Contraception

unplanned, low, color, depression, life, less

Intro to Contraception

• As of 2019, 41.6% of pregnancies in the US are ____________

• Unintended pregnancy rates are highest among

  • ____-income women

  • Women aged 18-24

  • Women of ______

• Consequences

  • An unintended pregnancy is a risk factor for poor maternal mental health

    • Perinatal ___________

    • Lower levels of psychological well-being and _____ satisfaction

• Preventing unintended pregnancies is ____ expensive than treating maternal/infant complications of pregnancy

safest, effective, vasectomy, reversal, salpingectomy

Sterilization

• One of the ______, most ________, and most cost-effective contraceptive methods available

• Most commonly used family planning method in the US

• Although comparable in effectiveness, _________ is simpler, safer, and less expensive

• Permanent (usually)

  • __________ of tubal ligation and vasectomy is expensive adn results are not guaranteed

  • ____________ cannot be reversed

permanent, recovery, long, partner, OR, regret, ectopic, STIs

Counseling and Sterilization

• Advantages

  • ___________ and highly effective

  • Safe with quick _________ (usually)

  • Minimal ____ term side effects

  • No need for _________ compliance

• Disadvantages

  • Not easily reversible or irreversible

  • Cost is higher if __ is required (not common anymore)

  • Potential for _______

  • Risk of _______ with tubal ligations

  • Lack protection against ____

local, incisions, cautery, local, puncture, fewer, less

Male Sterilization Techniques

• Conventional Vasectomy

  • Anesthesia: _______

  • Midline or lateral ________

  • Division and _________

• No-Scalpel Vasectomy

  • Anesthesia: ______

  • Skin ________, no scalpel incision

  • _______ complications

  • ____ pain and bleeding

tubal, bilateral salpingectomy, increased, decreased, laparoscopically, ovarian

Female Sterilization

• AKA ______ ligation

• 10-year failure rate is 1-2%

  • Less if ________ ____________ is performed instead of ligation

• Tubal ligation is associated with an ___________ risk of ectopic pregnancy and a __________ risk of endometrial cancer

• Typically performed __________

• Bilateral salpingectomy is performed more and more frequently d/t a potential reduction in ________ cancer risk

surgical sterilization, long, reversible, discomfort, perforation, STIs, ectopic

Intrauterine Device

• The efficacy of IUDs is similar to ________ ____________

• Advantages

  • ____-term pregnancy prevention

  • __________

• Disadvantages

  • __________ with insertion and/or removal

  • Risks of complications: __________, PID, expulsion

  • No protection against ____

  • If contraceptive failure occurs → increased risk of ________ pregnancy

polyethylene, string, immune, hostile, fertilization, 10, emergency, 5, ongoing, regular

CopperT IUD

• Made of __________ with copper along the vertical stem and side arms

• Has a monofilament polyethylene ______

• Mechanism: Copper causes ______ response that creates a __________ environment for sperm → prevents ___________

• Duration of use → __-12 years

• Can also be used as ___________ contraception

  • Insert up to _ days after unprotected intercourse

  • Can be left in place to provide _______ contraception

• Menses should still be ________

atrophy, flow, amenorrhea, fertilization, thickens, motility, implantation

Levonorgestrel IUD

• Releases levonorgestrel

  • Causes endometrial _______ → markedly decreased menstrual ____

  • __________ is common

• Mechanism → prevents ___________

  • ________ cervical mucus

  • Inhibits sperm ________ and function

  • Endometrial atrophy impairs _____________

• Mirena, Liletta, Kyleena, Skyla

unpredictable, spotting, progestin, months, acne, follicular, pain

Complications of LNG IUDs

• Bleeding is initially __________

  • Frequent ___________

• Side effects from the _________

  • Uncommon, but when they occur, typically decrease within first several _______

  • ______, mood changes, headache, breast tenderness

• May cause _________ ovarian cysts and pelvic ____

anatomic, expulsion, infection, pregnancy, abnormal, evaluation, Wilsons, dysmenorrhea, breast, liver

