Women's Health, Contraceptive Counseling- Schoenwald Flashcards
Decision Making
-For many people, personal and sensitive issue–> Religious or philosophical
- High rate of unintended or unplanned pregnancy, 2009 ~49.2%
- Oral contraceptives: Side effects, access, methods difficult to use correctly
Approximately __% of unintended pregnancies occur in women who do not desire pregnancy yet do not use a method of contraception
40%
Approximately ___% of unintended pregnancies occur in women using some form of birth control
60%
Teenage pregnancy has dropped, 2009 study found rate dropped ___% from 1990 to 2005
40%
Why use birth control?
- Family Planning – limit family size, space children
- Avoid child bearing – personal, medical condition
- Provider to discuss information on both benefits and risks of both contraception and pregnancy – so the patient can make an informed choice
- Most states have laws that permit access to contraception for minors (under 18yo)- confidential visits
- Signed consent forms (IUD, injections, Nexplanon, sterilization)
- Pregnancy test – documented negative
Methods of contraception:
- Folk methods – coitus interruptus, postcoital douche, lactational amenorrhea, and periodic abstinence (rhythm or natural family planning)
- Barrier methods
- Hormonal methods
- LARC – Long acting reversible contraception (IUDs and implantable progestin)
- Sterilization
List Ex’s of barrier methods
condoms (male and female), diaphragm, cervical cap, vaginal sponge, and spermicides
List Ex’s of Hormonal methods
oral contraceptives, patches, ring, and injectable
Describe Sterilization Procedures
tubal ligation or vasectomy
(BOTH are reversible, tubal ligation is more difficult to reverse due to scarring. Vasectomy is 1 procedure, and if it was decided to be reversed later on–> then you can do a reversible but it’s another procedure)
Comparing Effectiveness of Family Planning Methods:
Least effective: withdrawal methods, spermicide usage,
Next: condoms
Next: Injectables, Pills (OCPs), Patch, ring
Most effective: implants, IUD, sterilization
CDC Medical Eligibility criteria (for initiating contraception)
1- method can be used without restriction
2- Advantages of use generally outweigh theoretical or proved risk
3- Method usually not recommended unless other, more appropriate methods are NOT available or acceptable
4-Absolute contraindication, method NOT to be used
Coitus Interruptus
- One of the oldest contraceptive methods= pullout method
- Withdrawal of penis before ejaculation
- **Failure rate higher than most methods
Postcoital Douche=
- Plain water, vinegar, and a number of feminine hygiene products used
- Theoretically, douche flushes semen out of vagina
- Ineffective and unreliable
- Contributes to lack of normal vaginal flora>increased risk of infection
CDC chart on Contraceptive use:
know for exam
takeaways:
- Pts on OCPs are at a HIGHER risk for DVTs, OCPs in the setting of clotting history= 3,4 (if you can use something else you should, (ie a woman with Factor 5 may opt for an IUD in place of OCPs)
- -add in smoking in a Pt with clotting risk–> BAD
-any Pt with a clotting history SHOULD NOT be prescribed an OCP. safest to have another method
Lactational Amenorrhea=
Efficient method for breastfeeding women
Lactational Amenorrhea:
-suckling results in decreased ____
GnRH, LH, and FSH
Lactational Amenorrhea: results in ________ and anovulation
amenorrhea
anovulation (dont ovulate)
Lactational Amenorrhea:
During first 6 months, if breast feeding exclusively, menses are mostly anovulatory and fertility remains ____
low (0.9 – 1.2%)
Lactational amenorrhea:
-after 12 months, pregnancy rates ____
rose (7.4%)
Lactational Amenorrhea:
Must use breastfeeding as the ____ ____ of infant nutrition
only form
Periodic Abstinence=
-Women fertile for only a few days of menstrual cycle (so menstrual cycles are then mapped out)
- Rhythm or natural family planning method
- -Avoid coitus during the time of the cycle when woman most fertile
- -Fertile period=ovulation to 2-3 days after
What is the pregnancy rate for Pts using the periodic abstinence method?
Pregnancy rate 10-25%
Periodic Abstinence:
-Methods?
- Calendar method - failure rate up to 35%
- Temperature method – record upon wakening basal body temperature – temperature has slight drop 24-36 hours after ovulation. The temperature then rises abruptly (0.5-0.7 degrees F)for remainder of cycle.
- Cervical mucus method (Billings) – uses changes in cervical mucus to predict ovulation – starting several days before until just after ovulation, mucus becomes thin and watery, at other times mucus thick and opaque
Male Condom:
- Cover for the penis during coitus–> prevents deposition of semen into vagina
- Reduce transmission of infectious agents
Material: -Latex (most common) -Polyurethane (vinyl) -lamb intestine (lamb skin) effective and inexpensive contraception protection from STIs including HIV - no prescription needed -Some condoms contain spermicide
- Failure rate 10-30% in first year of use-technique?
