Contraception PDF 9/12/2017

9/12/2017 Contraception Mary Serowoky, DNP, FNP-BC NUR 5150 Sexual Development-In Utero At 6 weeks – male and female embryos are identical in appearance Embryonic male and female reproductive organs develop from exactly the same tissues Week 7-majo...

9/12/2017 Contraception Mary Serowoky, DNP, FNP-BC NUR 5150 Sexual Development-In Utero At 6 weeks – male and female embryos are identical in appearance Embryonic male and female reproductive organs develop from exactly the same tissues Week 7-major changes in steroid hormone production – Testes (primary reproductive organ) produce androgens – Ovaries (primary reproductive organ) produce estrogens After birth, testes and ovaries continue to produce small amounts of sex hormones – Continue to influence the development of the Reproductive Organs Sexual Development -Puberty Puberty-a period of rapid growth and sexual maturation during which the reproductive system becomes fully functional – At puberty, the ovaries or testes are capable of producing active reproductive cells (Gametes) – Onset varies – average 9 to 15 yr old Begins earlier in females 1  9/12/2017 Sexual Development -Puberty Hypothalmus regulates secretion of Gonadotropin Releasing Hormone (GnRH) GnRH causes changes in the Pituitary Gland to produce – Follicle Stimulating Hormone (FSH) – Luteinizing Hormone (LH) Male Sexual Development in Puberty Pituitary Gland begins to release FSH and LH to simulate the testes to make testosterone Cells all over the body respond to testosterone Secondary Sex Characteristics – Voice deepens, beard grows, body hair, muscle mass FSH and testosterone stimulate spermatogenesis Female Sexual Development in Puberty Pituitary Gland begins to release FSH and LH FSH simulates the Ovaries to make Estrogen Cells all over the body respond to Estrogen Secondary Sex Characteristics – Breast enlargement, hips widen, body hair 2  9/12/2017 Female Reproductive Cycle Phase I: Menstruation and the Follicular Phase Phase II: Ovulation Phase III: Luteal Phase Figure 60-1 The menstrual cycle: anatomic and hormonal changes. 3  9/12/2017 Menstruation When the egg is not fertilized from the previous cycle the hypothalamus, pituitary and ovary reset…initiating a new reproductive cycle First day of menstrual bleeding is the first day of the cycle – Endometrium is sloughed d/t progesterone withdrawal Menstruation Menstruation generally 3-5 days Shed 30-50 ml of blood Mixture of blood, cells etc. = 80ml Cramps result from endometrial liberation of prostaglandins – Anti-prostaglandins for treatment Normal cycle from 21-35 days Menses also marks beginning of follicular phase Follicular phase Follicle Stimulating Hormone (FSH) – Starts to increase 2 days prior to start of menstruation – Stimulates the maturation of ovarian follicles and influences secretion of estradiol Estradiol (estrogen) – secreted from granulosa cells that migrate to surround the oocyte – 4th day of cycle levels rise 4  9/12/2017 Follicular phase Estradiol – Provides negative feedback to pituitary gland to decrease release of FSH and positive feedback to release LH (lutenizing hormone) – follicles release androgens and estrogens as they increase in size – dominant follicle will have an estradiol:androgen ratio of >1 Follicular Phase As the dominant follicle secretes more and more estradiol there is positive feedback to pituitary to secrete more LH By day 11-13, an LH surge causes the oocyte to be expelled from the follicle; ovulation occurs 30-36 hours after LH surge Dominant follicle converts into the corpus luteum Ovulation As dominant follicle enlarges and accumulates fluid, it is thought to “ripen” – only one oocyte reaches full maturation each month Twinge of pain (mittleschmertz) with release of the egg from the follicle Mechanism of movement of egg – actually “bursts” forth from side of ovary and is then swept by waves from the fimbriae into the fallopian tube 5  9/12/2017 Corpus Luteum Corpus luteum facilitates progesterone production during remainder of cycle If fertilization occurs, the corpus luteum will continue to produce hormones to maintain the pregnancy until the placenta is able to take over this function at 12 weeks gestation Luteal Phase Predominance of hormone production changes from estradiol to progesterone Progesterone begins production about 24 hours before ovulation and rises rapidly after that Maximal production is 3-4 days after ovulation and maintains at that level for 11 days, then rapidly diminishes resulting in next menses Luteal Phase Adequate progesterone is necessary for the viability of a fertilized egg Corpus luteum has fixed life span of 9-10 days, unless fertilization