Contraception and STIs

Categories of birth control methods

1)Natural family planning

2)Barrier

3)Hormonal contraceptives

4)Intrauterine devices (IUD)

5)Surgical

Natural family planning-Basal Body Temp

•temperature drops slightly, then rises 1° F at time of ovulation

•First day of slight drop= first fertile day

•Ovulation occurs when temperature spikes 1°F

•Refrain from intercourse from first fertile day to 3 days after ovulation

Cervical Mucous Method/ Billings method

cervical mucous becomes thin, watery, transparent, and stretches between the fingers (spinnbarkeit sign)

Lactation amenorrhea method

Safe method with failure rate of 1% to 5% if:

•Infant under 6 months of age

•Breastfeeding with no supplements

•Menses has not returned

Diaphragm & Spermicide Pros and Cons

•PROS- gives client more control over contraception; easier to insert than female condom

•CONS- requires prescription & visit to a provider for proper fit, interferes with spontaneity, no protection against STIs, must be inserted correctly to be effective, requires re-fit every 2 years, 20% weight fluctuation, abdominal surgery, pregnancy

Diaphragm & Spermicide Education

Education- can be inserted 6 hrs before intercourse, empty bladder prior to insertion; must stay in place 6-24 hrs after; new spermicide application required for each act of intercourse

Cervical Cap & Spermicide Pros and Cons

•PROS- can be left in place up to 48 hrs after intercourse because no pressure placed on vaginal walls or urethra

•CONS- dislodge more readily than diaphragm, requires re-fit every 2 years, 20% weight fluctuation, abdominal surgery, pregnancy

Cervical Cap & Spermicide Education

Education- can be inserted 6 hrs before intercourse; must stay in place 6-48 hrs after; new spermicide application required for each act of intercourse

Barrier methods

condom

Diaphragm & spermicide

Cervical cap & spermicide

Hormonal contraceptives

1)Combined Oral Contraceptives - estrogen and progestin

1)Progestin-only Mini Pill

1)Emergency oral contraceptive (Plan B Pill) - progestin

4)Transdermal Patch - estrogen & progestin

4)Vaginal Ring (NuvaRing) - estrogen & progestin

6)Injectable progestin (Depo-Provera)

6)Implantable progestin rod (Implanon, Nexplanon)

Intrauterine Devices (IUD)

•Most effective contraceptive (99.9%)

•Hormonal brands= 3-5 years

•Copper IUD= 10 years

•Easily reversible, immediate return to fertility

•Can be used by nulliparous or multiparous clients

•Safe for breastfeeding

•Monitored monthly by presence of strings in upper vagina

•Increased risk for PID, uterine perforation, ectopic pregnancy

T-shaped device inserted into uterus

progestin IUD

A patient comes into the family planning clinic and requests a prescription for birth control pills. Which assessment finding indicates that birth control pills would not be the best contraceptive method for the patient?

A."I should plan on regaining fertility 5 months after the IUD is removed."

B."An IUD should be replaced annually during a pelvic exam."

C."I cannot get an IUD until after I've had my first baby."

D."I will check to be sure the strings of the IUD are still present each month after my periods."

ABC

A patient comes into the family planning clinic and requests a prescription for birth control pills. Which assessment finding indicates that birth control pills would not be the best contraceptive method for the patient?

A.Irregular menstrual cycles

B.Allergy to latex

C.Hypertension dx

D.Age of 33 years

C

Combined Oral Contraceptives - estrogen and progestin

•Requires prescription

•Take at same time every day for optimum effectiveness

•Must use back up method if more than 2 doses missed

•Effects can be inhibited by other medications (antibiotics)

•Major risks: thromboembolism, stroke, heart attack, hypertension (especially if smoker, >35 years of age, hx of clotting disorder)