- More effective if used in conjunction with other birth control method
- Still may have skin contact of scrotal-labial
Female Condom:
- material?
- describe this method
- disadvantages?
- Failure rate?
- Made of thin polyurethane material with 2 flexible rings on either end
- One ring fits inside vagina and other ring sits outside near the introitus
- Under control of female and offer some protection against STIs
- Disadvantages – cost and bulkiness
- 6 month failure rate with perfect use 2.6%
- Reduces annual risk of HIV by more than 90%
Can you use a female condom with a male condom?
NO -Do not use with male condom
Vaginal Diaphragm
=Mechanical barrier between vagina and cervical canal
- Designed to fit in vaginal canal and cover cervix
- Contraceptive jelly or cream should be placed on the cervical side of the diaphragm(insert with dome facing down)
- Can be inserted up to 6 hours before intercourse
- Should be left in place for at least 6-24 hours after intercourse
- Perfect use failure rate 6%,
- Normal use 15-20%
- Must be fitted by a healthcare provider, prescription needed
- May need size adjustment
- May protect against STIs-(minimal to none)
- May cause vaginal wall irritation or increased risk of UTIs
Cervical Cap
=Small cuplike diaphragms placed on cervix and held in place by suction
- Most be fitted tightly over cervix to provide barrier for sperm
- Must be measured by healthcare provider
- Difficulty placing cap
- May remain in place for 1-2 days at a time
- Cap should be left in place for 8-48 hours after intercourse
- Foul discharge may develop after this
- Proper placement over cervix confirmed by digital self exam after each sexual act
- Failure rate similar to that of diaphragm
Spermicides: list Ex’s
Spermicidal vaginal jellies, creams, gels, suppositories, vaginal sponge, and foams
Spermicides: effect?
- Toxic effect on sperm also act as mechanical barrier
- Can be used alone or in conjunction with diaphragm or condom
Spermicides: Failure rate?
15% per year with perfect use but double with typical use
Spermicides: irritation S/E
Chemicals may irritate vaginal mucosa/genitalia
T/F: spermicides are not effective in preventing gonorrhea, chlamydia, or HIV
true
Genital lesions from frequent use of spermicides may be linked to increased risk _____
HIV infection
Oral Hormonal Contraceptives
- General use started in 1960s
- MC used method is combined method – pills containing both estrogen and progestin are taken for 21 days followed by 7 days of placebo during which time most women have withdrawal bleeding
- Estrogen dose has been reduced over past decades, usually 15-35 micrograms
- Progestin dose has also been reduced
- Studies show reduced risk of endometrial and ovarian cancers, ectopic pregnancy, PID, menstrual disorders, benign breast disease, and acne
OCP:
-timing?
- In general start with onset of menstrual cycle
- -First Sunday after menses began
- -Quick start – start immediately regardless of menses
- -Recommend backup contraception for at least *7 days after
-Administer pills for prolonged period of time to cause extended periods of amenorrhea (reduce number of periods) significant amount of women experience irregular bleeding
OCP:
-failure rate?
1.26 – 8% in first year
OCP:
return of fertility rate?
Return of fertility soon after discontinuation
How OCPs work
- Alter pituitary gonadotropin release (LH and FSH)
- No rise in first half of cycle, thus growth of dominant follicle and ovulation do not occur
- Change in consistency of cervical mucus, resulting in less sperm penetration
- Endometrial lining less receptive to implantation
- Alter tubal transport of both sperm and oocytes
- Monophasic (constant dose of hormones) or Multiphasic (varying doses of hormones)
- Advise to use alternate form of contraception if OCP use interrupted because of forgotten pills or side effects
Antibiotic usage can alter effectiveness of OCP- How???
Antibiotic usage can alter effectiveness of OCP- How???
-if you’re on ABX and you kill off all the good bacteria in the gut (GIT), this can interfere with the metabolism of the OCP–> decreased absorption of the OCP
OCPs:
-risks?
