Pregnancy and STI Prevention

Question 1

Unintended Pregnancies

Answer 1

• 45% in US are unintended
• 75% unintended in 15-19 yr old
• Unintended pregnancy rates/1,000 persons is highest among:
  • Aged 18-24 years old
  • Low income <100% of federal poverty level
  • Those not completing high school
  • Non-Hispanic black or African American
  • Cohabiting but never married

Question 2

How Pregnancy Occurs

Answer 2

• Viable egg released during ovulation to be available for fertilization
• Conception occurs during a 6-day window
• How to prevent pregnancy
  • Suppress ovulation
  • Prevent fertilization***
  • Prevent implantation

Question 3

STIs Overview

Answer 3

• Via contact with infected partner
- Genital tissues, mucus membranes, body fluids
• Equally effect genders; patients with a uterus more prone to reproductive consequences
- Pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, epididymitis, malignancy, and infertility
• Perinatal consequences
- Morbidity/mortality, low birth weight, premature birth, transmission

Question 4

STI Transmission

Answer 4

• Spread through infected secretions

• HIV
• Gonorrhea
• Chlamydia
• Trichomoniasis
• Bacterial vaginosis (BV)
• Hepatitis B

• Spread through infected skin or mucosal surfaces

• Herpes simplex virus (HSV)
• Syphilis
• Chancroid
• Human papilloma virus (HPV)

Question 5

Prevention of STIs and Pregnancy Self-care Overview

Answer 5

• Vaccines

• HPV
• Hepatitis B

• Contraception

• Condoms, spermicides, sponge
• Fertility Awareness-Based Methods
• Emergency contraception
• Hormonal contraception

Question 6

HPV and Vaccine

Answer 6

• Most common STI in the US
• Highest risk of infection during first few years after sexual activity begins
• HPV is a major cause of genital warts and cervical cancer

Question 7

Gardasil-9

Answer 7

• Approved for age 9-45 years old to prevent precancerous or dysplastic lesions

• <15 years old: 2-doses at 0 and 6-12 months
• ≥15 years old (+immuno): 3-doses at 0, 1-2 months, and 6 months
• Best prior to HPV exposure but previous sexual intercourse does not preclude vaccination with expected benefit
• Adverse effects: injection site irritation, malaise, syncope (monitor x15 min)

Question 8

Hepatitis B and Vaccines

Answer 8

• Infection has long-term complications (hepatitis, cirrhosis, hepatic carcinoma, death)
• New infections associated with high-risk sexual behaviors or injection drug use
• Inactivated hepatitis B vaccine
• 3-doses at 0, 1, and 6 months
• 2-doses at 0 and 1 month

• Candidates not previous vaccinated who meet risk criteria

• Sexual exposure to partners of hepatitis B-infected persons
• Not in long-term mutually monogamous sexual relationships
• In need of evaluation/treatment for a STI
• Men who have sex with men

Question 9

Contraception

Answer 9

• No method is 100% effective (except abstinence)
• Effectiveness is reported as accidental pregnancy rate in the first year of:
• PERFECT use (method-related failure)
• TYPICAL use (use/user-related failure)
• Most effective way to avoid STIs is to abstain from risky sexual activity or be involved in long-term mutually monogamous relationship with uninfected partner
• Otherwise, preventive strategies + contraceptive(s) may be best for reducing risk

Question 10

Choosing Contraception

Answer 10

• Effectiveness
• Accessibility
• Convenience of use
• Duration of action/reversibility
• Effect on menstruation
• Adverse effects
• Cost
• STI protection
• Partner’s preferences

Question 11

External Condoms

Answer 11

• Most important barrier contraceptive device to protect against STIs
• FDA regulates condoms as medical devices
• Spermicide-coated condoms no more effective at STI or pregnancy prevention and may cause irritation which can increase infection risk
• Breakage rates unknown and vary widely
• Proper use is essential to efficacy

Question 12

Internal Condoms

Answer 12

• Nitrile with outer ring, a sheath or pouch that fits over vaginal mucosa, and inner ring that secures the sheath by fitting like a diaphragm over the cervix
• Lower breakage rate but higher slippage rates than male condoms
• Effective barrier to STIs
• One time use; may insert up to 2 hours before intercourse, effective immediately
• Must ensure that condom has not expired
• Complaints include vaginal irritation and “squeaking” – alleviated by additional lubrication
• Wearers may have decreased sensation or even discomfort d/t outer ring
• Do NOT use with external condoms (friction increases risk of breakage of both)

Question 13

Vaginal Spermicides

Answer 13

• Use surface-active agents to immobilize and kill sperm
• Also acts as physical barrier when in gel or foam formulation
• In US, all products contain nonoxynol-9
• Not protective against STI transmission (use WITH condoms for STI protection)
• High failure rate when used alone, good option when need back up method
• Not recommended for patients with vaginal anatomic abnormalities
• Delay douching at least 6 hours after intercourse
• Gels: +lubrication, applicators
• Foams: even, adhere well
• Suppositories: may need to fridge
• Contraceptive films: hard to use, least messy

Question 14

Emergency Contraception (EC)

Answer 14

• Prevent pregnancy up to 3-5 days after unprotected sex

• Hormones in EC:
• Progestin (synthetic progesterone, usually levonorgestrel) OR
• Estrogen + progestin (levonorgestrel) OR
• Selective progesterone receptor modulator
• For patients who can get pregnant who’ve had recent unprotected sex, experienced method failure, or who desire advance provision in the event of a need for EC
• Should not be used as routine contraception
• Levonorgestrel EC (Plan B) reduces pregnancies by 52-100%
• Suppresses ovulation
• May interfere with transport of sperm or egg
• Thickens cervical mucus

• EC will NOT affect an already-implanted embryo or increase risk of fetal malformations

Question 15

California HC Furnishing

Answer 15

• Pharmacists may furnish self-administered hormonal contraception

• Oral tablets (combo hormonal contraception)
• Transdermal patch
• Vaginal ring
• Depot injection

• Requirements

• Patient fills out self-screening tool and pharmacist reviews it
• Check and record patient’s seated blood pressure if desiring oral tablets
• Counsel on how to use contraceptive (dose, effectiveness, side effects, safety, importance of preventative health screenings, lack of STI protection)