occurs Human chorionic gonadotropin (hCG) maintains the corpus luteum As progesterone suddenly decreases it allows the feedback for FSH to begin production for the next cycle 6  9/12/2017 Physical Manifestation of Follicular Phase Endometrial proliferation: increasing estradiol causes the endometrial stroma to thicken and endometrial glands elongate Near end of phase before ovulation, cervical mucus is thin, clear, stretchy (like egg whites) and watery; facilitates sperm motility (spinnbarkeit) Increased vaginal lubrication near ovulation: sexual excitement Physical Manifestation: Ovulation Mittelschmertz - sharp “ping” to dull ache for several hours – spinnbarkeit - maximal at this time Proliferative endometrium now becomes secretory endometrium Basal body temperature rises by 0.6 to 1.0 degrees at ovulation and remain elevated until next menses (use BBT thermometer) Physical Manifestation: Luteal Phase Endometrium thickens until end of phase when it outgrows it’s blood supply and starts to slough Endocervical mucus thickens, becomes cloudy and sticky (helps to impede sperm) Progesterone increases breast tenderness Sexual desire/enjoyment may decrease 7  9/12/2017 Ovarian and Uterine Cycles Ovarian Events Uterine Events Cycle Cycle Follicular Phase FSH Menstruation Endometrium Days 1 – 13 Days 1-5 breaks down Follicle maturation Proliferateive phase Endometrium Estrogens Days 6-13 rebuilds Ovulation – Day 14 LH spike Luteal phase LH Secretory phase Endometrium Days 15 – 28 Corpus luteum Days – 15-28 thickens and glands Progesterone are secretory Fertility More likely to conceive if fresh sperm are present at ovulation Oocyte is viable for 24-48 hours Sperm is viable for 72 hours or longer Implantation During intercourse, 300 million sperm suspended in seminal fluid are deposited Within 30 minutes sperm are in cervical canal and a continuous supply present for several days Oocyte is fertilized in ampulla of tube, takes 2-3 days to reach uterus and implants by day 6-7 after ovulation 8  9/12/2017 Contraception 1965 the U.S. government began to support family planning initiatives The NP must know his/her own feelings and values and attitudes – Sex and sexuality – Religion – Race – Economic status – Marital status 9  9/12/2017 Contraception When counseling client regarding selection of a method – Need to know benefits and potential dangers and side effects to make an informed choice – Effectiveness Correct and consistent use EBP: Education and Counseling Demonstrate the actual methods, and encourage handling materials ACOG 2009 encouraged the use of motivational interviewing – Motivational interviewing outperforms traditional advice Expect ambivalence Ask them what they want to know – Don’t impose on them what you think they should know (excepting safety issues US Eligibility Criteria (Adapted from WHO) 1. No restriction for the use of contraception 2. A condition where the advantages generally outweigh the risks 3. A condition where the risks outweigh the advantages 4. A condition that represents an unacceptable health risk 10  9/12/2017 Eligibility Recommendations for Specific Conditions Condition Sub- Combined IUD-CU & LNG; condition Pill/Patch/ Implant; DMPA; POP Ring (CHC) Headache Non-migraine Initiate: 1 1 Without aura 1, 2 1 (including MM) With aura 4 1 MEC Cardiovascular Disorders CV CHC POP DMPA Implant IUD IUD (LNG) (CU) Risk factors: 2 2 2 2 2 1 DM (no CV) Smoke age 2 1 1 1 1 1 35 (35 (>15 cig) HTN Controlled 3 1 2 1 1 1 S 140-159 3 1 2 1 1 1 D 90-99 S > 160 4 2 3 2 2 1 D > 100 Other recommendations: IUD (CU) 30-efficacy not impaired) DMPA and bone mineral loss age 18; MEC Cat. 2 Antimicrobial therapies: all broad spectrum ABs, antifungals-Category 1) AEDs 11  9/12/2017 Types of Contraception Fertility awareness Barriers (condoms/diaphragm/cap) Spermicides Hormonal contraception – CHCs: oral, ring, transdermal; POPs – DepoProvera; Nexplanon; Emergency Contraception IUDs Sterilization Fertility Awareness Methods Calendar-predict the days in the menstrual cycle during which one might get pregnant (and abstain) BBT-detects when ovulation actually occurs – buy a special thermometer Cervical Mucus – distinct changes in cervical mucus Symptothermal-using all of the signs and symptoms that ovulation is coming or has occurred Point of care home tests 12  9/12/2017 Fertility Awareness Methods Disadvantages: – if approaching menopause; breastfeeding; recent pregnancy; – doesn’t work for women with irregular cycles Advantages: – to conceive – to detect pregnancy – to avoid pregnancy – to detect impaired fertility Spermicides Nonoxynol-9 – Caution re: HIV prevention Ph 4.5 keep vagina acidic, hostile environment for