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Contraception
Slides Notes
Question | Answer |
---|---|
50% pregnancy | unintended (435 TERMINATED) increased in last 20 yrs. |
rate of unintended pregnancy | 5x INCrease below poverty. unintended pregnancies have decreased in middle-modern women. |
there is no perfect contraceptive | 3 decades avoiding pregnancy.most effective contraceptives (LARCs) generally have a high initial price. |
G1P1001 | G1P1001 means pregnant once, one delivery, no premies, no abortions and one live birth. |
nulligravid | never been pregnant |
She recently developed DVT in her right leg during a return flight from China; OCs were discontinued. What is her best contraceptive choice now? | Does pt want to retain fertility? If so, LARC best choice, since need for highly-effective method. DVT does not contraindicate any LARC. |
One week ago she had pregnancy termination at 8 weeks gestation. She is worried that the OCs “didn’t work”.What would you give her? | Higher failure rate of OCs in teens. Depo may be acceptable. Options of IUD, Nexplanon if pt can be educated appropriately. Efficacy of DMPA in teens. |
the health risks of pregnancy are greater.. | than those with any contraceptives. |
Her periods have been heavy and painful since the birth of her child 18 months ago. Pelvic ultrasound shows small uterine fibroids. What are reasonable contraceptive choices for her? | OCs or Mirena would be reasonable. Estrogen in combination OCs will not cause growth of myomas. 2 year interval will allow Mirena to be cost-effective. |
LARC methods - mirena, paragard, skyla, nexplanon, sterilization | most effective OC |
depo=provera, OCP, ortho, nuva | effective OC |
diaphragm, cervical cap, condoms, spermicide, withdrawal, periodic | least effective OC |
birth controls have failure rate of | .9% |
risks: no systemic health risk, UTI (diaphragm), local irritatoin (spermicide), 20% failure rate. STI protection - noncontraceptive. | barrier methods |
important concept of typical use and correct use | failure rates differ (sometimes dramatically) between ideal use and actual use.male condoms correct use 2. typical 18. |
fitted Rx length of vagina, 65mm, 50$ for 2yrs with spermicide (inserted 2hr prior,6hr after). risk: toxic shock, UTI, HIV, slips. | diaphragm (symphysis pubis and extends to posterior vagina up to cul-de-sac) |
rx, used with spermicide, post 8 hrs, less effective - 68$ | cervical cap |
correct 2%, typical 18% risk, latex condom reduces risk of pregn/STI. not used with oil-based or latex-allergic | condom (male) |
synthetic, natural | synthetic: non-allergic, compatible with lub (STI?) Natural: Porous; may allow passage of viruses/ compat with lub |
place condom on erect penis before any genital contact, fit to base, hold when removing penis from vagina | correct condom use |
FC2, nitrile, instered prior to erection, left after ejaculation $2. | female condom |
progestin-only contraceptives and estrogen/progesterone combo | hormonal contraception, oral, patch, ring, Injection Implant (LARC category) IUD (LARC category) |
suppress ovulation, mow endometrium, thick cervical mucus | estrogen-progestin contraceptive (correct 1%, actual 9% in 1st yr - pill patch, ring ) |
MI, ischemic stroke, thromboembolism (age, 3rd gen progestin), protein S, Factor 5 increase, hepatic adenoma, breast ca/cervical ca | estrogen-progestin contraceptive risk factors (estrogen is the main reason) |
Not assoc. w cancer risk. Not associated with increase mortality | OC |
smoker >35, HTN, stroke hx, HTN, VTE, Lupus, migraine, breast CA, cirrhosis, LIVER tumor | OC CONTRAINDICATIONs (less than 35 okay - not contraindication) |
Breakthrough bleeding (progestin sloughing low dose), amenorrhea, bloating, N, breast tender, wt gain, HA | SE of OC estrogen-progestin (pill, patch, ring) |
breakthrough bleeding | OC still working, call me in 3-4 weeks if not resolved. |
reduces heavy periods, cramps, PMS, menstual HA, ovarian cysts, breast dz, acne, hirsutism, uterine leiomyomata, suppress endometriosis, ca risk | BENEFITS of estrogen-progestin OC |
review medical hx, measure BP | before prescribing combined OC |
Sunday Start: Quick Start: First Day start: | first pill on sunday (no menses on weekends); take first pill rx given (r/o existing pregnancy);max contraceptive effect with first cycle (starts first day of period). |
21/7 regimen; 24/4 regimen; 12 wk cycle; continuous | placebo phase (allows withdrawal bleeding), begin agent again on designated day. |
