L5- contraception and sterilization

fertility awareness based method- fertile window

• two days proceeding ovulation

  • shows increased probability of pregnancy form unprotected intercourse

fertility awareness based method- cycle length

• ovulation occurs 4 days before or after midpoint of cycle

fertility awareness based method- cervical secretions

• abundant, clear, wet, stretchy cervical secretions occur immediately before, during, adn immediately after ovulation

fertility awareness based method- basal body temp

• increase in basal body temp 1-2 days after LH surge

• identifies end of fertile period

fertility awareness based method- ideao candidates

• compliant

• abstain from intercourse/use barrier son fertile days

• communicate with partner

• supportive partner

fertility awareness based method- contraindiactions

• irregular cycles

• interruption of cycles (postpartum, pregnancy loss, abortion)

• inability to trace physiologic changes

• lack of supportive partner

fertility awareness based method- efficacy

pregnancy rates ~25%

fertility awareness based method- standard days method

• uses fertility days using 2 sets of probabilities:

  • prob of pregnancy with respect ti ovulation and

  • prob that ovualtion occurs at midpoint of cycle

• easiest to teach

• appropriate when cycle is btwn 26-32 days

• fewest days requiring abstinence or barrier contraception

• avoid unprotected intercourse from dat 8-19 of cycle

fertility awareness based method- cervical mucus/ovulation method

• observe cervical secretions throughout the day

  • dry after menstruation

  • subsequently- thick, sticky mucus appears

  • changes to thin, stretchy, clear cervical mucus (Spinnbarkeit)

  • last day of wetness= PEAK =ovulation

  • fertiel period usually occurs with first signs of thsi mucus and continues 4days after PEAK day

  • avoid unprotected intercourse fro ~13-17 days each cycle

fertility awareness based method- multimodal methods

• symptothermal medthod- changes in cervical secretions and basal body temp

  • observe cervical secretions adn take BBT each morning before rising

  • abstain all days with secretions and until 3 days o fincreased BBT or 4th day after last day with wet secretions

• device assisted methods

• fertility monitor

• computer aspps

• lactational amenorrhea- generally effective fro up to 6 months adter birth IF amenorrhea is maintained and is exclusively breastfeeding

external/internal condoms- efficacy

• external: 18% with typical use

• internal: 21% with typical use

external/internal condoms- benefits

• reduced risk of pregnancy

• reduces STI transmission

• reversible- no interruption to fertility

• easily accessible

• inexpensive

• discrete

external/internal condoms- disadv

• device failure

• latex allergy

• decreased sensitivity

diaphragms and cervical caps- efficacy

• diaphragm: 12% with typical use

• cervical cap: 23-32% with multiparous women

diaphragms and cervical caps- use

• spermicide is typically applied inside BEFORE insertion and reapplied after each sexual encounter while device is in place

• requires rx and fitting

diaphragms and cervical caps- contraindications

• pelvic organ prolapse

• allergy to amterial

• frequent UTIs ot h/o TSS

diaphragms and cervical caps- complications/risks

• UTI

• vaginal irritation

• TSS

• increased risk of HIV infection (microabrasions in epithelium)

cervical sponge, spermicides- efficacy

• cervical sponge: nulliparous 9%, 21% typical use; multiparous perfect use 20%, typical use 24%

• spermicide: 18% perfect use; 28% typical use

cervical sponge, spermicides- use

• sponge: pillow shaped sponge containing spermicide, one size only, leabe in place 6hrs AFTER intercourse, but not >8hrs

• spermicide: inserted highinto vagina 10-30 min BEFORE. intercourse (lasts no longer than >1hr); very effective when used in combo with condom

cervical sponge, spermicides- contraindications

• high risk HIV

• allergy with material

• frequent UTis or h.o TSS

cervical sponge, spermicides- complications

• UTI

• vaginal irritaiton, genital lesions

• TSS
  increased risk of HIV infection

vaginal pH modulator- MOA

• maintain vaginal pH in acidic range→ decrease sperm mobility

vaginal pH modulator- route

• insert contents of 1 prefilled applicator vaginally immediately before or up to 1 hours BEFORe each act of vaginal intercourse

