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Contraception

Slides Notes

QuestionAnswer
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
Created by: jamieseals