- Lower dose estrogen in birth controls - safe for most women
- Cervical cancer risk - increased after 5 years of use, but some studies show risk declined after stopping for 10 years
- Breast cancer risk – large study in 1996 showed increased risk 1.24% compared with non-users, risk disappears after 10 years discontinuation
- **VTE/blood clot – triples a users risk from 3 to 9 events per 100,000 (overall risk is still low)
- Pregnancy, childbirth, and puerperium are associated with risk of VTE higher than that associated with the use of OCs
- Think about other risk factors such as age, SMOKING, diabetes, HTN, migraines, clotting disorders (Factor V Leiden)
- Smoking + OC’s act synergistically to increase risk + age >35yo
- -Stroke
- -MI
- -Increased triglycerides
OCP’s:
Contraindications/Caution
- Pregnancy
- Undiagnosed vaginal bleeding
- Prior history VTE, MI, or stroke
- Increased risk for CV event – SLE, uncontrolled diabetes, or HTN
- Cigarette smoking + age >35yo
- Current or prior breast cancer
- Active liver disease
What do to if missed Pill?
OCs need to be taken consistently for contraceptive efficacy and reduced side effects
Patch:
-describe this method
- 1 patch applied weekly x 3 weeks, then removed for 1 week
- Patch is roughly size of small post- it note
- Apply to buttocks, lower abdomen, upper outer arm, torso
- Used on 28 day cycle
- Time needed to achieve steady hormone level
- Use back-up contraception
- Risks similar to that of OCPs, risk of VTE, headache, nausea
- **Site reaction, more breast symptoms, and more dysmenorrhea
- Detachment of patch – reattach within 24 hours, if longer, need new patch
- Failure rate similar to OCPs, increased in women weighing over 198lbs
Patch:
-brand name Ex’s
Ortho Evra and Xulane (newest)
Vaginal ring:
-describe this method
- Vaginal ring approximately 5cm in diameter, flexible
- Releases hormones at fairly constant rate
- Maintains efficacy even if removed for 3 hours
- Designed to be left in place during intercourse
- 1 ring inserted and left for 3 weeks, then removed for one ring-free week
Vaginal Ring:
10-15% of users report _____
vaginal related symptoms – discomfort, leukorrhea, vaginitis, sensation of foreign body, or problems with intercourse
Progestin only (Minipill): -describe this method
- Small dose of progestin alone taken every day– Norethindrone 0.35mg
- Provides reasonably good protection against pregnancy without suppressing ovulation
- Mechanism of action not known – possible cervical mucus less permeable to sperm and endometrial activity goes out of phase
Progestin only (Minipill): -Failure rate?
2-7%
Progestin only (Minipill):
- describe how this pill must be taken?
- who is this option ideal for?
- Minipill must be taken each day promptly, delay of even 2-3 hours diminishes contraceptive effectiveness of coming 48hours
- EC recommended if more than 1 pill missed
- Ideal for women for whom estrogen is contraindicated - >35yo who smoke, migraine headache, HTN, SLE, or breastfeeding
Depo:
-describe this method
-how does it work?
=Injection of Depo medroxyprogesterone acetate (DMPA) given every 3 months
-Works by suppressing surge of gonadotropins thus suppressing ovulation, thickening cervical mucus, and thinning endometrium so implantation less likely
Depo:
-where is the injection usually given?
Usual dosage is 150mg IM administered into gluteus or deltoid
Depo:
-is labeled as effective for up to ___ weeks
- *13 weeks but contraceptive activity persists for up to 4 months
- Irregular bleeding and prolonged menses common in first 6 months, then amenorrhea with continued use - 70%
Depo:
-failure rate?
0.3 - 3% per year
Depo:
-when do menses and fertility return after d/c?
Menses and fertility may take a while to return after discontinuation – average of 10 months
Depo:
MOST Significant S/E?
- **reduction in bone mineral density (1.5 - 2.3%)with current use, but shown to return to normal after discontinuation. Not linked to increase in fracture risk.
- -Encourage adequate calcium intake and weight bearing exercise
- -Mood change and depression have been reported
-Weight gain 5lbs after 1 year use in earlier studies, recent studies suggest depo not associated with weight gain/changes
Depo:
-significantly reduces risk of ______ CA
- endometrial CA
- & Risk of ectopic pregnancy reduced
Depo:
-may improve ______
endometriosis
Emergency Contraception:
-methods?
Plan B
EllaOne
Emergency Contraception:
-methods?
- Plan B
- EllaOne
Plan B not likely to be effective in BMI >___
> 26
Ella not likely to be effective in BMI >___
35
Emergency Contraception (EC): -used to?
- Used to prevent unwanted pregnancy after unprotected intercourse or after failure of contraceptive method
- Hormonal methods prevent pregnancy by delaying or inhibiting ovulation or by disrupting functioning of corpus luteum
Plan B:
- Levonorgestrel 1.5 mg - Single dose, 1 tablet po x 1 dose within 72 hours.
- Need back-up method of contraception x 7 days. May resume OCPs ASAP
Ella:
- Ulipristal 30 mg x 1 dose. Need back-up method of contraception x 14 days or next period.