Contraindications to IUDs

• All IUDs

  • Severe distortion of the uterine cavity / _______ abnormalities

    • D/t increased difficulty with insertion and increased risk of _________

  • Active pelvic ________

    • PID, endometriosis, mucopurulent cervicitis, pelvic tuberculosis

  • Known or suspected __________

  • Unexplained ________ uterine bleeding

    • __________ of AUD should be done BEFORE IUD placement

• Copper IUD

  • _______ disease or copper allergy

  • Relative contraindication → current hx of _________ or menorrhagia

    • These can be worsened by the copper IUD

• Levonorgestrel IUD

  • _______ cancer

• Active ______ disease

  • Acute hepatic disease or hepatic tumors (benign or malignant)

progestin etonogestrel, arm, thickens, fertilization, gonadotropin, 3, long, rapidly, irregular, STIs

Implant (Nexplanon)

• Semirigid rod containing 68 mg of the _______ _________

• Placed subdermally in the inner upper ___

• Mechanism:

  • _________ cervical mucus → prevents ____________

  • Progestin also inhibits _________ secretion at high doses → inhibits follicular and ovulation

• Duration of use → _ years

• Advantages

  • Highly effective

  • ____ acting

  • ________ reversible

• Disadvantages

  • Must be inserted by provider

  • _________ bleeding and other side effects

  • No protection against ____

reactions, unscheduled, gain, breast, 7, pregnancy, thrombosis, hepatic, bleeding, progestin, allergic

Implant (Nexplanon)

• Side Effects

  • Implant site ________ (erythema, bruising, swelling, etc)

  • ____________, irregular uterine bleeding

  • Headache

  • Weight _____

  • Acne

  • ________ tenderness

• Insertion can only be performed by clinicians who performed specific training

• Abstinence or back-up contraception is suggested for _ days after insertion

• Contraindications

  • Known or suspected ________

  • Current or past history of ___________ or thromboembolic disorders

  • __________ tumor or active liver disease

  • Undiagnosed abnormal genital _________

  • Known or suspected breast cancer, hx of breast cancer, or other _________-sensitive cancer

  • __________ reaction to any component of the method

estrogen, progestin, pills, patch, ring

Combined Hormonal Contraceptives

• Contain both ________ and __________

• Most formulations contain 20-35 mcg of ethinyl estradiol and 1 of 8 available progestins

• Forms available

  • Combined oral contraceptive _______

  • Transdermal _______

  • Vaginal ______

• Safe and effective for vast majority of reproductive-aged women

• Key to successful use is selection of appropriate candidates, patient motivation, and effective counseling

ethinyl estradiol, tenderness, edema, hypertension

Estrogens used in combined hormonal contraception

• Types

  • ________ _________ - most common

  • Estetrol

  • Estradiol

• Side Effects

  • Breast __________

  • Nausea

  • Fluid retention / _______

  • ___________ occurs in 1/200

    • Mechanism → increases in angiotensinogen

first, second, third, fourth

Progestins

• ______ Generation

  • Norethindrone acetate

  • Ethynodiol diacetate

• _________ generation

  • Levonorgestrel

  • Norgestrel

• ________ Generation

  • Desogestrel

  • Norgestimate

• ________ generation

  • Drospirenone

  • Segesterone

progestin, spironolactone, potassium, androgenic, mineralocorticoid, VTE

Drospirenone

• Fourth-generation _________

• Derived from ____________ (_________-sparing diuretic)

• Anti-__________

• Exerts progestational and anti-____________ effects by competitively inhibiting and binding androgens to its receptors

• May be associated with increased risk of ___

3-3.5, 3-7, 3, 1, 24, 3, continuous, monophasic, placebo

How Combined OCPs are Taken

• Combination oral contraceptives are taken for a _-_._ weeks and then followed by _-_ days of “placebo pills”

  • 21/7 - _ weeks of OCPs, _ week of placebo pills, then start over with a new pack

  • 24/3 - __ days of OCPs, _ days of placebo pills, then start over with a new pack

• Some contraceptives are formulated for _________ use

• However, most __________ hormonal contraceptive pills will produce acceptable results when used continuously (AKA no ________ pills)

monophasic, biphasic, triphasic, multiphasic, monophasic, multiphasic

What the Difference of OCPs?