• if>1 act of intercourse occurs within 1hr, additional doses must be applied

vaginal pH modulator- SE

• vulvovaginal burning

• pruritis

• urinary sx

• UTI

• vaginitis

vaginal pH modulator- contrindications

hx of recurrent UTIs

vaginal pH modulator- benefits

• rapidly reversible contraceptive, non-hormonal

vaginal pH modulator- efficacy

• 14 typical use; 7% perfect use

combined estrogen-progestin- MOA

• ovulation suppression (inhibit GnRH, LH, FSH)

• estrogen:

  • suppress FSH, preventing folliculogenesis

  • potentiates effects of progesterone agent

  • improves cycles control by stabilizing endometrium→ min breakthrough bleeding

• progesterone:

  • suppresses LH surge→ prevent ovulation

  • affects endometrium making it less suitable for implantation

  • cervical mucus thickening

  • impairs tubal motility and peristalsis

combined oral contraception pills (COCP)- efficacy + type and dosing

• 7%

• 20-25mcg of ethinyl estradiol and varying formulations of progestin

• monophasic: same estrogen-progestin dose fro active pills

• multiphasic: varied dose of hormones; reduce SE adn breakthrough bleeding

combined oral contraception pills (COCP)- regimen

• cyclic: 21 active pills + 7 placebo or 24/4

• continuous: takes COCP every day

• extended: 84/7 regimen

combined oral contraception pills (COCP)- benefits

• rapid reversibility

• tx of various menstrual disorders: AUB, PCOS, PMS, PMDD

• tx pelvic pain disorders

• prevention of ovarian cysts

• hyperandrogenism (reduce hirstuism/acne)

• can be used as hormone replacement for priamry hypogonadism or premature ovarian insuff

• cancer risk reduction

• improved bone density

combined oral contraception pills (COCP)- side effects

• breast tenderness

• nausea

• bloating

• breakthrough bleeding

• headaches

• maybe mood changes and decreased libido

combined oral contraception pills (COCP)- risks

• ± increased risk VTE/CVA

  • depend on age, obesity, smoking status, and lifestyle (sedintary)

combined oral contraception pills (COCP)- avoid in

• ≥35yo AND smoke more than 15 cigs a day

• multiple CVD RF

• HTN ≥160 SBP or 100 DBP

• VTE

• h/o ischemic heart idz, stroke, valvular heart dz

• breast cancer

• liver dz

• migraine with aura

• DM>20year duration or with nephropathy, retinopathy, or neuropathy

• early postpartum

• breastfeeding until 30 days postpartum

• sickle cell dz

combined oral contraception pills (COCP)- DDI

• antiseizure meds

• rifampin

• grisefolin

• st johns wort

• certain HIV antivirals

combined oral contraception pills (COCP)- initiation

1) first day of menses, within 7days following pregnancy loss or abortion

2) quickstart

• neg urine preg test

• consider LMP and timing of last episode of unprotected sex

• use back up method fro first 7 days

combined oral contraception pills (COCP)- stopping

• regular menses return in 30days after stopping

• fertility returns within 90 days after stopping

transdermal patch- types

• ethinyl estradiol (35)- norelgestromin (15)

• ethinyl estradiol (30)- levonorgestrel (120)

transdermal patch- frequency

• apply weekly to lower abdomen buttocks, upper back fro 3 weeks

  • one week off for withdrawl bleeding

  • avoid more than 7days patch free

transdermal patch- benefits

• weekly dosing

• non-oral route

• rapid reversibility

• tx of various menstrual disorders: AUB, PCOS, PMS, PMDD

• tx pelvic pain disorders

• prevention of ovarian cysts

• hyperandrogenism (reduce hirstuism/acne)

• can be used as hormone replacement for priamry hypogonadism or premature ovarian insuff

• cancer risk reduction

• improved bone density

transdermal patch- SE

• skin irritation

• breast tenderness

• nausea

• bloating

• breakthrough bleeding

• headaches

• maybe mood changes and decreased libido

transdermal patch- risks

• slight increase in risk of thrombosis (higher steady state of estrogen)

  • ± increased risk VTE/CVA

    • depend on age, obesity, smoking status, and lifestyle (sedintary)

transdermal patch: MOA

• ovulation suppression (inhibit GnRH, LH, FSH)

transdermal patch- DDI

• antiseizure meds

• rifampin

• grisefolin

• st johns wort

• certain HIV antivirals

transdermal patch- avoid in

• BMI≥30 due to increased risk of thromboembolism and lower efficacy

• ≥35yo AND smoke more than 15 cigs a day

• multiple CVD RF

• HTN ≥160 SBP or 100 DBP

• VTE

• h/o ischemic heart idz, stroke, valvular heart dz

• breast cancer

• liver dz

• migraine with aura

• DM>20year duration or with nephropathy, retinopathy, or neuropathy

• early postpartum

• breastfeeding until 30 days postpartum

• sickle cell dz

vaginal ring- route

• flexible device inserted vaginally

vaginal ring- types

• etonogestrel(120)/ethinyl estradiol (15)