Progestin-only Mini Pill

•Safe for breastfeeding

•Action & use the same as combined oral contraceptives

•May have more breakthrough, irregular vaginal bleeding

Emergency oral contraceptive (Plan B Pill) - progestin

•Must be taken within 72 hours of unprotected intercourse

•Can be purchased OTC at pharmacy, no age minimum

•Evaluate for pregnancy if menstruation does not begin within 21 days

•Will not terminate an already established pregnancy

Transdermal Patch - estrogen & progestin

•Applied to subcutaneous tissue of buttock, abdomen, upper arm, or torso

•Replace on same day of the week x 3 weeks, no application the 4th week

•Decreases risk of forgetting to take a pill

•Less effective in obese women

•Same adverse effects as oral contraceptives

•Avoids liver metabolism

•If possible, change sites with new patch

Vaginal Ring (NuvaRing) - estrogen & progestin

•Inserted vaginally once per month; remains in place for 3 weeks; removed for 1 week before new ring inserted

•Does not require fit

•Can be removed for up to 3 hrs without compromising effectiveness, but removal is not required for intercourse

Avoids liver metabolism

Transdermal Patch - estrogen & progestin application

•Applied to subcutaneous tissue of buttock, abdomen, upper arm, or torso

Major risks: thromboembolism, stroke, heart attack, hypertension (especially if smoker, >35 years of age, hx of clotting disorder)

1)Combined Oral Contraceptives - estrogen and progestin

Safe for breastfeeding

1)Progestin-only Mini Pill

1)Emergency oral contraceptive (Plan B Pill) - progestin

6)Injectable progestin (Depo-Provera)

6)Implantable progestin rod (Implanon, Nexplanon)

Intrauterine Devices (IUD)

Injectable progestin (Depo-Provera)

•Given IM q 11-13 weeks (4 per year)

•Safe for breastfeeding

•Decreased risk of uterine cancer if used long-term

•Need adequate intake of calcium & vitamin D

•May cause weight gain

•Return to fertility may be delayed up to 18 months after discontinuation

Implantable progestin rod (Implanon, Nexplanon)

•Subdermally implanted into upper aspect of arm

•Effective, continuous for up to 3 years

•Safe for breastfeeding

•More rapid return to fertility after removal

•Must avoid trauma to insertion site- can cause infection

Male: Vasectomy

•Ligation of vas deferens through puncture wound in scrotum

•can be done outpatient under conscious sedation

•Sterility not achieved until all sperm is cleared from proximal vas deferens (~20 ejaculations); must use alternate form of birth control

•Does not affect sexual function or sperm production

•99.5% effective

Sterility not achieved until all sperm is cleared from proximal vas deferens (around __ ejaculations); must use alternate form of birth control

20

Female: Tubal Ligation

Female: Tubal Ligation

•Severance & cauterization of fallopian tubes

•surgical procedure in OR requiring anesthesia

•Can be done immediately after childbirth

•No back-up birth control required

•Does not affect sexual function

•99.5% effective

Elective termination of pregnancy

•Surgical or Medical

(use of medications: Mifepristone, Methotrexate, Misoprostol)

•Called Therapeutic/Medical abortion

(TAB vs. SAB)

•Implications:

-pregnancy that threatens health of mother (ex: ectopic, woman with class IV heart disease)

-Fetus with chromosomal defect incompatible with life

-Rape, Incest

-Unwanted pregnancy due to personal, financial, social reasons

•Women with Rh- blood should receive RhoGAM immune globulin after procedure to protect future fertility

A nurse is admitting a client who is in labor and has HIV. Which of the following therapeutic interventions should the nurse identify as contraindicated for this client (select all that apply)?

Vacuum extractor

Oxytocin infusion

Forceps

Cesarean birth

Internal fetal monitoring

ACE

Bacterial STI

Chlamydia

Gonorrhea

Syphilis

Viral STI

Human Papilloma Virus (HPV)

Herpes Simplex Virus (HSV)

Human Immunodeficiency Virus (HIV)

Parasitic STI

Trichomoniasis

Chlamydia

-Most common bacterial ATI

-Usually asymptomatic

-Gray-white discharge

-Dysuria, increased urinary frequency, bleed after sex, testicular pain

-Should test for gonorrhea (due to strong association of co-infection)

Reportable Diseases

-Chamidia

-Syphillis

-Gonorrhea

-HIV/AIDS

A nurse is admitting a client who is in labor and has HIV. Which of the following therapeutic interventions should the nurse identify as contraindicated for this client (select all that apply)?

