OB: Contraception, Abortion & Infertility

Question 1

What is fertility awareness methods (FAMs)?

Answer 1

Identifying the beginning and end of the fertile period of the menstrual cycle. There are three phases:

1. Infertile phase: period before ovulation.
2. Fertile phase: approx. 5 to 7 days around the middle of the cycle, including days before, during, and the day after ovulation.
3. Infertile phase: after ovulation

Question 2

When can an ovum be fertilized?

Answer 2

No later than 16 to 24 hours after ovulation. However, ability of a motile sperm can last up to 24 - 48 hours. Pregnancy is unlikely to occur if abstaining from intercourse for 4 days before and for 3 - 4 days after ovulation (fertile period).

Question 3

What is calendar rhythm method?

Answer 3

Based on number of days in each cycle counting from the first day of menses. Fertile period is determined by recording teh lengths of menstrual cycles for 6 months.

• Beginning of the fertile period = Subtracting 18 days from shortest cycle.
• End of the fertile period = Subtracting 11 days from the length of the longest cycle.

Question 4

What is the standard days method?

Answer 4

It is a modified calendar rhythm method. Has fixed numbers of fertility days (days 8 to 19). Using a CycleBeads necklace to count. Useful for women whose cycles are 26 to 32 days.

Question 5

What is Two Day method?

Answer 5

The woman asks two questions:

1. “Did I note secretions today?”
2. “Did I note secretions yesterday?”

If the answer is yes to either questions, she should avoid coitus. If no to both, probability of getting pregnant is very low.

Question 6

What is symptothermal method?

Answer 6

Method combines at least two methods, usually cervical mucus changes with basal body temperature (BBT), in addition to heightened awareness of secondary, cycle phase related symptoms.

Question 7

How does cervical mucus change throughout the menstrual cycle?

Answer 7

• Postmenstrual mucus: scant
• Preovulation mucus: cloudy, yellow or white, sticky
• Ovulation mucus: clear, wet, sticky.
• Postovulation fertile mucus: thick, cloudy, sticky

Right before ovulation, the watery, thin, clear mucus becomes more abundant and thick.

Question 8

How often should a diaphragm examined?

Answer 8

An annual gynecologic examination is needed to assess fit of the diaphragm. Woman should inspect device before and every use and replace it at least every 2 years.

Needs to be refitted if:

• 20% weight fluctuation
• after any abdominal or pelvic surgery
• every term prgenancy and miscarriage
• abortions that occurs after 14 weeks of gestation

Question 9

When to insert and remove diaphragm?

Answer 9

Diaphragm can be inserted up to 6 hours before intercourse and must be left in place at least 6 hours after teh last intercourse.

Question 10

What is toxic shock syndrome?

Answer 10

Occurs in association with use of contraceptive diaphragms and cervical caps. To reduce risk, promptly remove diaphragm 6 to 8 hours after intercourse and not using themduringe menses, and learning and watching for danger signs.

Question 11

How long should the cervical cap remain?

Answer 11

No less than 6 hours and not more than 48 hours at a time. Should be left in place 6 hours after the last act of intercourse.

Question 12

When to insert the cervical cap?

Answer 12

Cap can be inserted hours before sexual intercourse with a need for additional spermicide later. No additional spermicide is required for repeated acts of intercourse when the cap is used.

Question 13

How is the menstrual cycle feedback mechanism maintained?

Answer 13

Body secretes follicle-stimulating hormone (FSH) and LH in response to fluctuating levels of ovarian estrogen and progesterone. Regular ingestion of combined oral contraceptive pills (COCs) suppresses the action of teh hypothalamus and anterior pituitary that inhibits production of FSH and LH, therefore follicles do not mature, suppressing ovulation.

Question 14

What are the noncontraceptive benefits of COCs?

Answer 14

1. Decreased menstrual blood loss
2. Decreased iron-deficiency anemia
3. Regulation of menorrhagia and irregular cycles
4. Reduced incidence of premenstrual syndrome (PMS)
5. Protection against endometrial & ovarian cancer
6. Reduced incidence of benign breast disease & acne
7. Decreased risk of ectopic pregnancy

Question 15

How are oral contraceptives initiated?

Answer 15

They are initiated three ways:

1. Quick start - taking the 1st pill the same day as the clinic appointment & using a back-up method for 7 days.
2. First day start - taking the 1st pill on the 1st day of the menstrual cycle, and
3. Sunday start - taking the 1st pill on the 1st Sunday after the start of the menstrual period.

Question 16

What are the contraindications for COCs?

Answer 16

• Hx or presence of:
  
  • thromboembolic disorders
  • cerebrovascular or coronary arty disease
  • valvular heart disease
  • breast cancer or estrogen-dependent tumors
  • impaired liver function & liver tumor
  • hypertension
  • HAs with focal neurologic symptoms

Question 17

What are common side effects of excess estrogen?

Answer 17

• Nausea
• Breast tenderness
• Fluid retention
• Chloasma (dark patches on the skin)

Question 18

How do you apply a contraceptive transdermal patch and what does it deliver?

Answer 18

The patch is appled on the same day once a week for 3 weeks followed by a week without. Withdrawal bleeding occurs during the “no patch” week. The patch delivers continuous levels of noreglestromin (progesterone) and ethinyl estradiol.

