Non-Hormonal & Long-Acting Reversible Contraception (LARC)

what are the least effective methods of contraception?

natural

- should not be used if pregnancy prevention is a high priority

- includes: FABMs/periodic abstinence, withdrawal, & lactational amenorrhea

fertility awareness-based methods (FABMs)/periodic abstinence

emphasizes abstinence shortly before & after the estimated ovulation period

- utilizes ovulation assessment methods (prediction kits, basal body temp, menstrual tracking, cervical mucus eval, documentation of premenstrual or ovulatory sx)

- requires couples to be highly motivated, learn reproductive physiology, & be willing to abstain from intercourse

- preferable for women to have very regular menstrual cycles

- efficacy: 55-80%

what is basal body temperature?

temperature of the body under conditions of absolute rest

- can be taken orally, rectally, or vaginally immediately at the time of awakening

after LH surge, what occurs?

ovulation & progesterone begins to rise

what does the rise in progesterone do to basal body temp?

causes it to rise

- which would then indicate to the patient that she has ovulated

low progesterone = ____ cervical mucus

thin

- which facilitates sperm into upper reproductive tract

high progesterone = ____ cervical mucus

thick

- which hinders sperm

what does the change of cervical mucus from thin to thick indicate?

that ovulation has occurred

withdrawal/coitus interruptus

withdrawal of the penis from the vagina before ejaculation

lactational amenorrhea

breast feeding to prevent ovulation

- high levels of prolactin inhibits GnRH from the hypothalamus ultimately resulting in suppression of ovulation

after delivery, return of ovulation occurs ______ return of menstruation

before

1 multiple choice option

lactational amenorrhea is ONLY effective IF the mother is practicing..

exclusive breastfeeding

- required to keep prolactin levels high enough to inhibit GnRH

even when breastfeeding, ovulation usually begins after __ months

6

male condoms

- provide some protection against STDs (including HIV)

- cheap

- over the counter (OTC)

- efficacy: 98% when used properly, 82% actual

female condoms

- also provide some protection against STDs/STIs

- efficacy: 79%

diaphragm

dome-shaped latex sheet placed in the vagina w/ spermicide

- must leave in place for 6-8 hrs after intercourse & be fitted/prescribed by a physician (refit if weight change or pregnancy)

- efficacy: 88%

cervical cap

silicone cap that fits directly over the cervix; used w/ spermicide

- can be inserted 6 hrs before intercourse & left in place for 1-2 days

- must be fitted by a physician

- widely used in Europe

- efficacy: 68-84%

spermicides

work by disrupting the cell membranes of spermatozoa as well as acting as a mechanical barrier

- can irritate the vagina (making women MORE susceptible to STDs)

- NOT recommended for women w/ HIV or at risk of contracting HIV

are spermicides effective when used alone?

no, should never be used alone

- use in combo w/ another barrier method

IM or SQ injection given once each 3 months (12-14 wks)

Depot Medroxyprogesterone

(Depo-Provera or Depo-subQ Provera 104)

MOA of Depo:

- thickens cervical mucus, which inihibits sperm migration

- alters endometrium making it less favorable for implantation

- progestin suppresses LH surge, which inhibits ovulation

what is the most common SE of Depo?

menstrual irregularities (25-30%) that can take months to resolve

- others include: weight gain, depression, increase risk of bone mineral density reductions, & HIV

how long after the last injection of Depo does infertility persist?

avg. of 10 months, but in some cases 1-2 yrs

what is the black box warning associated w/ Depo?

limit use to < 2 yrs

- prolonged use may result in a loss of bone mineral density (<21 y/o are most vulnerable) which may not be completely reversible on discontinuation

are combination or progestin-only birth control methods more likely to cause acne or hirsutism?

progestin-only

which barrier method is the most effective?

male condoms

what is the most widely used form of non-surgical contraception in the world?

intrauterine devices (IUDs)

what are the 2 types of IUDs?

1. Copper-T

2. levonorgestrel (LNG)

Copper-T IUD can be used for __ yrs

10

levonorgestrel (LNG) IUD can be used for __ yrs

3 (Skyla), 5 (Kyleena), or 8 (Mirena & Liletta)

which type of BC has a MOA predominately aimed at preventing fertilization?

IUDs

copper IUD MOA

causes a sterile inflammatory response in the uterus that is toxic to sperm (as well as ova), resulting in sperm death or reduced motility & the inability to complete maturity (capacitation), so sperm do not usually reach the fallopian tube, & fertilization cannot occur due to no capacitation

LNG IUD MOA

causes a sterile inflammatory response that is toxic to sperm as well as:

- thickens cervical mucus, inhibiting sperm migration

- which in turn inhibits the final development of the sperm (capacitation)

- results in an inability to fertilize ovum

what happens if the sperm get past the inflammatory spermicide challenge, the inhibiting mucus challenge, and succeed in fertilizing an egg?

there is a secondary mechanism where the low level of progesterone causes atrophy of the endometrium & prevents implantation

- however, studies have not found blastocytes present in fallopian tubes & evidence supports no fertilization occurs

does the copper IUD affect ovulation?

no

does the LNG IUD affect ovulation?

yes, it prevents ovulation in some women, but not all

- in many women, the progesterone largely remains in the uterus & is not absorbed systemically at a high enough level to prevent ovulation

what is the efficacy of IUDs?

