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natural methods of contraception
calendar (cycle tracking to determine when ovulating)
basal body temperature
cervical mucus method (thickness tells when ovulating)
symptothermal method (mucus + temp)
lactational amenorrhea
lactational amenorrhea requirements
must be fully BF (<4hr daytime, 6 night time), baby <6mo, amenorrhoeic
list the barrier contraception methods
condoms (polyurethane and lambskin)
internal condom- nitrile polymer
diaphragm + spermacide
cervical cap
sponge + spermacide N9
VCF contraceptive foam and film (w/ N9)
lactic acid buffering gel (contragel and caya gel)
copper IUD
which condom has no STI protection
lambskin
allergies to be mindful of when selecting condoms
latex, lanolin
what type of barrier method condom is hypoallergenic, and what is it made of
internal condom- made of nitrile polymer
how to use diaphragm as a barrier method
insert up to 2hr prior to sex, leave in atleast 6hr after, reusable for 1-2yrs
must use spermacide
there is a TSS risk with which barrier methods and after how long
diaphragm- if >24hr
cervical cap if >48hr
how to use cervical cap
insert up to 1hr prior, in place for 6hr after intercourse
3 diff sizes depending on pregnancy hx
side effects of cervical cap
discharge/odor, TSS >48hrs
how to use sponge for barrier method
insert anytime, in place for 6hr post intercourse. single use only
risk with sponge as barrier method
vaginosis >30hr
how to use VCF contraceptive foam and film
insert 15min before intercourse
ae of VCF foam and film
irritation and abrasions which can increase risk of infections
efficacy of contragel/caya gel compared to other barriers
less effective than N-9, spermacide and diaphragm, may cause less irritation than N-9 though
most effective method of emergency contraception
copper IUD
Contrandications of copper IUD
pregnancy
unexplained vaginal bleeding
current STIs
PID
known distorted uterine cavity
post sepsis
active intrauterine disease
side effects of copper iud
irregular bleeding, device expulsion, pain/cramping
onset of copper iud
effective immediately
MOA of hormonal contraceptives
estrogen- prevents release of FSH, keeps ovaries inactive
progestin- suppresses mid cycle peaks of FSH and LH, increases thickness and decreases volume of cervical mucous, decreases sperm motility, inhbiits development of uterine lining, may decrease cilia activity of fallopian tubes, may inhibit ovulation in some women
1st gen progestin
norethindrone, ethynodiol
2nd gen progestins
levonorgestrel, norgestrol
3rd gen progestins
norgestimate, desogestrel
4th gen progestins
drospirenone, dienogest
which progestins have MOST androgenic/progestinic activity
2nd gen- levonorgestrel, norgestrol
available estrogens in COC
ethinyl estradiol 10-35mcg, estetrol 14.2mg
what makes estetrol different
plant derived native estrogen with selective actions in tissues (lacks evidence that it decreases risk of BC, clots, etc)
nextsellis ingrediants
estetrol/drospirenone
benefit of nextstellis
no androgenic activity
if someone cant take estrogen can they take nextstellis
no
medical history assessment questions for contraception
CV rf:
smoker
obesity (BMI >30)
history of MI, angina, stroke, VTE
uncontrolled HTN
dyslipidemia
diabetes (complex)
migraine with aura
other RF:
hx of breast cancer
Hx of liver disease
IBD
SLE
thrombophilia
smoking status considerations in patient assessment
age <35 advantages generally outweigh risks
age 35+ <15 cig/day risks usually outweigh benefits
age >35 + >15cig/day unacceptable health risk (do not use method)
obesity (>90kg) may decrease the effectiveness of which products
patch and possibly nextstellis
only product with sufficient evidence of weight gain as ae
depo provera
recommended contraception for patients taking strong CYP3A4 inhibitors
levo IUD, depo provera q 10wks
menstruation hx questions in pt assessment
has pt reached menarch
when was last period
has pt had unprotected sex since last period