A.Vacuum extractor

B.Oxytocin infusion

C.Forceps

D.Cesarean birth

E.Internal fetal monitoring

ACE

Chlamydia Presentation

•Usually asymptomatic about 80%

•Mucopurulent endocervical or penile discharge (i.e., heavy gray-white discharge)

Vulvar/penile itching

•Dysuria, urinary frequency, post-coital bleeding in females, testicular pain in

Bacterial STIs

•Chlamydia

•Gonorrhea

•Syphilis

Chlamydia Treatment

•Abstain from sex for 7 days- •Must treat all sexual partners

•Doxycycline and Levofloxacin (contraindicated in pregnancy)

•Azithromycin 1 gram PO (recommended)

Chlamydia Impact on Pregnancy

•Maternal complications: PROM, preterm labor, PP endometritis

•Neonatal complications: conjunctivitis, pneumonia

•Administer erythromycin to all infants following delivery

Gonorrhea Presentation

•Usually asymptomatic

•Yellowish-green vaginal/penile discharge

•Dysuria

•Irregular vaginal bleeding, dysmenorrhea

Gonorrhea Treatment

•Must treat all sexual partners- Antibiotic resistant major public health concern

•Ceftriaxone IM 1 gram

•Should test for chlamydia (due to strong association of co-infection)

Gonorrhea Impact on Pregnancy

•Maternal complications: spontaneous miscarriage, PTL, PP endometritis

•Neonatal complications: Conjunctivitis

•Administer erythromycin to all infants following delivery

Gonorrhea, Bacterial Vaginosis, and Chlamydia Complications

•Pelvic Inflammatory Disease (PID)

•Infertility

HPV vaccine

•Vaccination - Gardasil

•Protects against types of HPV that cause cervical cancer

•HPV 16 & 18 (70% of cervical cancers)

•HPV 6 & 11 (90% of genital warts)

•Administered in series of two doses if started before 15

•Initial dose ideally between 9-14 years of age both males and females

•Maximum benefit: before onset of sexual activity

Chlamydia & Gonorrhea Screening

•Annual screening if sexually active & younger than 25 and/or older with risk factors (i.e. multiple partners, unprotected sex)

•Screening at first prenatal visit and rescreened in third trimester if risky behaviors present

•If positive & treated, should retest 4 weeks after completing prescription regime

Syphilis Stages

Primary

Presence of painless chancre sore in genital area

Secondary - Occurs

weeks to months following primary outbreak

Skin rashes, often on palmar surface of the hands & soles of feet

Tertiary

Damage to internal organs - Tumors in skin, bones, and liver with effects to the heart, brain, and other organs of the body

Latent - May last 1 year to a lifetime

No signs or symptoms

Syphilis Treatment

•Penicillin G IM - single dose

•Abstain from sexual practices until sores have completely healed

•Identify and treat all sexual partners

Syphilis Screening

•All pregnant women should be screened at first prenatal visit

•Rescreen in 3rd trimester if high-risk (i.e. lives in area with high infection rate, not previously tested, or positive test in first trimester)- 40% of newborns from a mother with untreated Syphilis will be stillborn or die from the infection- most dangerous STI for infants

Most dangerous STI for infants

Syphilis

Human Papilloma Virus (HPV)

•Most common viral STI - Causes genital or anal warts and can lead to cervical, anal, throat or penile cancer. Cervical cancer in women is the most common type of cancer caused

•Often asymptomatic

•Genital warts with cauliflower-like appearance

HPV Treatment

- May spontaneously resolve

•Client-applied cream (i.e. imiquimod)

•Provider-administered therapy (i.e. trichloroacetic acid application)

HPV/Genital Warts Screening

•Pap test with or without co-testing

•Females 21-29 years old should have a Pap test every 3 years.

•Females 30-65 years old should have a Pap test & ____ test every 5 years.

