GYN - Contraception

What are the contraceptive options?

Natural methods, barrier methods, spermicides or vaginal gels, hormonal, permanent sterilization

What lifestyle modifications can be suggested in contraceptive counseling?

Take Ca, folic acid, and vit D supplements, exercise, smoking/vaping cessation (inc risk of VTE)

What is a patient over the age of 35 who is a smoker and on birth control containing estrogen at a higher risk for?

Thrombosis

What are the natural barrier methods?

Abstinence, coitus interruptus, fertility awareness method

What is coitus interrupts?

Withdrawal/Pull out method - penis withdrawn just before ejaculation

How effective is coitus interruptus?

Unreliable - pre-ejaculate contains high sperm concentration

What is the fertility awareness method?

Avoid intercourse during the fertile window - periodic abstinence

How can people estimate their fertile window?

Timing cycles, recognize cervical mucus, basal body temperature tracking, ovulation kits, cycle beads / standard days

When does ovulation occur?

~14 days before onset of next cycle (most women have fertile window around day 8-19)

How does cervical mucus appear around ovulation?

Increased clear, slippery discharge

(white, cloudy, & sticky in follicular and luteal phases / outside of fertile window)

How does the basal body temperature method of tracking fertility work?

Take BBT fully at rest (before getting out of bed) - looking for up trend of temp

*most fertile 2-3 days before temp rises ~ 0.5°F

How do ovulation kits work?

Detect LH surge, best to use 1-2 days before expected ovulation & with 2nd morning void

darkest line = ovulation likely w/in 1-3 days

What are standard days / cycle beads?

Color coded string of 32 beads to represent the menstrual cycle and track ovulation (fertility awareness method)

What is the MOA of a spermicide?

Chemical/detergent that kills sperm (MC Nonoxynol 9); new dose must be inserted prior to each act of intercourse

What are disadvantages to spermicides?

Messy, local irritation to vagina/penis, inc risk of vaginitis infx & UTIs, possible carcinogen

26% unintended pregnancy w/ typical use (6% w/ perfect use)

What should be avoided with condoms?

Oil or silicone based lubricants → can cause breakage

What is a female condom?

Polyurethane or nitrile sheath placed into vagina to keep sperm out

What is a diaphragm?

Soft latex or silicone rubber cup that goes into vagina and covers cervix to block semen from entering

Must place 2 tsp of spermicide into the inside

What is a cervical cap?

Similar to diaphragm; fits snugly onto cervix / adhere to vaginal walls & used with spermicide to prevent sperm from entering cervical os

The following health benefits are seen with what type of BC?

• dec endometrial & ovarian CA risk

• dec bone density risk

• tx IDA if due to heavy menses

• tx dysmenorrhea, menorrhagia, menstrual cycle disorders

Combo pills

What drugs can decrease levels of birth control pills making them less effective?

Rifampin and griseofulvin

What is the MOA of combination OCPs?

Contains both estrogen & progestin → suppress ovulation by preventing mid cycle LH surge, thins endometrium & thickens cervical mucus

What is monophasic dosing of combo OCPS?

Same doses of hormones every day minus placebo/sugar pills (most popular)

What is biphasic dosing of combo OCPS?

Lower estrogen/progesterone ratio in first half of pill cycle followed by higher ratio

What is Triphasic dosing of combo OCPS?

Each week of the 3 active pills weeks has an increasingly higher estrogen/progesterone ratio

What drug?

• extended cycle OCP - designed to eliminate women’s periods

• combo levonorgestrel / ethinyl estradiol

• can cause irregular spotting

Amethyst / “365 day pill”

What drug?

• progestin w/ anti-mineralocorticoid effects that can help with water retention & bloating during menses

• antiandrogenic properties → helps w/ hormonal acne, hair loss, hirsutism

Drospirenone

What are CIs to drospirenone?

Liver, kidney or adrenal disease & hyperkalemia

The following advantages are seen with what form of contraceptive?

• reversibly

• improve dysmenorrhea & AUB

• protective against osteoporosis, ovarian cysts, ovarian & endometrial CA

• improve acne/hyperandrogenic effects

• less associated w/ PID & ectopics

Combo OCPs

What can cause breast tenderness, HA/migraine, HTN, and increased secretion of biles leading to gallstone formation?

Exogenous estrogen

The following disadvantages are seen with what form of contraception?

• increase fluid retention

• increased risk VTE, HCC

• exogenous estrogen effects

Combo OCPs

In what patients should combo OCPs be used w/ caution?

Pre-existing HTN, DM, HLD, liver/gallbladder dz

must be stopped in smokers > 35 y/o

What are contraindications to combo OCPs?