does the pt have undiagnosed vaginal bleeding
how to rule out pregnancy
no Sx of pregnancy AND any one of:
exclusively BF, amenorrheic and <6mo PP
no intercourse since last menses
correctly using reliable contraception
<7d after menses
<7d after abortion or miscarriage
<4wk PP
different COC dosing regimens
1 tab x 21 days then 7 days of No pills or 7 days of non hormonal pills
can take continuously- but avoid multiphasic
shortened pill free days - 24/4 or 24/2/2
extended hormonal contraception- 84/7 hormone free, 84/7 ultra low dose
advantages of extended/continuous use of COC
decrease menstrual associated Sx and dysmenorrhea
may improve other conditions such as menstrual migraines, anemia, endometriosis, pelvic ovarian syndrome
convenient (delays or eliminates menstruation)
pregnancy rates may be slightly lower
good adherence
disadvantages of extended/continuous use COC
possible delay in recognition of pregnancy
unscheduled bleeding and spotting
slightly higher cost
if someone missed a pill and its within <24hr what to do
take 1 active pill asap and continue pack as usual
dose of POP
1 tab daily for 28 days with no hormone free interval
window to take POP
3hr window
when is backup required when starting POP
required for first 2 days unless:
day 1 start (no backup)
starting >5 days after onset of menses, then backup needed for 7 days
when to assess need for intervention when missing POP doses
dose is delayed by >3hr
miss one dose
vomiting/diarrhea within 3hr of dose
most common SE of POP
menstrual cycle disturbance (14-30% have shorter cycle)
androgenic SE (acne, hirsutism)
h/a, breast tenderness, nausea, dizziness, mood disturbances
contraindications to POP
current breast cancer
SLE
conditions that cause malabsorption (use COC)
benefits of POP
may decrease endometriosis related pain, premenstrual tension, frequency and/or severity of migraine headaches
dosing of nuva ring
insert 1 ring every 3-4 wks
backup requirement when starting nuva ring
needed for 7 days if starting immediately, not required if starting on day 1 of menses
when to assess need for intervention with missed nuva ring dose
removal for 3hr
>48hr delayed insertion
inserted for >/= 28 days
common SE vaginal ring
headache, vaginitis, leukorrhea (may cause foreign body sensation, vaginal discomfort)
nausea, breast tenderness
main advantages of vaginal ring over OC
daily action not required- may enhance compliance in some patients leading to better efficacy
better for pts with difficulty taking oral meds/issues with GI absorption
less nausea, acne, emotional effects, mood, and unscheduled bleeding than coc
dosing of transdermal patch
apply 1 patch once weekly x 3 weeks, then 1 week patch free
when to assess need for intervention with missed dose of transdermal patch
detached >24hr
1st patch delayed by >/= 24hr
>7 day HFI
common SE of transdermal patch
breast Sx, h/a, nausea, application site rxns
where to place transdermal patch
place on clean, dry, hairless skin of buttocks, abdomen, upper torso (excluding breasts) or upper outer arm
preferably not in an area rubbed by tight clothing
main advantages of patch over OC
daily action not required- may enhance compliance
when a pt has difficulting taking oral meds/issues with GI absorption like IBD
how often is depo given
IM q 12-13wks
administration of depo
deltoid or ventrogluteal muscle any time of the cycle
when to use backup with missed depo dose
if injection interval is >/=14 wks, use 7 day backup
common SE of depo
irregular bleeding for first few months, amenorrhea after 1yr, weight gain, mood changes, bloating, headache
CI of depo
breast cancer, unexplained vaginal or urinary tract bleeding
when does fertility return after depo
6-12mo
depo black box warning
decrease in bone mineral density- conflicting evidence on this as it is largely reversible once d/c
advise pts on factors that can improve overall bone health, such as exercise, calcium vit d consumption
