contraception

Contraception

HPA III Health Promotions Across the Lifespan III

  • Instructor: Julie Larson MSN, RN

Objectives

  • Understand the various contraceptive options for family planning.

  • Identify potential advantages and disadvantages of various contraceptive options.

  • Recognize the nurse’s role in providing support and education for family planning.

Contraception: Nursing Assessment

  • Perform a health history and physical assessment to screen for risk factors.

  • Be familiar with various methods of contraception including:
      - Typical use
      - Advantages
      - Disadvantages
      - Efficacy

  • Understand what influences the choice of one contraception method over another.

  • Provide accurate information in an unbiased, nonjudgmental manner; prioritize patient’s feelings and beliefs regarding contraception; dispel misconceptions.

  • Contraception is indicated for anyone who wants to prevent pregnancy, regardless of gender identity or sexual orientation.

Contraceptive Methods

  • Behavioral Methods
      - Abstinence
      - Fertility Awareness-Based Methods: Utilize monitoring of bodily signals such as
    the cervical mucus, basal body temperature, and methods like the Standard Days Method and CycleBeads, along with various phone apps.
      - Withdrawal (pull-out method)
      - Lactational Amenorrhea: Effective only with continuous lactation up to 6 months.

  • Barrier Methods
      - Condom (Penile/External): Most effective with approximately 15% failure rate.
      - Vaginal/Internal Condom: Inserted vaginally, held by the pubic bone.
      - Diaphragm: Requires prescription and fitting; used with spermicide; must remain in place for 6 hours post-intercourse; may require refitting.
      - Cervical Cap: Smaller counterpart to diaphragm; similarly requires spermicide and fitting; keeps in place post-intercourse.
      - Sponge: No prescription needed; contains spermicide; must remain in place post-intercourse.

  • Hormonal Methods
      - Oral Contraceptives (Combined): Either combination pills or progestin-only pills.
        - Combination pills work by suppressing ovulation, adding estrogen and progesterone to mimic pregnancy, suppressing FSH and LH, inhibiting ovulation; thickening cervical mucus inhibits sperm transport.
        - Regimen: Active and placebo pills, with regimens including 21/7 or 24/4 options; extended-cycles available (84/7 or 365).
        - Monophasic: Consistent estrogen/progestin through the cycle.
        - Multiphasic: Varying amounts of estrogen/progestin throughout the cycle.

  • Permanent Methods
      - Tubal Ligation: Fallopian tubes cauterized/sealed through rings, bands, clips; permanent but may be reversible.
      - Vasectomy: Cutting of the vas deferens under local anesthesia; semen will no longer contain sperm; permanent but potentially reversible.

  • Emergency Contraceptives: Used primarily to reduce the risk of pregnancy after unprotected intercourse; does NOT work after fertilization occurs.
      - Plan B (Progestin-only): Use within 72 hours; reduced efficacy with higher body weight/BMI.
      - Ella (Ulipristal acetate, requires prescription): Use within 5 days.
      - Insertion of Copper IUD: Effective if done within 5 days.
      - Yuzpe Method: High-dose combined oral contraceptives; not as effective as the above methods.

Advantages and Disadvantages of Oral Contraceptives (cOCPs)

Advantages:

  • Regulation of menstrual cycles.

  • Decrease in severe cramping and bleeding.

  • Reduction of anemia.

  • Reduction of risk for various cancers (e.g., ovarian, endometrial, colorectal).

  • Improvement of acne and reduction of menstrual headaches.

  • Reduction of premenstrual dysphoric disorder.

  • Minimization of perimenopausal symptoms and improvement of PMS symptoms.

  • Protection against loss of bone density and decreased risk of osteoporosis.

  • Reduction in the incidence of rheumatoid arthritis.

Disadvantages:

  • No protection against STIs.

  • Modest risk for venous thrombosis and pulmonary embolism.

  • Associated with increased risks for myocardial infarction, stroke, and hypertension.

  • Potential increase in risk of depression.

  • May increase the risk for cervical cancer if used for more than 5 years.

  • User must remember to take the pill daily.

