Obj 33: Contraception & Sterilization Flashcards
A 36-year-old G2P2 woman presents with irregular vaginal bleeding. Six weeks ago, she had her first Depo-Provera® injection and now she has unpredictable bleeding. She is concerned by these symptoms. She has a history of hypertension but is currently on no medications. Vital signs reveal: blood pressure 130/90; weight 188 pounds; height 5 feet 5 inches; BMI 31.4kg/m2. Which of the following is the most appropriate next step in the management of this patient?
A. Reassurance
B. Begin oral contraceptives
C. Begin estrogen
D. Insert etonogestrel implant (Implanon)
E. Perform an endometrial biopsy
A. The patient should be reassured since initially after Depo-Provera injection there may be unpredictable bleeding. This usually resolves in 2-3 months. In general, after one year of using Depo-Provera, nearly 50% of users have amenorrhea.
A 23-year-old G0 woman with last menstrual period 14 days ago presents to the office because she had unprotected intercourse the night before. She does not desire pregnancy at this time and is requesting contraception. She has no medical problems and is not taking any medications. In addition to offering her counseling and testing for sexually transmitted infections, which of the following is the most appropriate next step in the management of this patient?
A. Observation for two weeks to establish if pregnancy occurred before initiating treatment
B. Oral contraceptives now
C. Oral contraceptives after her next normal menstrual period
D. Emergency contraception and follow-up after next menstrual period
E. Provide emergency contraception, then begin oral contraceptives immediately
E. Emergency contraceptive pills are not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy. They are more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours. Plan B®, the levonorgestrel pills, can be taken in one or two doses and cause few side effects. Emergency contraceptive pills may be used anytime during a woman’s cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light, to normal, to heavy.
A 35-year-old G3P3 woman requests contraception. Her youngest child is seven years old. Her periods have been regular since she discontinued breastfeeding five years ago. Her past medical history includes depression that is controlled with antidepressants, and a history of deep venous thrombosis. She denies smoking or alcohol use. In the past, oral contraceptive pills have caused her to have severe gastrointestinal upset. What in her history makes her an ideal candidate for progestin-only pills?
A. Depression
B. Smoking history
C. Severe nausea on combined oral contraceptives
D. Lactation history
E. Deep venous thrombosis
E. Ideal candidates for progestin-only pills include women who have contraindications to using combined oral contraceptives (estrogen and progestin containing). Contraindications to estrogen include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills. Progestins should be used with caution in women with a history of depression.
A 24-year-old G1P1 woman comes to the office requesting contraception. Her past medical history is unremarkable, except for a family history of ovarian cancer. She denies alcohol, smoking and recreational drug use. She is in a monogamous relationship. She wants to decrease her risk of gynecological cancer. Of the following, what is the best method of contraception for this patient?
A. Diaphragms
B. Condoms
C. Copper containing intrauterine device
D. Progesterone containing intrauterine device
E. Combined oral contraceptives
E. Oral contraceptives will decrease a woman’s risk of developing ovarian and endometrial cancer. The first developed higher dose oral contraceptive pills have been linked to a slight increase in breast cancer, but not the most recent (current) lower dose pills. Women who use oral contraceptive pills have a slightly higher risk of developing cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis, benign breast changes and ectopic pregnancy are reduced. Both hypertension and thromboembolic disorders can be a potential side effect from using oral contraceptive pills.
Diaphragms, condoms and intrauterine devices will not lower her risk of ovarian cancer.
The progesterone IUD may decrease a woman’s risk for endometrial cancer but would not affect her risk for ovarian cancer, and have been associated with increased ovarian cysts.
A 37-year-old G3P3 woman presents for contraceptive counseling. She and her husband have decided that they no longer plan to have children and desire permanent sterilization. Her husband refuses to have a vasectomy. On exam, her BMI is 52; blood pressure is 140/80; and heart rate is 86. She has had three previous Cesarean deliveries. Which of the following options would be the be the best method of permanent sterilization?
A. Laparoscopic tubal ligation
B. Mini-laparotomy with tubal ligation
C. Hysterectomy
D. Hysteroscopic tubal occlusion (Essure)
E. Endometrial ablation
D. Hysteroscopic tubal occlusion is the best option for this patient. Hysteroscopic tubal occlusion (Essure®) can be performed in the office and places coils into the fallopian tubes that cause scarring that blocks the tubes. Patients are required to use a back up method of contraception for three months following the procedure until a hysterosalpingogram is performed confirming complete occlusion of the tubes.
While tubal ligation, either by laparoscopy or mini-laparotomy, are common and effective forms of permanent sterilization, for this patient with her BMI and previous surgeries, this would carry more surgical risks.
Hysterectomy is not an indicated procedure for sterilization.
Endometrial ablation, or thermal destruction of the endometrial tissue, is an effective treatment for menorrhagia but is not reliable for permanent sterilization.
