contraception

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