• ___________ → fixed amount of estrogen and progestin in each active pill

• ________ or __________ → varying amounts of estrogen and progestin each week according to the stage of the cycle

• _________ pills were developed to reduce side effects of monophasic pills

• However, __________ pills give better cycle control

• __________ pills cannot be taken continuously

3, 1, 1, 7, reversible, VTE, back-up, 30, thromboembolism, lower

Transdermal Patch

• Patch applied once per week for _ weeks, followed by _ patch-free week

• Must start using on day _ of menstrual cycle

  • If not, use back up contraception for _ days

• Advantages

  • As effective as oral combined hormonal contraceptives

  • ___________

• Disadvantages

  • Increased risk of ___

  • If a patch is not changed at the appropriate time, ____-__ contraception may be needed

• Contraindications

  • Same for anyone who cannot use estrogen-progestin

  • BMI > __

    • Increased risk of ____________

    • Concerns for _______ efficacy

vagina, 3, one, first, 7, coital, expulsion, breast, estrogen, removed, 3

Vaginal Ring

• Flexible, unfitted ring placed in the ________

• Delivers medication over _ weeks, followed by a _ week break

• Must insert within _______ first days after LMP

• Use non-hormonal backup method for the first _ days

• Ring-specific side effects

  • ________ problems

  • __________

  • Vaginal discharge

• Advantages

  • Less ________ tenderness and nausea than other _________-containing hormonal contraception

  • Does not need to be _________ during sexual intercourse, but may be removed for up to _ hours without affecting contraceptive efficacy

    • If removed, rinse and reinsert within 3 hours

irregular, breast, thromboembolism, nonsmokers, 35

Remember the risks and side effects

• Side effects of combined hormonal contraception

  • __________ bleeding

  • _______ tenderness

  • Nausea

• Venous _____________ risk

• Does not increase risk of heart attack or stroke in health _____________ < __ years old with no other risk factors

clotting, aura, liver, breast, hypertension, smokers

Remember the Contraindications

• Known ________ disorders

• Migraines with visual ______

• ______ disease

• _______ cancer

• Moderate to severe ___________

• Older _________

mini, cervical, ovulation, estrogen, consistent, time, 3, 2, pregnancy, breast, bleeding, liver

Progestin-Only Oral Contraceptives

• Also called the “____-pill”

• Two formulations: norethindrone and drospirenone

• Mechanism

  • Thicken ________ mucus

  • Suppress ___________ (not consistently with norethindrone, but is the main mechanism of drospirenone)

• Advantage → Good for women who cannot use _________

• Disadvantage → _______ use is critical

  • Must be taken at the same ______ each day

    • If dose is missed by >_ hours, use back-up contraception for at least _ days

• Contraindications

  • Known or suspected __________

  • Known or suspected ________ cancer

  • Undiagnosed abnormal uterine __________

  • Benign or malignant _______ tumors, or acute liver disease

13, adolescents, daily, estrogen, bleeding, remember

Injectable Progestin

• Depot medroxyprogesterone acetate

• Intramuscular injection given every __ weeks

• Effective and popular in ________

• Great for the following criteria

  • Desire a highly effective reversible contraceptive that doesn’t require ______ use

  • Have a contraindication to, or wish to avoid, an ________-containing contraceptive

  • Desire or medical indication for eliminating menstrual _________

  • Wish to take advantage of DMPA’s noncontraceptive benefits

  • Prefer a private/discrete method of contraception

  • May not consistently _________ to use types of contraception that require frequent or pericoital administration

  • Have difficulty using other forms of contraception

bleeding, decrease, amenorrhea, gain

Depo-Provera Side Effects

• Irregular _________

  • Common in first few months of use, _________ with increased duration of use

  • __________ in 50% after one year of use

• Weight _____

• Headache

latex, STI, synthetic, barrier, synthetics

External Condoms

• Material

  • _______

  • Natural animal membrane

    • Not effective for ___ prevention (contain small pores that may permit passage of viruses)

  • ________

    • Polyurethane, silicone

• Mechanism → _________; condom catches semen

• Effectiveness greatest when both partners understand how to properly use

• STI/HIV protection (latex and _________ only!)