A 24-year-old G2P2 woman with a history of two prior Cesarean deliveries desires a tubal ligation for permanent sterilization. She has two daughters, who are 3 and 1 years old. She is very sure she does not desire any more children. She is happily married and is a stay-at-home-mom. What is the strongest predictor of post-sterilization regret for this patient?
A. Not working outside the home
B. Parity
C. Marital status
D. Age
E. Children’s gender
D. Approximately 10% of women who have been sterilized regret having had the procedure with the strongest predictor of regret being undergoing the procedure at a young age.
The percentage expressing regret was 20% for women less than 30 years old at the time of sterilization. For those under age 25, the rate was as high as 40%. The regret rate was also high for women who were not married at the time of their tubal ligation, when tubal ligation was performed less than a year after delivery, and if there was conflict between the woman and her partner.
A 32-year-old G3P3 woman comes to the office to discuss permanent sterilization. She has a history of hypertension and asthma (on corticosteroids). She has been married for 10 years. Vital signs show: blood pressure 140/90; weight 280 pounds; height 5 feet 9 inches; and BMI 41.4kg/m2. You discuss with her risks and benefits of contraception. Which of the following would be the best form of permanent sterilization to recommend for this patient?
A. Laparoscopic bilateral tubal ligation
B. Mini laparotomy tubal ligation
C. Exploratory laparotomy with bilateral salpingectomy
D. Total abdominal hysterectomy
E. Vasectomy for her husband
E. Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are performed as an outpatient procedure under local anesthesia, while tubal ligations are typically performed in the operating room under regional or general anesthesia; therefore carrying slightly more risk to the woman, assuming both are healthy. She is morbidly obese, so the risk of anesthesia and surgery are increased. In addition, she has chronic medical problems that put her at increased risk of having complications from surgery.
A 35-year-old G3P3 woman comes to the office because she desires contraception. Her past medical history is significant for Wilson’s disease, chronic hypertension and anemia secondary to menorrhagia. She is currently on no medications. Her vital signs reveal a blood pressure of 144/96. Which of the following contraceptives is the best option for this patient?
A. Progestin-only pill
B. Low dose combination contraceptive
C. Continuous oral contraceptive
D. Copper containing intrauterine device
E. Levonorgestrel intrauterine device
E. The levonorgestrel intrauterine device has lower failure rates within the first year of use than does the copper containing intrauterine device. It causes more disruption in menstrual bleeding, especially during the first few months of use, although the overall volume of bleeding is decreased long-term and many women become amenorrheic.
The levonorgestrel intrauterine device is protective against endometrial cancer due to release of progestin in the endometrial cavity.
She is not a candidate for oral contraceptive pills because of her poorly controlled chronic hypertension. The progestin-only pills have a much higher failure rate than the progesterone intrauterine device. She is not a candidate for the copper-containing intrauterine device because of her history of Wilson’s disease
A 23-year-old G0 woman comes to the office to discuss contraception. Her past medical history is remarkable for hypothyroidism and mild hypertension. She has a history of slightly irregular menses. Her best friend recently got a “patch,” so she is interested in using a transdermal system (patch). Her vital signs are: blood pressure 130/84; weight 210 pounds; height 5 feet 4 inches. What is the most compelling reason for her to use a different method of contraception?
A. Age
B. Hypothyroidism
C. Weight
D. Unpredictable periods
E. Her blood pressure
C. The patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use. It has a significantly higher failure rate when used in women who weigh more than 198 pounds. The patch is a transdermal system that is placed on a woman’s upper arm or torso (except breasts). The patch (Ortho Evra®) slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for seven days. A woman should apply one patch in a different area each week for three weeks, then have a patch-free week, during which time she will have a withdrawal bleed.
A 20-year-old G2P2 healthy woman presents for her post-partum check six weeks after a full term normal spontaneous delivery. She has a 13 month old in addition to the six-week newborn, and is already feeling overwhelmed. She desires a reliable form of contraception. On exam, her vital signs are normal. BMI is 27. The remainder of the exam is unremarkable. Of the following, what is the most effective and appropriate form of contraception for this patient?
A. Intrauterine device
B. Tubal ligation
C. Depo-Provera®
D. Oral contraceptive pills
E. Essure®
A. Long-acting reversible contraceptives (LARC) methods such as contraceptive implants and intrauterine devices are a good option for this patient. Despite high up-front costs and the need for office visits for insertion and removal, LARC methods provide many distinct advantages over other contraceptive methods as Depo-Provera® and oral contraceptives. While Depo-Provera is an effective form of contraception, it may not be the best choice in this woman with a high BMI.
For this young mother who desires a reversible, but reliable form of contraception, the high effectiveness, continuation rate and user satisfaction of LARC methods would be of most benefit. Emerging evidence indicates that increasing the use of LARC methods also could reduce repeat pregnancy among adolescent mothers and repeat abortions among women seeking induced abortion. (“Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy,” ACOG Committee Opinion, No. 450, 2009).
Tubal ligation and Essure® are permanent and are not appropriate for this patient.