Smokers > 35 y/o,

uncontrolled HTN or >35, DM vascular dz or >35,

migraines w/ focal neuro sx or >35,

vascular dz assoc w/ SLE,

known/suspected pregnancy or estrogen dependent cancers

unexplained vaginal bleeding

liver tumor

jaundice assoc w/ pregnancy or OCP use

What are the early warning signs to watch for w/ combo OCPs?

Abdominal pain (severe)- mesenteric occlusion

CP (severe, cough, SOB, pain breathing in)- PE

HA (severe, dizzy, weak, numb)- stroke

Eye problem (vision loss / blurring) & speech problems - retinal artery occlusion

Severe leg pain (calf or thigh) - DVT

When should patients be instructed to start combo OCP?

First day of menses (less risk BTB + immediately effective if regular)

Sunday start

Quick start (first pill in office, must r/o pregnancy)

What is the best way to start OCP to ensure compliance?

Quick start w/ first pill while in office (reduces risk of delay of starting)

What additional pt ed should be told to the pt starting OCP?

Take around the same time every day & use back up method during 1st cycle (esp 1st week of pills)

How does the patch work?

Transdermal combo patch with once weekly dosing for 3 weeks of the month / 21 day regimen (last week for withdrawal bleeding)

What form of BC is associated with better compliance than triphasic OCP & bypasses hepatic first past metabolism?

Transdermal patch

The following disadvantages are seen with what form of BC?

• slightly greater risk of clots

• application site reactions

• significantly more breast discomfort (early cycles) and dysmenorrhea

• less effective if ≥198 lbs

The patch

In what patients would the patch not be recommended in?

BMI > 30

What form of BC is a flexible, non biodegradable, transparent copolymer ring of etonogestrel / ethinyl estradiol that requires self insertion and vaginal removal?

The ring

What BC has a 3 week regimen (improved compliance) , bypasses GI absorption and hepatic first pass metabolism, and can be removed up to 3 hrs w/o losing efficacy?

Ring

What is the MOA of progesterone only pill (POP or mini pill)?

Inhibits ovulation inconsistently; Thickens cervical mucus making it difficult for sperm & infx to enter upper reproductive tract; Thins endometrium to make less likely for fertilized egg to attach

alters ovum transport → slows fallopian tube motility

What form of BC is associated with the following advantages?

• indicated for pts who can’t take estrogen

• safe while breastfeeding & in F > 35 y/o

• reversible

• can start on any day of the cycle

• protects against endometrial > ovarian CA

• dec risk PID (bc thick cervical mucus)

POP

The following disadvantages are associated with what form of BC?

• no STD protection

• change in menstrual cycle (irregular/longer), more BTB

• less effective than combo pills

• must take at same time everyday

• higher risk ectopic pregnancy

POP

What form of BC is associated with a higher risk of ectopic pregnancy due to reduced fallopian motility?

Progesterone only pill / POP

Which is more effective- combo or POP?

combo OCP

What form of BC?

• administered in arm or buttocks every 12 weeks in office or at home

• one week grace period to 13 weeks

  • if > 13 → r/o pregnancy before injection, use back up method for 1-2 wks

Medroxyprogesterone acetate (DMPA) / Depo

What is the MOA of DMPA?

Suppress ovulation, thicken cervical mucus & thin endometrium

Why do 70% discontinue the Depo shot after 1 year?

side effects (injection site pain, weight gain 2-5lbs/year, HAs, depression, bone loss)

What patient education is important to give a patient receiving DMPA?

Don’t rub injection site →. crystals absorb earlier & decreases efficacy

The following advantages are seen with what form of BC?

• quick onset (24 hrs if started w/in 7 days of period)

• long term contraception, good for compliance / memory issues w/ pill

• inc amenorrhea

• no estrogen

Depo

How long can it take for ovulatory cycles / fertility to return to normal after discontinuing the depo shot?

6-24 mos

What BBW is associated with Depo Provera injection?

Significant decrease in bone mineral density, might not be completely reversible

When would the Depo provera shot be indicated for use over 2 years?

Other BC methods are inadequate (take 6-12 mos off before returning to use)

At what ages is there caution around using DMPA?

under 18 and over 40

What form of BC is an etonogestrel containing SC implant in the upper arm that is effective w/in 24 hours of insertion?

Nexplanon

What SE is common with nexplanon?

Irregular, unscheduled bleeding

The following advantages are seen with what form of BC?

