Lecture 7: Contraception Flashcards
How common are unintended pregnancies?
45%
What is the main cause of 40% of unwanted pregnancies?
Not using birth control
Top 3 reasons for not using contraception
- They dont care if they get pregnant
- Worried about the side effects
- Did not think they’d get pregnant
What is the general consensus regarding contraceptives in adolescents?
Give it to them!
What other disorders may use contraceptives as a form of tx? (3)
- Endometriosis
- PCOS
- Premenstrual dysphoric disorder (PMDD)
What are the 4 most effective contraceptive methods?
- Implant (F)
- Vasectomy (M)
- Tubal occlusion (F)
- IUD (F)
What methods are considered the worse for contraception?
- Coitus interruptus (pull-out method)
- Postcoital douche
- Periodic abstinence
- Lactational amenorrhea
Not using any birth control products
When is it appropriate to restart contraceptives after delivery?
3 months after
What is the most effective determinant of periodic abstinence?
Serum LH peak
What is the MC method of periodic abstinence?
Calendar method
It is also the least reliable
What is the billings method/cervical mucus method for periodic abstinence?
- Checking ovulation by checking cervical mucus
- Thin/watery = right before ovulation
- Thicker = rest of cycle
Thin/watery = you are about to ovulate
What is the likely most effective method for periodic abstinence?
Symptothermal: Cervical mucus + temperature
thick mucus + 3rd day after elevated temp should be safe?
How does temperature vary in ovulation?
- Drops slightly 24-36 hrs before ovulation
- 3rd day after onset of elevated temp = fertile period over
What is in COC (combination oral contraceptives)?
- Estrogen: ethanyl estradiol (MC), mestranol, 17b-estradiol, or estradiol valerate
- Progestin: norethindrone, levonorgestrel, desogestrel, norgestimate, drosperinone
Which progestin ingredient is a spironolactone analogue?
Drosperinone, which is less androgenic but higher VTE risk.
What is the cycle of COCs?
- 21 days of active hormones
- 7 days of placebo
Newer is 24-4
What should patients expect after stopping active COCs?
Withdrawal bleed 2-5 days after
What are the 3 ways of beginning the administration of COCs?
- Ideal: first day of menstrual cycle
- Traditional: first sunday following menses
- Quickstart: day you get it
When is missing a pill concerning/emergency?
Any missed pill + coitus in past 5 days
What is the MOA of COCs?
Suppression of ovulation
Alters consistency of mucus
Makes endometrium less receptive to implantation
What is the MC drug class that interacts with COCs?
Anticonvulsants
What are the benefits of using COCs? (8)
- Reduced ovarian cx
- Reduced endometrial cx
- Improved bone mass
- Decreased progression of RA
- Improves acne
- Lower risk of ectopic + PID
- Decreased risk of benign fibrocystic breast dz
- Improvement in dysmenorrhea and premenstrual s/s
What are the major SEs of COCs? (6)
- VTE
- MI
- Stroke
- Liver dz
- Cervical dysplasia/cancer
- Breast cancer (controversial)
clotsx3, liver + cervix
CIs to COCs (8)
- Pregnant
- Undxd vaginal bleeding
- Migraine w/ aura
- Prior hx of VTE/MI/Stroke
- Increased risk for CV issues (SLE, DM, HTN uncontrolled)
- Smoking over 35
- Current/hx of breast cx
- Active liver dz
Bottom 5 are all things it enhances
What should we keep in mind regarding POCs (progestin-only contraceptives)?
Does not suppress ovulation
Estrogen suppresses ovulation by inhibiting FSH
Why would someone take POCs?
- No estrogen effects
- No special sequence for pill-taking
Cons of using POCs? (3)
- Must take at same time daily
- Higher rates of irregular bleeding
- Higher overall pregnancy rate
CIs to POCs (5)?
- Unexplained uterine bleeding
- Breast cx
- Hepatic neoplasms
- Pregnancy
- Active liver dz
Primarily liver issues
What are the 3 methods for emergency contraception?
- Yuzpe method
- Levonorgestrel
- Copper IUD
After you have unprotected sex or misused contraceptive
Describe the Yuzpe method, including dosages and dosing
- COCs containing levonorgestrel
- 100mcg ethinyl estradiol + 500-600mcg levono
- 2 doses, 12 hrs apart
- 1st dose must be taken within 72 hrs of sex
Main SEs of Yuzpe method (2)
N/V, recommended to premedicate.
Describe levonorgestrel/Plan B/Aftera, including dosages and dosing
- Single dose of 1500mcg of levono or 2 12hrs apart
- Take within 72hrs
- Prevents LH surge
Single doseor double if you want
Yuzpe is double
Describe Ulipristal/Ella, including dosages and dosing
- Single dose of 30mg
- Within 72 hrs of sex
- Prevents LH surge/may delay ovulation post LH surge
Single dose, similar to levono/plan B
Yuzpe is the only 2 pill emergency
When does a copper IUD need to be inserted to be used as emergency contraception?
5-7 days from the time of sex
When does a levono IUD for emergency contraception need to be implanted relative to last time of intercourse?