Question 19

What is the health concern of contraceptive transdermal patch?

Answer 19

Increased risk of venous thrombophlebotic conditions due to total serum estrogen levels may be higher than with COCs.

Question 20

How is vaginal ring applied?

Answer 20

The woman wears the vaginal ring for 3 weeks followed by a week without. The ring can also be used for extended cycles of 49 to 364 days (with changes every 21 days).

• Mechanism of action, efficiency, contradictions and side effects are similar to those of COCs.

Question 21

How often must women take Oral progestins (minipill)?

Answer 21

Given that progestin-only pills (POPs) contain low doses of progestin, women must take the pill at teh same time every day.

Question 22

How do progestin-only methods work?

Answer 22

Impair fertility by inhibiting ovulation by thickening and decreasing the amount of cervical mucus, thinning the endometrium, and altering cilia in the uterine tubes.

Question 23

How is depot medroxyprogesterone acetate (DMPA or Depo-Provera) administered?

Answer 23

Its given intramuscularly (150mg) in the deltoid or gluteus maximus muscle. 21-23 gauge needle, 2.5 to 4cm long. It’s initiated during the first 5 days of the menstrual cycle and administered every 12 weeks or 3 months.

Question 24

What are the advantages of DMPA?

Answer 24

Advantages include:

• a contraceptive effectiveness comparable to COCs,
• long lasting effects
• requirement of injection only 4 times a year

Question 25

What are the side effects of DMPA?

Answer 25

Side Effects

• Decreased bone mineral density
• weight gain
• lipid changes
• increased risk of venous thrombosis and thromboembolism
• irregular vaginal spotting
• decreased libido
• breast changes
• lack protection against STIs
• delay return to fertility may be as long as 6 to 12 months

Question 26

How do implantable progestins work?

Answer 26

Implants consist of one or more nonbiodegradable flexible tubes or rods that are inserted under the skin of woman’s nondominating arm. The implants contain progestin hormone that are effective for at least 3 years. They must be removed at the end of the recommended time.

Question 27

What are the side effects of implantable progestins?

Answer 27

Side effects include:

• irregular menstrual bleeding

Less common are:

• headaches
• nervousness
• nausea
• skin changes
• vertigo

Question 28

What emergency contraceptions (EC) are available in the U.S.?

Answer 28

EC include:

• Ella (Ulipristal): single 30-mg pill containing an antiprogestin
• Plan B One-Step: single progestin pill (1.5mg levonorgestrel
• Next Choice: 2 levonorgestrel .75mg tablets taken orally 12 hrs apart or together
• Combined oral: estrogen-progestin pills (100mcg ethynyl estradiol + .5mg levonorgestrel); 2 doses given 12 hrs apart
• Copper intrauterine devices (IUD) insertion within 12 hrs of intercourse

Question 29

How soon should a women take an EC?

Answer 29

As soon as possible, but within 72 hours of unprotected intercourse.

Question 30

Which EC are approved by the FDA for over-the-counter sales?

Answer 30

Plan B One-Step and Next Choice for women ages 17 and older with proof of age. Adolescents 16 years and under require a prescription. Ella is available only with a prescription.

Question 31

What are the advantages and disadvantages of choosing inrauterine devices (IUDs)?

Answer 31

Advantage:

• long-term protection from pregnancy and immediate return to fertility when removed.
• Used as effective form of EC inserted shortly after unprotected intercourse

Disadvantage:

• Increased risk of pelvic inflammatory disease (PID) shortly after placement
• Infection and possible uterine perforation

Question 32

Signs of potential complications with IUDs?

Answer 32

Includes:

1. Severe abdominal pain, pain with intercourse
2. Late or missed period; abnormal spotting or bleeding
3. Abnormal vaginal discharge
4. Not feeling well, fever, or chills
5. String missing, shorter or longer
6. Presence of the device outside the cervix or in the vagina

Question 33

What is induced abortion?

Question 34

What are the methods available for first-trimester abortion?

Answer 34

Methods for performing early abortion (less than 9 weeks) include surgical (aspiration) and medical methods (mifepristone with misoprostol and methotrexate with misoprostol).

Question 35

What are signs of potenial complications with induced abortion?

Answer 35

• Fever great than 38C (100.4F)
• Chills
• Bleeding greater than two saturated pads in 2 hrs or heavy bleeding lasting a few days
• Foul-smelling vaginal discharge
• Severe abdominal pain, cramping or backache
• Abdominal tenderness (when pressure applied)
• No return of menstrual period within 6 weeks

Question 36

What are the drugs used to induce early abortion?

Answer 36

• Methotrexate: cytotoxic drug that causes early abortion by blocking folic acid in fetal cells so that they can divide.
• Misoprostol (Cytotec): prostaglandin analog that acts directly on the cervix to soften and dilate the uterine muscle to stimulate contractions.
• Mifepristone: binds to progesterone receptors and blocks the action of progesterone, which is necessary for maintaing pregnancy.

Question 37

What method is used for secon-trimester abortion?

Answer 37

Dilation and evacuation (D&E). It accounts for almost all second-trimester abortions performed in the U.S.

Question 38

How is D&E performed?

Answer 38

1. Osmotic dilators are inserted several hours or days before the procedure. Or misoprostol is applied to the cervix.
2. A large cannula and other instruments are used to remove teh fetus and the placenta.