• segesterone (103) ethinyl estradiol (17.4) - lasts 13 cycles

vaginal ring- frequency

• inserted vaginally for 3 weeks and removed and discarded fro 1 week

  • continuous regimen is available

  • dos enot needed to be removed fro sexual intercourse

vaginal ring- benefits

• avoids daily compliance

• private

• less impact on insulin resistance and less breakthrough bleeding than OCPs

• rapid reversibility

• tx of various menstrual disorders: AUB, PCOS, PMS, PMDD

• tx pelvic pain disorders

• prevention of ovarian cysts

• hyperandrogenism (reduce hirstuism/acne)

• can be used as hormone replacement for priamry hypogonadism or premature ovarian insuff

• cancer risk reduction

• improved bone density

vaginal ring- SE

• vaginitis

• leukorrhea

• breast tenderness

• nausea

• bloating

• breakthrough bleeding

• headaches

• maybe mood changes and decreased libido

vaginal ring- MOA

• ovulation suppression (inhibit GnRH, LH, FSH)

vaginal ring- DDI

• antiseizure meds

• rifampin

• grisefolin

• st johns wort

• certain HIV antivirals

vaginal ring- avoid in

• ≥35yo AND smoke more than 15 cigs a day

• multiple CVD RF

• HTN ≥160 SBP or 100 DBP

• VTE

• h/o ischemic heart idz, stroke, valvular heart dz

• breast cancer

• liver dz

• migraine with aura

• DM>20year duration or with nephropathy, retinopathy, or neuropathy

• early postpartum

• breastfeeding until 30 days postpartum

• sickle cell dz

vaginal ring- risks

• ± increased risk VTE/CVA

  • depend on age, obesity, smoking status, and lifestyle (sedintary)

OCP progesterone only- route and efficacy

• oral

• 91-93%

OCP progesterone only- frequency

• norethindrone (28 active pills)

• drospirenon (24-4 pills)

• continuous regimen, norgestrel (28 active pills)

NEED to be taken at the same time every day

OCP progesterone only- benefits

• protects against endometrial/ovarian cancer

• lower ectopic risk

• rapidly reversible

• good choice for breastfeeding women and women with contraindications to estrogen

OCP progesterone only- SE

• breat tenderness

• nausea

• bloating

• meed changes

• benign follicular ovarian cysts

• breakthrough bleeding

OCP progesterone only- risks

• safer fro pts iwth CVD risks

• more sensitive to missed or delayed dose

OCP progesterone only- MOA

• suppression of ovulation via inhibition of GnRH in hypothalamus→ inhib of LH and FSH with disruption of mid cycle LH lurge

• endometrial lining more hostile for implantation

• thickening of cervical mucus

• neg effects on tubal motility and peristalsis

OCP progesterone only- DDI

• antiseizure meds

• rifampin

• griseofluvin

• st johns wort

• certain HIV antivirals

OCP progesterone only- avoid in

• known pregnancy

• breast cancer

• undx abnormal uterine bleeding

• severe liver dz or tumor

long acting reversible contraception (LARC)- implant

• implanted subdermally

LARC implant- frequency

• continuous contraception 5 years

• use back up for 7 days after placement

LARC implant- benefits

• MOST effective form

• quick return to ovulation (within 3-4 weeks after removal)

• usually lightens bleedings

  • very unpredictable bleeding for first 3 months

• good choice for breastfeeding women and women with contraindications to estrogen

LARC implant- SE

• local site irritaiton

• changes in bleeding patterns

• possbily:

  • HA

  • weight gain

  • acne

  • breast tenderness

  • emotional lability

  • abdominal pain

LARC implant- risks

• safer for pts with CVD risks

LARC implant- MOA

• endometrial lining more hostile for implantation

• thickening of cervical mucus

• inhibiting ovulation (suppresses LH)