• highly effective and rapidly reversible

• discrete- can palpate but not see

• 3 years of continuous non fluctuating hormones

• progestin only- no estrogen

• safe for breastfeeding

Nexplanon

What is the MOA of a hormonal IUD?

Progesterone thickens cervical mucus, partly suppresses ovulation, thins uterine lining which interferes with implantation & sperm penetration

What is the MOA of copper/nonhormonal IUDs?

Copper can kill sperm/inhibit motility, device creates mild inflammatory response preventing implantation, ovulation is not inhibited

does not kill fertilized egg → not abortive

What are the 5 IUDs being used in the US?

Copper (Paragard), Mirena or Liletta, Kyleena, Skyla

What must be done before IUD insertion?

STD test - if positive, must treat before procedure

When is the best time to insert an IUD?

While menstruating

How long should a patient avoid having anything in the vagina after an IUD insertion due to the risk of infx/PID?

1 week

Does an IUD need to be removed if a patient diagnosed with an STD?

No, unless it is within the first 7 days or concern for PID

Which IUD option makes periods heavier, longer and more painful, esp for first 6 mos - 1 year?

Copper IUD

Which IUD is best in parous women because it is slightly bigger?

Mirena

Which IUD is better in nulliparous women?

Skyla

The following advantages are seen with what form of BC?

• effective immediately

• Return to fertility relative quickly after discontinuation / removal

• No estrogen

• If hormonal, dec cramping and blood loss

• Can be used postpartum and during breastfeeding

IUDs

The following disadvantages are associated with what form of BC?

• cramping/pain/spotting after insertion

• can erode into endometrial lining and myometrium leading to perforation (can be complete and enter peritoneal cavity)

• can become displaced which reduces efficacy and leads to pregnancy

• irregular periods

• inc risk of PID(up to 20 days after insertion) and recurrent vaginal infx

IUD

In what patients should hormonal IUDs not be used / be removed if new diagnosis?

Cervical dysplasia

What is the MC reason for IUD discontinuation?

ongoing pain and irregular bleeding

the following CIs are to what form of BC?

• pregnancy/suspicion of pregnancy

• uterine anomaly- submucosal fibroids

• acute PID / hx PID unless subsequent intrauterine pregnancy

• postpartum endometriosis or infected abortion past 3 mos

• unresolved abnormal pap or cervical / uterine neoplasia

• undx genital bleeding

• untx infx

• acute liver disease or tumor, known/suspected breast CA

IUD

What are advantages to regulating/stopping menses while on BC?

Reduced menorrhagia, dysmenorrhea, anemia, & menstrual related sx

In the state of Florida, can minors seek medical care for pregnancy & STD screening without parental consent?

Yes :)

What allows a minor to seek contraceptive counseling without parental consent?

Contraceptives required for health reasons (dysmenorrhea, menorrhagia, etc), married, have a child, or have ever been pregnant

What drugs intend to disrupt ovulation or fertilization necessary for pregnancy?

Contraceptives

What drugs prevent the implantation of a human embryo in the uterus, thus preventing pregnancy?

Contragestives (not abortive)

What are the emergency contraceptive (ECP) options?

High dose POP, combo estrogen/progestin pill, Ulipristal, Copper IUD

How do high dose progestin only pills (levonorgestrel / plan B) work as emergency contraceptives?

Prevents ovulation (most effective prior to ovulation, not at all effective during/after ovulation)

Take ASAP or w/in 72 hours of unprotected sex

When would a patient have to repeat a dose of plan B?

If thrown up w/in 2 hours

How do combined estrogen/progestin pills (Yuzpe method) work as an ECP?

4 OCPs- take 2 tabs at 12 hr intervals, taken ASAP or w/in 5 days (120 hrs) of unprotected sex

best before ovulation

How does Ulipristal (Ella) work as an ECP?

Delay ovulation and possible implantation, take ASAP or w/in 5 days (120 hrs)

What form of emergency contraception is 99.9% effective if done w/in 5 days of unprotected sex, but is NOT recommended for pts at risk of STDs?

Copper IUD insertion

Who can get plan B OTC in Florida?

Women over 18

What permanent sterilization option exists for men?

Vasectomy

What permanent sterilization options exist for women?

Tubal ligation, salpingectomy, essure

When form of permanent sterilization cuts, ties, or blocks the fallopian tube, and is technically reversible?

Tubal ligation

What can occur with tubal ligation?

Ectopic pregnancy

What form of permanent sterilization removals the fallopian tubes and also reduces the risk of ovarian CA?

What form of permanent sterilization inserts metal coils into the fallopian tubes causes blockage and fibrosis?

Essure

What is an SE of Essure?

Chronic pelvic pain and risk of displacement