why do you cycle? | normal; reassurance; increased breakthrough bleeding with cycle length; PMS/dysmenorrhea benefits |
unscheduled bleeding is the most common reason women stop using OCPs | estrogen low - rates of irregular bleeding OCPs go up. (but estrogen has SE - start in middle when dosing). |
anticonvulsants (phen, topiramate, carbamazepine); antibotics (rifampin ONLY), St john's wort | OC drug interactions |
rhythm method, abstinence beofre and after predicted ovulation | natural method (20-40% effective) - requires abstinence. no barriers/chemicals, long periods of abstinence. |
if you have missed one dose, take 2 pills... | if you miss more than 1, redo. (withdrawal bleeding, wait 5 days |
changed weekly, better steady-state level, high serum levels of estrogen, DVT risk | patch (refractory breakthrough bleeding - skin patch works better) |
changed monthly, 21on/7off, increased discharge? | vaginal ring, NuvaRing |
mini-pills, DMPA, implant, IUD, emergency Contraceptive | progestin-only OCs |
thickens mucus, thins endometrium, suppresses ovulation, monthly periods (no placebo phase) | |
after delivery, ovulation delayed (hypothalamic suppression) due to nursing. max 6 mon after delivery. failure rate is high 50% - least effective | lactational amenorrhea |
NOT contraindicated in women with hx of stroke, MI or DVT | progestin-only OC |
irregular bleeding, amenorrhea, use in lactating women | progestin-only OC (SE) |
Contraindications Breast cancer Undiagnosed abnormal uterine bleeding Active liver disease | contraindications to progestin-only |
progestin injected MI over 3 mon. MOA suppresses ovulation, thickening mucus, endometrium unsuitable for implantation | Depo-Provera (very low failure rate .3%, 6%) |
irregular vaginal bleeding - change in bleed (freq, irregular x 6mon, subsequent amenorrhea), depression, tender breasts, wt gain, reversible loss of bone density, withdrawal: delayed 18mon ovulation | Depo-Provera SE (contraception in teenagers, immobility) |
plastic metal device in endometrial cavity. elicit spermicide. low failure rate. contraindicated: pregnant, abn vaginal bleed, gyn cancer, uterus infection, prior ectopic pregnancy | IUD, intrauterine devices (<1%, <1%) - hx of PID |
3 yr effective, very effective, progestin only, implant by phx, MOA thick cervical mucus, decreased tubal motility, inhibits ovulation, endometrial thinning | implant (nexplanon) LARC (<1%, <1%) |
NO association between the etonogestrel implant and risk of myocardial infarction, stroke or VTEBreast cancer Undiagnosed abnormal uterine bleeding Active liver disease | IMPLANT (nexplanon) |
Unscheduled bleeding 15% will d/c use for this reason May persist for the life of the device Most women will have ~5 days of bleeding/month, not predictable. mood, acne, wt gain. | nexplanon implant ($400-800) |
Prevent fertilization (toxic to sperm/ova), | IUD MOA |
mirena (5yr), skyla (3 yr). | IUC/homormonal ($500) |
OC make pt sick, cost issue, needs long duration. Copper (paragard) 10yr (2nd only to steriolization) | paragard (contraindications: wilson's copper) |
cramping pain, | need hormonal mirena, skyla |
adverse events: expulsion (cramping/asx, confirm with pelvic exam), uterine perforation (partner discomfort) | IUD |
Risk limited to the insertion process (first 20 days after insertion Associated with STI (chlamydia, gonorrhea) Long-term use of IUD is NOT associated with increased risk of pelvic infection | IUD |
Irregular bleeding Amenorrhea Hormonal side-effects Acne, weight gain, nausea, headache, breast tenderness mood changes | unique to skyla, mirena |
Increase in dysmenorrhea Increase in menstrual bleeding | paragard |
vasectomy (in office), tubes (postpartum, laparoscopic cautery, clips = opperation) | sterilization |
safer, less costly, more effective, office porcedure, gold standard. | vasectomy (permanent sterilzation) |
5x more common procedure for sterilization | tubes |
hysteroscopic sterilization - female sterilization (essure) | office-based, not require general anethesia. blocking by fibrosis tissue/inflammatory |
bleeding, infection, organs, ectopic risks, anesthsia risk, regret (25%, postpartum) | female sterilization SE |
to ensure event does not result in pregnancy (emergency) | Plan B (up to 72 post intercourse)- OTC, not conception aborter but preventer. ella (extended - take pregnancy test first), paragard = delays ovulation |