contraindications of progestin IUD
same as copper IUD (preg, unexplained vag bleeding, current STI, PID, known distorted uterine cavity, post sepsis, active intrauterine disease)
with addition of Breast cancer, cerviccal cancer, or endometrial cancer
SE of progestin only IUD
irregular bleeding (first 3-6mo), amenorrhea or decrease in amount of menstrual bleeding, expulsion of IUD, pain cramping following insertion
other mirena indication besides contraception
idiopathic menorrhagia (heavy menstrual bleeding)
when does normal menstruation restart with IUD removal
1-3mo
IUD may cause increased risk in developing _____
PID
meds used for IUD insertion
Misoprostol 400mcg SL or PV 3hr before IUD
oral NSAIDs for post insertion relief
2% lidocaine
how often is implant inserted
q 3yr
CI of subdermal implant
<18yr of age
known or suspected preg
current or past hx of thrombosis or thromboembolic disorders
liver tumours (benign or maligant) or active liver disease
undiagnosed abnormal genital bleeding
breast cancer or other progestin sensitive cancer
common SE of subdermal implant
changes in menstruak bleeding, mood swings, weight gain, headache, acne, breast pain, ab pain, post insertion site pain/irritation, chloasma (more likely if pt had choleasma gravidarum)
when does pt need BP check with subdermal implant
3mo post insertion
when is return to fertility after implant removal
7-14 days
indications for EC
no contraceptive method used or incorrect use of regular contraception method
condom slip or break
displacement of cervical cap or diaphragm
removal, displacement or missing IUD
missed COC esp in first week of pack or if starting a new pack lat e (see ind monograph)
>3hr late taking POP
removed ring for >3hr during a ring week
removed patch for >24hr during a patch week
>14wk interval btwn depo inj
ejaculation on external genitalia
sexual assault
EC options
non Rx: levonorgestrol 1.5mg
Rx only: COC (yuzpe regimen), ulipristil acetate (ella), copper iud
when is levo EC most effective
when taken within 24hr-72hr post intercourse - can be used up to 5 days
common SE of levo EC
nausea, vomiting, dizziness, fatigue, h/a, breast tenderness, lower ab pain, spotting/breakthru bleeding, altered timing of next cycle
when to repeat dose of levo EC with vomiting
if vomiting occurs within 2hr
when may levo EC not be effective
BMI >30, weight >80kg
also if taking enzyme inducing drugs
when can hormonal contraception be started after levo EC use
day of or day after
can you use levo EC in pts with contraindications to COC
yes
best oral EC option for pts who are breastfeeding
levo EC
benefit of ella (ulipristal acetate) over levo EC
effectuve up to 5 days post intercourse
more effective if overweight
when to repeat ulipristal acetate dosing when vomiting occurs
within 3hr
contraindications of ulipristal acetate
preferably avoid in people who have used hormonal contraception or levo EC in past 7 days (theoretical DI but doesnt mean cant)
best oral EC if BMI >25
ulipristal acetate
when to initiate/resume regular hormonal contraception after taking ulipristal acetate
5 days after
ulipristal acetate recommendations when BF
pump and dump milk for 1wk
how long is copper IUD effective post intercourse
effective up to 7 days post intercourse
common SE of copper IUD
insertion pain,cramping, heavier menses
most effective EC option if BF
copper IUD
what is yuzpe regimen EC
2 doses 12hr apart of various COC
how soon after intercourse should yuzpe regimen be given
72hr post intercourse
common SE of yuzpe regimen EC
nausea/vomiting (highest rate of all the ECs)
dizziness, fatigue, headache, breast tenderness, lower ab pain, spotting, breakthru bleeding, changinging in timing of next menses
when to repeat yuzpe regimen if vomiting occurs
2hr
least effective EC
yuzpe regimen
best EC if drug interactions are a concern
copper iud
some experts suggest a diouble dose of levo but effectiveness unknown, or consider copper IUD in addition to levo