>99%

are IUDs safe in nulliparous women?

yes (both copper & LNG)

nulliparous

a woman who has never given birth

if the patient has a known STI, can an IUD be placed?

yes

- but wait for resolution of infection before insertion

is STI screening recommended in women at increased risk but without s/s prior to IUD insertion?

yes

- but insertion does not need to be delayed while results are pending

when during the menstrual cycle should the copper IUD be placed?

any time

when during the menstrual cycle should the LNG IUDs be placed?

1st week (right after menses stops or is ending), but any time is acceptable if pregnancy has been excluded

can IUDs be placed immediately after delivery (vaginal or c-section)?

yes, but waiting 6 wks will reduce risk of expulsion

can IUDs be placed immediately after induced or spontaneous abortion?

yes

1 multiple choice option

what are the possible side effects of IUDs?

- increased risk of spontaneous abortion if pregnancy does occur

- abdominal or back pain (r/o PID & pregnancy)

- bleeding

- perforation (occurs in 1/1000)

- expulsion or malpositioning (due to being placed too low [partially in the os])

increased bleeding volume & time is seen w/ the ________ IUD

Copper-T

amenorrhea or prolonged periods can be seen w/ the ______ IUD

Mirena

what is the most common reason for Mirena users to choose to have it removed?

systemic hormonal side effects (even though the LNG IUD is stated to only affect local tissues)

- such as, hirsutism or hair loss, acne, weight changes, nausea, HA, moodiness/depression, decreased libido, breast tenderness, & ovarian cysts

what are the absolute contraindications of IUDs?

- known or suspected pregnancy

- undiagnosed abnormal vaginal bleeding

- acute cervical, uterine, or salpingeal infection

- copper allergy or Wilson's diseases (Copper-T only)

- current breast cancer (LNG only)

what are the relative contraindications of IUDs?

- recent history of STD

- uterine anomaly or fibroid distorting the cavity

- current heavy menstrual bleeding (menorrhagia) or dysmenorrhea (Copper-T only)

explain the use of the Copper-T IUD as a form of emergency contraception?

must be inserted w/i 5 days of unprotected intercourse

- it is likely that fertilization has already occurred, & it's preventing pregnancy by preventing implantation

- when placed after intercourse for this use, it also has the ability to disrupt an implanted pregnancy

which IUD is often used for heavy menstrual bleeding (menorrhagia), dysmenorrhea, endometriosis, & endometrial hyperplasia?

Mirena

- can result in 90% less blood loss during menstruation

etonogestrel (Nexplanon)

implantable (sub dermal) sustained release rod (implanted inside of upper arm)

- MOA: suppresses ovulation, increases viscosity of cervical mucus, & alter endometrium

- provides efficacy for up to 3 yrs

- ovulation returns quickly after removal

- proper placement necessary to ensure efficacy (training required)

- detectable by XR or CT

what is the most common reason of discontinuation of Nexplanon?

unpredictable bleeding

mifepristone (RU 486) w/ Misoprostol (Mifeprex)

FDA approved to induce abortion in early pregnancy, w/i 10 wks of conception

- "medical abortion," NOT FOR USE FOR EMERGENCY CONTRACEPTION

- MOA: Mifepristone blocks progesterone & misoprostol stimulates uterine contractions (causing detachment & expulsion of embryo)

tubal sterilization

surgical occlusion or removal of fallopian tubes to prevent ovum & sperm from uniting

- mode: laproscopic, hysteroscopic, or postpartum w/ subumbilical incision

- methods: rings, bands, clips, ligation, electrosurgery/cautery), microinserts w/ spring coils (Essure d/c 12/2018), complete salpinectomy

- considered permanent & irreversible (include this in pt education w/ discussion of the risk of regret)

- success of surgical reversal depends on method of sterilization

why has the complete salpingectomy method of tubal ligation gained popularity?

bc ovarian cancer seems to initiate in the fallopian tubes, so this method provides both sterilization & ovarian cancer risk reduction

which method of tubal ligation has the highest success of reversal?

clips

which method of tubal ligation is considered completely irreversible?

microinserts

vasectomy

ligation of the vas deferens

- permanent

- very effective

- no long-term side effects

- reversal success = 60-70%

what is considered the safest method of permanent contraception?

vasectomy