8: Contraception and family planning

clinical approach to contraception selection, start with the patient:

• does the patient want _ now, soon, or not at all?

• can the patient adhere to _/_ methods?

• are there medical risks such as _, _ w/ _, _? does the patient need _ protection?

pregnancy

daily/weekly

venous thromboembolism (VTE), migraine with aura, hypertension

STI

after answering those previous questions then choose the best method that best balances:

• _ (typical use)

• _ (contraindications)

• _ and _

effectiveness

safety

convenience and reversibility

LARC= _ _ _ _

Long acting reversible contraception

Typical use failure rates of different birth controls:

• LARC (IUD, Implant):

• pill, patch, ring:

• condoms:

the reason is simple, the daily methods depend on _, but LARC works whether the patient _ or not

<1%

~7%

13%

remembering/remembers

estrogen is effective because it suppresses _ and improves cycle _

ovulation

control

the trade off for taking estrogen is that increases hepatic production of _ factors

clotting

the clinical risk of increasing clotting factors is a higher risk of _ _, _, and _ _

venous thromboembolism (VTE), stroke, and myocardial infarction

before prescribing estrogen you should ask:

• does she have _ w/ _

• any history of _

• _ >/= 35 years

• uncontrolled _

migraine w/ aura

VTE

smoker

HTN

combined hormonal methods have one mechanism but three delivery systems, the primary mechanism is they suppress _

ovulation

other mechanisms of combined hormonal methods besides suppressing ovulation is they thicken cervical _ (blocks _), and they thin the _ (creates an endometrium less receptive to _)

mucus, sperm

endometrium, implantation

combined hormonal methods are available as:

• _: daily

• _: weekly

• _ _: monthly

pill

patch

vaginal ring

why does it matter when you miss a pill?

missed pills → _ hormone levels → possible _

decreased

ovulation

if you miss one pill, you should take it as soon as _, and _ the pack

remembered

continue

if there were >/= to two pills missed, you should _ the pack, but use _ contraception for _ days

continue

backup for 7

if unprotected intercourse occurred, you should consider _ contraception

emergency

progestin-only methods work by the primary mechanism of thickening the cervical _, and maybe _ suppression (method-dependent)

mucus

ovulation

why would someone choose a progestin-only method?

no estrogen → no estrogen-related _ risk

thrombotic

progestin only methods are a good option for patients with:

• _ w/ _

• prior _

• _ status

migraine w/ aura

VTE

postpartum

LARC is considered first line, what are the different types of LARC?

• _ _, _ _, _

hormonal IUD, Copper IUD, Implant

why do guidelines recommend LARCs first?

• _% typical use failure

• no _, _, _ adherence

• effective for _-_ years

• rapid return to _ after removal

<1%

daily, weekly, monthly

3-10

fertility

hormonal IUDs work by thickening the cervical _, suppresses the _, and usually _ bleeding

mucus

endometrium

decreases

Copper IUDs work by creating a _ environment, copper is toxic to _, and may increase _/_

spermicidal

sperm

bleeding/cramping

what are the three different types of emergency contraception?

Levonorgestrel (Plan B), Ulipristal (Ella), Copper IUD

plan B is best within _ hours

72

ella is more effective than _ _, works up to _ hours (5 days)

plan b

120

Copper IUD is the most _; can be inserted within _ days and provides _ contraception

effective

5

ongoing

all emergency contraception works _ pregnancy is established

primary mechanism: _ or _ ovulation

does it terminate an existing pregnancy or disrupt an implanted embryo?

before

delays or prevents

NO

Levonorgestrel (Plan B) works best within _ hours, works best the _ it is taken

72

sooner

Ulipristal (Ella) is effective up to _ hours (5 days), and is more effective than _ _ late in the window

120

plan b

copper IUD is effective up to _ days, and is the _ _ emergency contraception

5

most effective

when it comes to emergency contraception, earlier treatment = _ _

higher effectiveness

when it comes to choosing emergency contraception, start with two questions:

• how _ has it been since unprotected intercourse?

• is _ an option for this patient?

then choose the best method

• </=72 hrs: _ _ is appropriate

• up to 5 days: _ is preferred

• best overall option: _ _ (if available and acceptable)

long

IUD

plan b

ella

copper IUD

Depo-provera is _ injection every _ months (good option for patient who dont want a daily pill)

one

three

depo-provera has reliable _ suppression, and also thickens cervical _ to reduce sperm penetration

ovulation

mucus

counseling points for depo-provera:

• _ bleeding is common early; many patients develop _ over time

• weight _ may occur

• bone mineral density _ during use but generally recovers after _

irregular; amenorrhea

gain

decreases; stopping

depo provera is a good fit for patients who…

• cannot use _

• want _ contraception without taking a daily pill

• dont mind returning every _ months for an injection

estrogen

reliable

3

you should carefully counsel the patient on depo-provera if the patient is

• an _ (discuss bone health)

• is concerned about weight _

• wants _ within the next year (delayed return to fertility)

adolescent

gain

pregnancy

Nexplanon (implant) works so well because it:

• _ suppresses ovulation with no daily adherence

• thickens cervical _ for additional contraceptive protection

continuously

mucus

patients should know that nexplanon is

• effective for _ years with _ failure rate

• _ _ is the most common reason for discontinuation

• _ returns rapidly after removal

3; <1%

irregular bleeding

fertility

before insertion of the implant, set expectations before insertions

• _ bleeding is expected, especially during the first _ months

• bleeding patterns are _ and vary from patient to patient

reassure patients

• irregular bleeding does not mean the implant isnt _

• bleeding often improves with _, although some irregularity may persist

clinical pearl:

• patients who know what to expect are much more likely to continue using the implant

irregular; several

unpredicatble

working

time

what drives the choice of postpartum contraception?

timing

the postpartum period carries the highest risk of _ _, especially during the first _-_ weeks

venous thromboembolism

3-6

you should avoid _-containing contraception in early postpartum because it further increases VTE risk

estrogen

what are the preferred options for postpartum contraception?

• _ only methods can generally be started immediately postpartum

• _ may be placed immediately after delivery or at a follow up postpartum visit

progestin

IUDs

postpartum high yield timing rules:

combined hormonal contraception-

• <_ days: avoid (highest VTE risk)

• _ - _ days: individualize based on VTE risk

• >_ days: generally acceptable if no contraindications

21

21-42

42

if the patient is breastfeeding, you should avoid _ in early postpartum (may reduce milk supply and increase VTE risk)

estrogen

bottom line:

_ only methods are preferred during the early postpartum period

progestin

certain _ medications and _ are strong liver enzyme induces

antiepileptic/ rifampin

if something is a strong liver enzyme inducer, this means there is

faster hormone metabolism → _ contraceptive hormone levels

_ hormone levels → _ contraceptive effectiveness

lower

lower; reduced

you should always review a patients _ list before prescribing hormonal contraception, consider a method not affected by enzyme _ (e.g. copper IUD and levonorgestrel IUD)

medication

induction

before choosing a contraceptive method, these are 5 questions a patient should answer:

• how well does it prevent _?

• can I use it _?

• what _ _ should i expect?

• will it fit my _?

• does it protect against _?

Bottom line: the “best” contraception is one that is _, _, and _ to the patient

pregnancy

safely

side effects

lifestyle

STI

safe, effective, acceptable

key takeaways:

start with the patients _, not your favorite contraception

choose the _ method before choosing the most _ one

remember that _ affects effectiveness

know when _ _ is indicated- and act quickly

good _ improves satisfaction, continuation and outcomes

goals

safest; effective

adherence

emergency contraception

counseling