expulsion may occur during menstruation
what are contraindications of copper IUCD (3)
- PID and STIs
- Cervical and endometrial cancer
- Uterine malformation
what are side effects of copper IUCD (3)
- heavy and longer periods
- cramping
- spotting
what is levonogestrel IUCD (mirena)
A small t-shaped plastic IUCD that is inserted in the uterus and releases a small amount of progestin hormone everyday
how does levonogestrel IUCD work (3)
The progestin hormone works as the natural progesterone and it:
- thickens the cervical mucus
- stops the ovulation
- thins the endometrium
how long does mirena last
5-7 years
what is the failure rate of mirena
0.2%
what are side effects of mirena
- irregular bleeding
- spotting
- amenorrhea
- hormonal symptoms:
- acne
-reduced libido
- breast tenderness
- headaches
what is a complication of mirena(2)
- PID
- uterine rupture
what is non hormonal effect of mirena
- treatment of heavy menstrual bleeding
what are combined oral contraceptives (3)
- These contain same amount of estrogen and progesterone in all pills.
- They are packaged as 21 “active pills” followed by 7 placebos in total there are 28 pills.
- The placebo used is ferrous sulphate, which is a prophylaxis against anemia.
what are types of COC (20
- microgynon
- zinnia
what is the active ingredient in microgynon (20
- levonorgesterol (150 micrograms)
- ethinyl estradiol (30 micrograms)
what is the MOA for COC (3)
- Inhibits of ovulation by suppressing release of FSH and LH
- Prevents implantation by altering endometrial lining
- Thickens the cervical mucus
what is the failure rate of COC
9%
what are side effects of COCs (6)
- Headaches
- Dizziness
- Nausea
- Breast tenderness
- Weight change
- Mood changes
COC are contraindicated in who (8)
- Hypertension
- Deep venous thrombosis
- Smokers
- Breast or liver cancer
- Severe cirrhosis
- Cardiovascular disease
- Diabetes with evidence of microvascular disease
- breast feeding women
what are non contraceptive benefits of COC (5)
- regulation of menstrual cycle
- reduction in dysmenorrhea
- decreased risk of ovarian and endometrial cancer and ovarian cysts
- reduces heavy menstrual flow- protecting against anemia
- protects against PID due to thickened cervical mucus
whats the effectiveness of coc
99.2%-99.9%
what is the combined patch contraceptive
Transdermal patch that releases estrogen and progesterone directly into the skin
how does the transdermal patch work (2)
- Each patch contains 1 week supply of both norelgestromin and ethnyl estradiol
- They releases norelgestromin 150 mg and ethinylestradiol 20 mg per 24hrs
what are advantages of transdermal patches (2)
- Greater compliance
- decreased adverse effects.
what are disadvantages of transdermal patches (2)
- Compromise in efficacy if removed unnoticed
- Other disadvantages and contraindications as in oral contraceptives
what are the progestin only pills
Pills that contain very low doses of a progestin like the natural hormone progesterone in a woman’s body.
because POP dont contain estrogen they can be used where
throughout breastfeeding and by women who cannot use methods with estrogen.
POP can also be called what (2)
- mini pills
- progestin only contraceptives
how do POP work (3)
- Thickening cervical mucus (this blocks sperm from meeting an egg)
- Suppresses ovulation
- Thins endometrial lining
what is the effectiveness of POP
When taken daily at the same time, POPs are 92 – 99% effective.
POP are less effective for who
women not breastfeeding
what are advantages of POP (10)
- Are controlled by the woman
- Do not interfere with sexual intercourse.
- Immediate return of fertility when stopped.
- User can stop any time when pregnancy is desired.
- Can be provided by trained non-medical staff.
- Does not affect breastfeeding.
- May decrease menstrual bleeding
- May prevent/correct anemia by decreasing menstrual flow.
- Protects against endometrial cancer.
- Offers some protection against PID
what are disadvantages of POP (2)
- Does not protect against STIs, HIV.
- Mild headaches and breast tenderness may occur.
what are the instructions for POP (5)
- Take one pill at the same time each day until the pack is empty.
- Start a new pack immediately (the following day) after you finish the previous pack.
- Taking a pill more than 3 hours late makes it less effective.
- It is normal to experience menstrual irregularities during the first 2-3 cycles. They are usually harmless. If worried report for a check-up.
