Contraception and Family Planning Study Notes

Presented by: Jennifer Talleff, MSN, RN, FNP-BC, Associate Clinical Professor, Texas Woman's University

Primary Emphasis:
- Consistent and correct use of contraceptive methods is critical.
- Dual method usage significantly reduces the chance of unintended pregnancy to less than 1%.
Effectiveness of Methods:
  - Most Effective Methods:
    - Intrauterine Device (IUD)
    - Implantable devices
    - Sterilization
    - Abstinence
  - Least Effective Methods:
    - Withdrawal
    - Spermicide
    - No contraception

- Robert Hatcher, MD, MPH emphasizes that simplification of efficacy numbers is essential.

Risk Comparisons:
- Risk of death from pregnancy: 1 in 6,900.
- Risk from combined oral contraceptive (OC) use in non-smoking women aged 15-34: 1 in 1,667,000.
Health Risks:
- Non-smoking, normotensive, and non-diabetic women not at increased risk for myocardial infarction (MI) when using combined OCs.
- Estrogen-containing contraceptives may increase risk for breast cancer depending on personal risk factors.
Common Side Effects of OCs:
  - Headaches (HA)
  - Nausea
  - Breast tenderness
  - Spotting
  - Changes in menstrual bleeding patterns
Quote by Paul Brenner, M.D.: “Birth control pills are not dangerous, but there are dangerous women out there…”
- Reiterates importance of provider assessment for appropriateness of OC use.

Benefits of Combined OCs, Patch, and Ring:
- Protect against ectopic pregnancy and cancers (ovarian, endometrial).
- Help in alleviating conditions such as acne, dysmenorrhea, menorrhagia, and anemia.
Mirena IUD Benefits:
- Protects against ectopic pregnancy and significantly reduces menorrhagia, contributing to lower anemia risk.
Safe for Lactation:
- Hormonal methods that do not interfere with breastfeeding include Depo Provera, Mirena IUD, Progestin-only pills, Implanon, and Paragard IUD.

Considerations include:
  - Individual wishes, fears, preferences, and lifestyle for optimal method selection and adherence.
  - Frequency of sexual intercourse
  - Number of sexual partners
  - Childbearing patterns
  - Accessibility to refill contraceptives

Most Common Method in the U.S.:
- Tubal sterilization has a failure rate of less than 1% (99.5% effective).
Mechanism of Action:
- Cutting or blocking fallopian tubes to prevent egg and sperm union.
Procedure:
- Tubal ligation involves tying, cutting, and burning ends and is performed via laparoscopy or minilaparotomy.

Key Points:
  - Effective male contraceptive with a failure rate of 0.15% (99.85% effective).
  - Mechanism of action: blocking the vas deferens, preventing sperm from being released during ejaculation.
  - Procedure duration: 5-15 minutes under local anesthesia.
  - Backup contraception is necessary for 12 weeks or until semen analysis confirms azoospermia (absence of sperm).

Types and Efficacy:
  - Paragard (1988): No hormones, effective for 10 years.
  - Mirena (2001): Hormonal IUD lasting 8 years.
  - Kyleena: 5 years, and Skyla: 3 years.
  - Very effective, with some studies showing higher effectiveness than sterilization.
  - Usage in the U.S. is low (only about 10.4% of women).
  - Provides long-term contraception with prompt fertility return post-removal.

Potential Complications:
  - Increased bleeding (noted with Paragard).
  - Expulsion rates: 2-10%, higher among nulliparous women or those with heavy bleeding.
  - Uterine perforation risk: 1 in 1,000.
  - String-related issues (missing or too long).

Description:
  - A single, implantable progestin rod (4cm x 2mm) placed under the skin of the upper arm.
  - Effective for up to 3 years with failure rate less than 1%.
  - Mechanism: suppresses ovulation, alters endometrial and cervical mucus.

Administration:
- Intramuscular or subcutaneous injection of progestin every 3 months.
- Effectively inhibits ovulation with a failure rate of 0.3% with consistent use.
Additional Effects:
  - Temporarily reduces bone mineral density due to estrogen deficiency (but should not impact practice).
  - Weight gain is generally around 5 lbs, though no consistent pattern has been observed.
  - Linked to irregular menstrual cycles, possibly leading to amenorrhea.

Standard:
- Over 50 years of U.S. clinical use; introduced in 1960.
- Combination OCPs contain estrogen (ethinyl estradiol) and a progestin, while Progestin-only pills contain only progestin.
Mechanism of Action:
- Progestin offers most contraceptive effect: prevents ovulation, thickens cervical mucus, and thins endometrial lining.
- Estrogen assists with cycle regulation and ovulation prevention.

Conditions Reduced by OCPs:
  - Menstrual cramps and pain
  - Irregular bleeding
  - Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)
  - Ovarian cysts
  - Menstrual migraines
  - Ovarian and endometrial cancer
  - Acne and hirsutism
  - Risk of iron-deficiency anemia

Women over 35 who smoke or have comorbid conditions (e.g., obesity, hypertension, diabetes) are at increased risk for venous thromboembolism (VTE), myocardial infarction (MI), and cerebrovascular accidents (CVA) with OCPs due to estrogen's effect on liver production of clot-promoting factors.
Note: These risks are rare in young, healthy individuals.