  • High ongoing costs for some patients.

Complications of cOCPs: Danger Signs

  • Abdominal Pain: Possible indicator of liver or gallbladder problems.

  • Chest Pain or Shortness of Breath: Potential sign of pulmonary embolism.

  • Headaches: Could indicate hypertension or impending stroke.

  • Eye Problems: May signify hypertension.

  • Severe Unilateral Leg Pain/Swelling: Could indicate thromboembolic events.

Transdermal Patch (Combined Hormonal)

  • Contains both estrogen and progesterone.

  • 2-inch square patch to be worn on the lower abdomen, outer arm, buttocks, or upper torso (not on breast tissue).

  • Applied weekly for 3 weeks followed by one week patch-free.

  • Direct absorption into the bloodstream, circumventing first-pass liver effects.

  • Reduced effectiveness in patients over 200 lbs.

Vaginal Ring (Combined Hormonal)

  • Contains both estrogen and progesterone.

  • Flexible, transparent ring inserted by the user for 3 weeks, followed by a ring-free week.

  • Hormones are excreted directly, requiring a smaller dose compared to cOCPs, resulting in fewer systemic side effects.

  • Cons: May cause vaginal irritation, accidental expulsion, and interference with sexual activity.

Progestin-Only Pills

  • Also known as “mini pill”; lower dose and less efficacy than combined OCPs; no placebo pills included.

  • Work best for patients with contraindications to estrogen (e.g., smokers with migraines).

  • Mechanism includes thickening cervical mucus and making the endometrium unfavorable for implantation.

  • Must be taken at the same time every day; breakthrough bleeding is common.

  • Can be prescribed post-delivery due to decreased risk for blood clots, not affecting milk supply.

Injectable Contraception (Progestin-Only)

  • Medroxyprogesterone (Depo-Provera): Administered via IM every 12-15 weeks; less common SQ form available.

  • Mechanism includes suppression of ovulation, increasing cervical mucus viscosity, and causing endometrial atrophy.

  • Side effects include menstrual cycle disturbances, possible bone loss after 2 years of use, and recommendations for bone density scans.

  • Other side effects: weight gain, acne, depression, hair loss.

Implantable Contraceptive (Progestin-Only)

  • Etonogestrel Implant (Nexplanon): Subdermal time-release method; inhibits ovulation, thickens cervical mucus.

  • Common complaint includes irregular bleeding.

  • Highly effective for 3-5 years with quick return of fertility.

Intrauterine Contraceptive Devices (IUD)

  • Types: Hormonal (progestin, plastic) or Copper (no hormones).

  • Mechanism of hormonal IUDs: Causes inflammatory reaction in the endometrium, inhibiting implantation, and thickening cervical mucus.

  • Copper IUDs provide a spermicidal effect.

  • Safety and efficacy for long-term (3-8 years for hormonal, 10-12 years for copper).

  • Protruding strings should be checked monthly for placement confirmation; can be applied post-delivery.

IUD Complications

  • Recognized through the acronym ACHES for cOCPs and PAINS for IUDs.

  • Higher risk of ectopic pregnancy & pelvic inflammatory disease (PID) due to irritation in the fallopian tube.

Choice of Contraception Method Factors

  • Motivation and ability to use it correctly.

  • Costs associated with the various methods.

  • Cultural and religious beliefs.

  • Convenience of use.

  • Current plans for future fertility.

  • Influence from partners on contraception decisions.

Knowledge Check Questions

  1. Implantable Form Active Ingredient: Point out that it contains A. Progestin.

  2. Transdermal Patch Teaching Needs: Identify statements requiring further education.

  3. Copper IUD Disadvantages: Discuss increased bleeding and cramping during menstruation.

  4. Emergency Contraception Following Broken Condom: Advise appropriate post-exposure options for prevention, considering the circumstances and educate about emergency contraceptive options.

Additional Teaching Points

  • Importance of using dual protection methods to guard against STIs.

  • Dosage and timing implications of all contraception methods.

  • Potential complications or side effects patients should be aware of when opting for methods.