- One may also experience mild headache and breast tenderness or fullness.
what are warning signs for POP (3)
- Severe lower abdominal pain (may be a symptom of ectopic pregnancy).
- Heavy bleeding or prolonged bleeding.
- Migraine headache, or blurred vision
what is an example of an injectable progesterone
depot medroxyprogesterone acetate 150mg (IM)
how does DMPA work (2)
- It leads to inhibition of ovulation with the suppression LH levels
- Eliminates the LH surge
how long does DMPA last
3 months (12 weeks)
what is the efficacy of DMPA
94%
what is the failure rate of DMPA
6%
what are advantages of DMPA (8)
- No serious adverse effects of estrogen like thromboembolism
- Diminished anemia
- Decreases dysmenorrhea
- Decreases risk of endometrial and ovarian cancer
- Safe for breastfeeding mothers and women who cannot/will not take estrogen products
- Rapidly and highly effective
- does not interfere with sexual intercourse
- only 4 clinic visits per year
what are disadvantages of DMPA (6)
- Menstrual cycle disruption
- Weight gain
- Headaches
- Mood changes
- Decreased libido
- delays return of fertility
how effective is the emergency oral contraception
75-89%
what is the other name of emergency oral contraceptive
morning after pill
when can you take emergency oral contraveptives
3-5 days after unprotected sex
when does the effectiveness of emergency oral contraception decrease
after 24 hours
when can you use emergency contraceptives (4)
- unprotected intercourse,
- contraceptive failure
- incorrect use of contraceptives
- in cases of sexual assault.
what are the types of barrier methods (4)
- Male condoms
- Female condom
- Spermicidal agents
- Diaphragm
what are advantages of male condoms (3)
- Readily available
- Inexpensive or free
- Effective against some sexually transmitted diseases
what are disadvantages of condoms (3)
- Latex allergy
- Breakage
- Slipping off during sexual intercourse
what is a femidom (female condom0
It is a sac with a wide ring that fits over the introitus with a loose inner ring that fits over the cervix
what are advantages of the female condom (3)
- Less likely to rupture
- Can be used without male having an erection
- Effective against some STIs
what are disadvantages of female condoms (3)
- Associated with increased sexually transmitted infection if used multiple times with multiple partners
- Vaginal placement is difficult
- Some complain of noisy sex hence less likelihood of usage
what is the failure rate of male condoms
18%
what is the failure rate of female condoms
21%
what are the 2 types of hormonal emergency pills
- emergency contraceptive pill
- the intrauterine device
what are examples of emergency contraceptive pill (2)
- levonelle
- ellaone
when should you put an IUCD for emergency contraception
must be fitted up to 5 days after intercourse or your last ovulation
what is the correct use of a condom (5)
- Use a new condom for each act of sex
- Before any physical contact, place the condom on the tip of the erect penis with the rolled side out
- Unroll the condom all the way to the base of the erect penis
- Immediately after ejaculation, hold the rim of the condom in place and withdraw the penis while it is still erect
- Dispose of the used condom safely
what are spermicides
Sperm-killing substances inserted deep in the vagina, near the cervix before sex.
what is MOA of spermicides
Causes the membrane of sperm cells to break, killing them or slowing their movement
what are side effects of spermicides (2)
- Irritation of the vagina or penis
- Urinary Infection
what is a diaphragm
These are latex or non-latex devices that are inserted into the vagina to prevent passage of sperm to the cervix. They can be inserted in advance of sex.
what is the failure rate of diaphragms
18%
what is the failure rate of withdrawals
22%
what is the failure rate of fertility awareness based methods
24%
diaphragms should be used in conjunction with what
spermicidal agents
what is a cervical cup
its a cup shaped latex device
what is the MOA of the cervical cup
uses mechanical and chemical barriers
when should you insert a cervical cup
8 hours before coitus up to 48 hours postcoital act
what is the advantage of the cervical cup
there is no use of hormonal contraceptive
what is the disadvantage of the cervical cup (2)
- cervical irritation
- doesnt protect against STI
what are examples of fertility awareness based methods (natural family planning) (2)
- cycle beads
- symptom bases like cervical secretions and basal body temperature
how does lactational amenorrhea method work (2)
- Elevated prolactin levels leads to suppression of ovulation.
- Reduction in LH release and inhibition of follicular maturation
for LAM to work what should be done (3)
- Complete amenorrhoea after cessation of the lochia
- Exclusive breastfeeding day and night with no additional food supplements
- Baby under six months of age