5 days from the time of sex
Why are IUDs preferred for emergency contraception? (3)
- Better efficacy
- No drop in efficacy if BMI increases
- Left in place
When are vaginal rings worn?
Nuvaring/Eluryng/annovera
- 3 weeks a month
- Designed to be left in place
- Can be disposable or reusable
How often are transdermal patches applied for birth control?
New patch Q weekly for 3 weeks
Same schedule as vaginal ring
If a contraceptive patch becomes detached, how long do you have to apply it back?
< 24 hrs
Otherwise, use a backup method for 1 week and then new patch.
Compared to COCs, what SEs are transdermal patches more likely to have?
- Breast symptoms
- Dysmenorrhea
- Higher failure rate if obese
How often is a Depo Shot given?
Progesterone shot IM Q 3 mo
Major SE of Depo Shots?
Decreased bone density
What is contained within the nexplanon implant?
Progesterone
How long does nexplanon work?
approved for 3 yrs
May work up to 5
Small rod, small time
MC SEs of nexplanon (3)
- Irregular menses
- Wt gain
- HA
How long is a copper IUD good for?
10 years
CIs to Copper IUD (5)
- Intrauterine contents: Pregnancy/displaced uterus
- Infections
- Uterine/cervical cx (known or suspected)
- Wilsons
- Allergy
How long does a levono IUD last?
8 years
Mirena
How does usage of a levono IUD work initially?
Mirena
- First causes irregular menses for 3-4 months
- Decreases menorrhea after
- Then improves
How long do kyleena and skyla, the lower dosage levono IUDs, last?
- Kyleena: only up to 5 yrs
- SKYla: only up to 3 yrs
Kyleen is sky’s big sister
What are the 2 main benefits of Mirena over Kyleena and Skyla?
- Longer lasting (up to 8y)
- Can also be used to treat heavy menses or dysmenorrhea
Mirena is kyleen’s older sister
CIs to progesterone IUDs
- Intrauterine contents
- Infections
- Cancer (uterine/cervical/breast)
- Acute liver dz
- HSR
- Prior ectopic
How do you check if an IUD is still in place?
Check if the string is still hanging out
What is the primary ingredient of most spermicides?
Nonoxynol-9 (destroyer of sperm): much cheaper
What is the alternative, more expensive option to nonoxyl-9 for spermicide?
Phexxi, which is acid based and lowers vaginal pH.
Also makes a physical barrier
PHexxi = affects pH
Patient education regarding using spermicides (5)
- Place right before sex: lasts 1 hr
- Avoid douching for 6 hrs after
- They suck
- DO NOT PROTECT AGAINST STDs
- Can cause local inflammation
What is a contraceptive sponge?
Sponge impregnated with nonoxyl-9
Leave in for 6 hrs after, but you can place it 24 hrs prior
For if you’re not sure if you’re doin it
What are condoms generally made of?
Latex
Which condom material is permeable?
Lamb’s cecum
What might an internal/female condom might be useful for?
Reducing risk of HIV
What are the components of a diaphragm + spermicide?
- Physical barrier
- Spermicide on cervical side
What are the issues with a diaphragm + spermicide setup? (2)
- Need spermicide to work
- Need to fit them
6 hours prior, 6-24 after
What is a cervical cap?
- Literally a cup for your cervix
- Can put spermicide in it
- Gotta check after sex everytime
What is the MC method of contraception worldwide for women?
Sterilization
Who legally cannot get permanent contraception?
- Pts < 21 (for most states)
- Mentally incompetent
4 methods for female tubal sterilization
- Electrocoagulation (low failure, high complication)
- Mechanical tubal occlusion (favorable long-term BUT NO LONGER DONE IN THE US!!!!!!!)
- Ligation of tube with suture material
- Salpingectomy (complete removal, estimated high efficacy)
Which female tubal sterilization technique is most associated with ectopic pregnancy?
Electrocoagulation
The one with high complication rate
Why do we not use chemical tubal occlusion?
Carcinogenesis and toxigenesis
Why is male sterilization preferable?
- Easier to reverse
- Much lower failure rates and postop complications
Safest and most effective method for abortion?
Suction curettage
12 wks or less gestation
What are the 4 combinations used for medical abortion? MC and effective among them?
- Mifepristone (mifeprex) + Misoprostol (Cytotec): MC and effective (mi & mi)
- Methotrexate + misoprostol
- Misoprostol alone
- Oral anti-progestin followed by misoprostol 48h after
Primarily used in 1st trimester, < 49d from FDLMP
Cytotec is in ALL 4 METHODS
After the 1st trimester, what are some of the abortion methods? (3)
- Intra-amniotic instillation (replacement of amniotic fluid with hypertonic saline)
- Dilation and evacuation (MC): modified suction curettage
- Hysterectomy/hysterotomy (cervical stenosis)
When is menstrual regulation used primarily?
Lack of access to pregnancy tests
What is the MOA of cytotec/misoprostol?
Synthetic PGE1
Causing contractions and ripening
When are we concerned about long-term for abortion sequelae?
2 or more procedures (increased risk of mid-trimester loss)
After abortion, how long should intra-vaginal products be avoided?
2 weeks
Including sex