reversible, STI, discretely, lower, sensation, oil

External Condoms

• Advantages

  • OTC

  • Easily ___________

  • ___ protection

  • Cheap

  • Able to be carried _________

  • minimal side effects

• Disadvantages

  • _______ effectiveness

  • Required with each act of intercourse

  • Reduced __________

  • Cannot use with _____-based lubricants

ring, open, cannot, female

Internal Condoms

• Polyurethan or nitrile sheath with closed flexible _____ on one end and _____-ended ring on other end

• _______ be used with male condom

• Only _______-controlled method that provides STI/HIV protection

reversible, STI, clitoris, difficulty, visible, failure, noise

Internal Condoms

• Advantages

  • Safe and __________

    • No delay in return of fertility following discontinuation

  • Minimal side effects

  • ___ protection

  • May stimulate the _________ with the external ring, thus enhancing sexual arousal

• Disadvantages

  • _________ with insertion and removal

  • The outer ring is _______ outside of the body, which can be unacceptable to some users or their sexual partners

  • It has higher ________ rate in preventing pregnancy compared with most other contraceptive methods

  • Can make ______ during intercourse

erect, latex, water, less, anal, synthetic, oil, more, anal

Comparing Condoms

• External

  • Require an _______ penis

  • Usually made of ______

  • Can only use _______-based lubricant

  • ____ expensive

  • Can be used for ______ intercourse

• Internal

  • Do not require an erect penis

  • Usually made of ________ materials

  • Can be used with both ____-based and water-based lubricants

  • ____ expensive

  • Cannot be used for _____ intercourse

effectively, negotiate, STIs, expiration, emergency

Condom Counseling

• How to use ___________

• How to _________ use with partner(s)

• Importance of use for all sexual activities that can transmit _____

• Check _________ dates

• Have __________ contraception in advance

reusable, spermicide, irritating, 1, 6, 24, UTIs, toxic shock

Diaphragm

• ___________ female contraceptive device consisting of a soft dome-shaped cup with a flexible rim

• Must be used with a __________

  • Placed within the dome and into the vagina

• Can be ___________

• Ideally inserted into the vagina <_ hour prior to intercourse

• Must remain in place for at least _ hours after the last act of intercourse to maximize effectiveness

  • But should be removed by __ hours

• Associated with ____

• Should not be used in pts with a hx of ______ _______ syndrome

silicone, spermicide, 6, 6, 48, UTIs

Cervical Cap (FEMCAP)

• Reusable ________ cup

• Must be used with ___________

  • Inserted both under the dome and within the rim

• Three sizes available

• Can be inserted up to _ hours prior to intercourse, and must be left in the vagina for at least _ hours after intercourse

• Can be left in place for up to __ hours

• Associated with _____

gel, pH, lower, alkaline, 10, hormones, prescription, 1, after

Phexxi

• New contraceptive ___ introduced in 2020

• Vagina __ regulator gel containing lactic acid, citric acid, and potassium bitartrate

  • Maintains a ______ vaginal pH of 3.5-4.5 even in the presence of _______ semen

• Coats the vagina and stays in place for up to __ hours

• Contains no ________

• Requires a __________

• Inserted into the vagina no more than _ hour prior to intercourse

• Common side effects included vulvovaginal burning and itching

• Not effective when used ______ sex

physiologic, lifespan, natural, 26-32, 8-19, temperature, mucus

Fertility Awareness-Based Methods

• Based upon the __________ changes during the menstrual cycle and the functional _________ of sperm and ova

• Also called “__________ family planning”

• Can follow standard days

  • Regular cycles are __-__ days in length

  • Plan includes avoiding intercourse during days _-__

• Other methods to track ovulation

  • Basal body __________

  • Cervical ________ changes

after, mifepristone, ovulation, fertilization, abortifacient, copper

Emergency Contraception

• Prevents pregnancy _______ unprotected sex

• NOT the same as __________ (aka the “abortion pill”

• Inhibits or delays ___________ and prevents __________ of an ovulated egg

• Not an ____________

• Methods

  • Plan B

  • Ulipristal

  • _______ IUD

control, health, efficacy, expectations, privacy

Contraceptive Counseling

• Recognize patient’s goals for ______ of fertility

• Identify _______ risks that may determine choice of contraception

• Determine patient’s ability to consistently and correctly use the preferred method

• Teach patients about contraceptive ___________

• Review risks, benefits, and ___________

• Practice non-judgemental and active listening

• Respect patient ________