- Wait 5 days to resume OCPs because combination may reduce effectiveness
IUD for EC
- Copper IUD is another EC option (off label use)
- May inhibit implantation or possibly interfere with sperm function
- Must be inserted within 5 days of unprotected intercourse
- 1% failure rate
- Offers continued contraceptive benefit
LARC=
long acting reversible contraception
LARC:
- how safe is this method?
- 3 types:
- Safe for most women
- Can be used by adolescents and nulliparous women
3 Types:
- Levonorgestrel IUD
- Copper IUD
- Etonogestrel (Nexplanon)single implantable rod
IUD-Intra uterine Device:
- how effective?
- Satisfaction rate?
- Complications?
IUDs highly effective Rapidly reversible High satisfaction and continuation rates Cost effective Complications are rare
Two types of IUDs available:
- Copper IUD
- Levonorgestrel IUD
Copper IUD:
-approved for up to __ years use
10 years!
- No hormones!!!
- Exact mechanism of action unknown, possible spermicidal activity, interference with either normal development of ova or fertilization of ova, activity on endometrium that may promote phagocytosis of sperm
- Highly effective, failure rate 0.6 - 0.8%
-Side effects – abnormal bleeding and cramping can treat with NSAIDs
Mirena IUD:
- Describe
- Approved for how many years of use?
- Releases 52mg levonorgestrel, initially released 20 mcg/day reduced by 50% after 5 years
- Approved for use up to 5 years
Mirena IUD:
-MOA?
Mechanisms of action:
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
Mirena IUD:
- Failure rate?
- best for which Pt population?
Highly effective , failure rate 0.1 - 0.7%
- Larger - best for women who have given birth but not required
- Good for heavy periods – some irregular bleeding in initial 3-4 months and then decrease in menstrual flow by as much as 70%
- Reported side effects – headache, acne, mastalgia
Liletta IUD:
- Releases?
- Approved for use up to ___ years
- Releases 52 mg levonorgestrel, avg. 15.6 mcg/day over 3 years
- Approved for use up to 3 years
Liletta IUD:
-MOA?
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
Liletta IUD:
-advantages
- Highly effective
* Cheaper than the Mirena IUD
Skyla IUD:
- releases?
- Approved for use up to __ years
- Releases 13.5 mg levonorgestrel, avg. 6 mcg/day
- Approved for use up to 3 years
Skyla IUD:
-MOA?
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
Skyla IUD:
- effectiveness?
- size?
Highly effective
Low hormone dose
One of smallest IUDs
Kyleena IUD:
- releases?
- approved for use up to __ years
Releases 19.5 mg levonorgestrel, avg. 9 mcg/day
-Approved for use up to 5 years
Kyleena IUD:
-MOA?
- Similar effects as copper IUD
- Also causes endometrial suppression and changes in cervical mucus
- All effects occur before implantation
Kyleena IUD:
- effectiveness?
- best for women who?
- Highly effective
- Best for women who have not given birth yet b/c very small
IUD Complications (there’s a lot)
- Ectopic pregnancy – increased risk, but still lower than non-IUD users because high effectiveness
- Spontaneous abortion – 50% if pregnant with device in place, recommend removal of IUD if possible
- Expulsion – More common in first few weeks of use, ~5%
- Uterine Perforation – 1-2 events per 1,000 insertions
- Infection – Risk PID remains low, screen for STIs
- Irregular bleeding
IUD:
-check Pt ____ weeks after IUD inserted and _____ after
Check patient 4-6 weeks after IUD inserted and yearly after, ask patient to check for strings
IUD:
-management of missing strings
- First encourage patient to use back-up method of BC
- Do pregnancy test
- Order transvaginal ultrasound to determine where IUD is located
- Refer to GYN for removal
Implant
- Etonogesterel (68 mg ) – Nexplanon
- Discreet
- Highly effective
- Similar mechanism of action to Depo
- Rapidly reversible
- Approved for up to 3 years
- May be inserted at anytime during menstrual cycle
- MC side effect is irregular bleeding/spotting
- Weight gain also reported
- Providers must be trained by manufacturer for insertion/removal
- No reported pregnancies in more than 70,000 cycles of use
Sterilization: list 4 procedure ex’s
- tubal ligation
- Essure
- Vasectomy
- Hysterectomy
Tubal ligation
- Surgical procedure
- “tie off” fallopian tubes
- Prevent eggs from traveling from ovaries to uterus
Essure=
=Implant into fallopian tubes that encourages scar buildup
-*Takes 3 months to be effective
Vasectomy=
- Surgical procedure
- Blocks or cuts vas deferens