LARC implant- DDI

• antiseizure meds

• rifampin

• griseofluvin

• st johns wort

• certain HIV antivirals

• efavirenz

LARC implant- avoid in

• known pregnancy

• breast cancer

• undx abnormal uterine bleeding

• severe liver dz or tumor

LARC IUD- route + efficacy

• intrauterine device placed in uterus

• >99%

LARC IUD- frequency

• levonorgestrel IUD (8yrs, 5yrs, 3 yrs)

• non hormonal Copper IUD- paraguard (10 years)

LARC IUD- benefits

• highly effective

• no daily compliance

• rapidly reversible

• logn acting

• private

• reduction of cervical/ovarian/endometrial cancers

• cost effective

• can be used as emergency contraception

LARC IUD- SE

• CU:

  • longer, heavier menses within 6 months

• LNG:

  • breakthrough bleeding, but less than implant

LARC IUD- risks

• expulsion, otherwise mostly associated with placement

• difficult insertion

• bleeding

• infection

• perforation of uterus

LARC IUD- MOA

Cu

• spermicidal copper ions, sterile inflammatory rxn of endometrium (sperm inhibition and phagocytosis)

LNG

• thickened cervical mucus, thinning of endometrium making it resistant to estrogen stimulation

LARC IUD- DDI

LNG

• local progestin dose in LNG is high enough that efficacy is not reduced y drugs that affect other hormonal contraceptives

Cu

• none

LARC IUD- avoid in

• known pregnancy

• breast cancer in LNG

• undx abnormal uterine bleeding

• severe liver dz or tumpr

• uterine structural abnormalities

• pelvic infection

• wilsons dz/Cu allergy

injectable DMPA- route and efficacy

• IM or SC injection

• >99perfect use; 94% typical use

DMPA- frequency

• q13 weeks

  • 2 week grace period

  • back up contraception fro 7 days after initiation

DMPA- benefits

• no daily compliance

• long acting

• private

• cost effective

• reduction of sickle cell crisis

• reduction in anemia

• improved fibroids

• reduced risk of endometrial cancer

DMPA- SE

• breakthrough bleeding

• reduction of bone density

• low risk injection site rxn

• weight gain

• HA

• mood

• recommended to supp with vit D and calcium

DMPA- risks

• increase in VTE adn CVD risk vs other LARC

• possible increased risk of FM

• return of fertility can take up to 12+ months

DMPA- MOA

• thickened cervical mucus

• atrophic endometrium

• ovulation suppression

DMPA- DDI

• aminoglutethimide (increase metabolism of progestins)

• antiseizure meds

• st john wort

• rifampin

DMPA- avoid in

• known pregnancy

• breast cancer in LNG

• undx abnormal uterine bleeding

• severe liver dz or tumor

• long term use of steroids

• use of aminoglutethimide (cushing’s tx)

• high CVD risk

• ischemic heart dz

• possibel meningioma risk

emergency contraceptive

• product that decreases risk of pregnancy after intercourse but before est of pregnancy

• oral or IUD

• does not interrupt an existing pregnancy, thus it does not cause abortion

oral ulipristal acetate (UPA)

• emergency contraception- most effective oral option

• take within 5 days of unprotected sex

• prevents ovulation

• rx needed

• should not be used with other progestin- containing contraceptives or for 5days after use

oral LNG (plan B)

• emergency contraception

• take within 72 hours of unprotected sex

• prevents ovulation

• available OTC. low cost

• reduced efficacy with high BMI

combined OCP- yuzpe

• emergency contraception

• take within 5days of unprotected sex

• repeat dosing in 12 hrs

• less effective and increased SE

• widely available, low cost

Cu IUD- emergency contraception

• most effective EC

• place within 5days of unprotected sex

• lasts fro 10 years

LNG IUD- emergency contraception

• comparabel to Cu IUD

• place within 5 days of unprotected sex

• lasts 8 years

vasectomy

• male sterilization

• occlusion of vas deferens preventing passage of sperm to ejaculate

• not effective for first 3 months (back up method needed)

vasectomy complications

• bleeding

• hematoma

• local infection

• pain

vasectomy reversal

• easier than female sterilization

  • depends on time since procedure (longer= less successs)

• generally safer, less expensive, and more effective

tubal ligation

• female sterilization

• permanent occlusion or removal of fallopian tubes

• immediately effective

tubal ligation complicaitons

• unplanned major surgery

• reoperation

• infection

• injury to other organs

• bleeding

• perforation of uterus

tubal ligation reversal

• expensive and low success rates

• most frequently used method of controlling fertility