•NO test currently exists for males

Vulvovaginal Candidiasis othr name

"Yeast Infection"

Yeast Infection Treatment

•Fluconazole - 1x PO dose

•Clotrimazole - OTC

•Diagnosis should be confirmed with provider prior to use

•Topical preferred for pregnancy

Vulvovaginal Candidiasis

("Yeast Infection")

Not necessarily related to sexual activity

•Thick, creamy, white cottage cheese-like vaginal discharge

•Vulvar and vaginal erythema and inflammation

•White patches on vaginal walls

•Neonate: Gray-white patches on tongue, gums

•Presence of yeast buds, hyphae, and pseudohyphae

•Negative whiff test

Bacterial Vaginosis ("BV")

Not necessarily related to sexual activity

•Often asymptomatic (50-75%)

•Thin/milky white/gray vaginal discharge

•Unpleasant, fishy smell, especially after intercourse

•Diagnosis

•presence of clue cells

•Positive whiff test

Bacterial Vaginosis Treatment

Treatment not indicated for male partners, but is especially important for pregnant females

•Metronidazole - PO or vaginal gel (Avoid alcohol)

Bacterial Vaginosis Impact on Pregnancy

•Maternal complications: Preterm labor

•Neonatal complications: Low birth weight

Trichomoniasis

•Treatment - Must treat all sexual partners

•Protozoan parasite

•Reinfection rate high - Recheck at 3 months

•Presence of trichomonad(s)

Trichomoniasis Presentation

•Often asymptomatic

•Females

•Malodorous, yellow-green, frothy discharge

•Dysuria, dyspareunia

•Vulvar irritation

•Male

•Penile itching/irritation

•Dysuria

HIV/AIDS High Risks

-Receptive anal sex with ejaculation

-Mother-to-child with no ART therapy

HPV

Greater than 100 types

Herpes Simplex Virus (HSV)

•Chronic life-long viral infection

•Often asymptomatic

•Outbreak of painful sores

•Prodrome ("pre-outbreak" S/S) includes tingling, itching, &/or burning sensation at site of infection

•First outbreak can include flu-like symptoms (i.e. fever, body aches, swollen glands)

•1 in 8 people aged 14-49 have genital herpes.

•No cure

•Meds should be initiated within 72 hours to decrease duration, severity of symptoms

•Cesarean section if active lesions present, prodromal symptoms at labor onset

HIV/AIDS Mode of Transmission

•Mode of Transmission: Contact with the blood, semen, genital fluids, or breast milk of a person infected with HIV

HIV/AIDS Presentation

•Mild symptoms- can take years to be diagnosed- average time to dx is 3-4 years

HIV/AIDS Diagnosis

•Obtain maternal consent prior to testing

•Antibody screening test (i.e. enzyme immunoassay) to screen

•Rapid antibody test (blood or urine) if in labor & status unknown

HIV/AIDS Treatment in Pregnancy

•Antiretroviral therapy (ART): Zidovudine, Ritonavir or Indinavir, & NRTI

•Administer at 14 weeks gestation, throughout pregnancy, & before onset of labor or Cesarean birth

•Administer to infant at delivery and for 6 weeks following birth

•Obtain frequent maternal viral loads and CD4 cell counts throughout pregnancy

HIV/AIDS Impact on Pregnancy

•Avoid procedures likely to mix maternal & fetal blood, including amniocentesis, episiotomy, internal fetal monitors, vacuums, &/or forceps

•Review plan for scheduled C-section at 38 weeks if maternal viral load > 1,000 copies/mL.

•Avoid breastfeeding- except in underdeveloped countries

Viral STIs

•Human Papilloma Virus (HPV)

•Herpes Simplex Virus (HSV)

•Human Immunodeficiency Virus (HIV)

Parasitic STIs

Trichomoniasis

Reportable Disease

Chlamydia

Gonorrhea

Syphilis

HIV/AIDS

A.Chlamydia

B.Gonorrhea

C.Syphilis

D.Herpes Simplex Virus (HSV)

E.Human Immunodeficiency Virus (HIV)

F.Trichomoniasis

G.Bacterial Vaginosis

H.Candidiasis

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1.Fluconazole

2.Metronidazole PO or Vag Gel

3.Metronidazole PO

4.Antiretroviral therapy (ART)

5.Acyclovir PO

6.Penicillin G IM

7.Ceftriaxone IM

8.Azithromycin PO

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Most commonly reported bacterial cause of STIs in U.S.

Chlamydia

With Chlamydia you should test for ____. Due to the strong association of co-infection.

Chlamydia