sperm Types: – film – foam – suppository – gels – creams Spermicides Advantages: – OTC / no medical visit – simple to use; intermittent use; reversible Disadvantages: – irritation – yeast or bacterial vaginosis – taste may be unpleasant – Not recommended for HIV prevention 13  9/12/2017 Barrier Methods male condoms female condoms diaphragm contraceptive sponge cervical cap Has to be fitted; requires Diaphragm script Use spermicide; effective for 6 hours Never wear more than 24 hours Lasts for 2 yrs if properly cared for Refitting after partuition Cervical Cap Soft, deep rubber cap Has to be fitted Use with spermicide (1/3 full) Continuous protection for 48 hours Repeated sex with no additional gel Risk of TSS; odor with prolonged use 14  9/12/2017 Contraceptive Sponge Contains Nonoxynol-9 Soft, pillow shaped Concave side over cervix One size OTC Protects 24 hours Must be left in 6 hours; Not to wear more than 24-30 hours Barrier Methods Advantages: – simple and non-invasive – used with little advanced planning – reduce risk for STD’s Disadvantages: – consistent and correct use essential – latex or allergy to spermicide – UTI or toxic shock syndrome – insertion techniques may be difficult Hormonal Contraception: CHC Manipulation of hormones by the use of estrogens and progestins – Prevent ovulation – Interfere with implantation Optimal features (defined by WHO) – Safe – Effective – Convenient – Maintain regular bleeding episodes – Rapidly reversible 15  9/12/2017 Pharmacotherapeutics for Nurse Practitioner Prescribers, 3rd Edition Mechanism of Pregnancy Prevention ▪ Progestins are primarily responsible for the contraceptive effect ▪ Progestins exhibit a negative effect in the hypothalamic-pituitary-ovarian axis ▪ Progestins cause atrophy of the endometrium, preventing implantation ▪ The estrogen component improves efficacy by suppressing FSH release ▪ Estrogen provides cycle control Copyright © 2012 F.A. Davis Company Pharmacotherapeutics for Nurse Practitioner Prescribers, 3rd Edition Estrogen & Progesterone ▪ Estrogen has positive effects on bone mass, increasing serum triglycerides, improving high-density lipoprotein (HDL) to low-density lipoprotein (LDL) ratios ▪ Estrogen stimulates coagulation and fibrinolytic pathways ▪ Progesterone increases body temperature, increases insulin levels ▪ Progesterone may depress the central nervous system Copyright © 2012 F.A. Davis Company Pharmacotherapeutics for Nurse Practitioner Prescribers, 3rd Edition Rational Drug Selection ▪ Start with absolute contraindications ▪ Delivery method of patient choice ▪ Fine tune based on: ▪ Bleeding pattern ▪ Side effect profile ▪ Consider ▪ Patient’s need for discretion ▪ Timing of subsequent pregnancy Copyright © 2012 F.A. Davis Company 16  9/12/2017 Pharmacotherapeutics for Nurse Practitioner Prescribers, 3rd Edition Rational Drug Selection ▪ All oral contraception have similar effectiveness ▪ Cost ▪ Retail cost of OCs is $30-$70 per cycle ▪ Generic OCs available on $4 retail lists ▪ IUD upfront cost expensive, but may have lower overall cost ▪ Nurx: app.nurx.com ▪ Patient variables Copyright © 2012 F.A. Davis Company Pharmacotherapeutics for Nurse Practitioner Prescribers, 3rd Edition Rational Drug Selection ▪ Drug Variables ▪ Drug interactions ▪ TB drugs, antiepileptic drugs, St John’s Wort ▪ Lipid levels may be affected by OCs ▪ ADRs ▪ Venous thromboembolism risk increases 3 to 5 times with OC use ▪ Also: cholestatic jaundice, benign hepatic neoplasms, myocardial infarction, stroke, and neurological migraines Copyright © 2012 F.A. Davis Company Hormonal Contraception: Progestin Only Pills (POP) Referred to as “mini pill” Suppress ovulation; thicken mucous- endometrium unsuitable for implantation One pill daily with no free days Highly effective; safe for most women including those with contraindications to other CHC Most common complaint: irregular bleeding Other androgenic SE: Nausea, weight changes, depression, fatigue, acne, hirsutism, lipid and CHO effects Least androgenic are 3rd generation – desogestrel and norgestimate 17  9/12/2017 WHO Contraindications POP Breastfeeding women < 6 wks postpartum – USMEC 2 Current DVT or PE Acute viral hepatitis or other liver disorders Breast cancer Not a good choice for women who can not tolerate irregular bleeding or amenorrhea There appears to be no increased risk of VTE in Progestin Only Pills Counseling POPs Start during the first 5 days of menstrual cycle or any day you are sure you are not pregnant (switching from COC to POP, start the day after the last active pill) Use back up method for the first 48 hours 1 pill/day at the same time (± 3 hours). No pill vacations between Miss pill-take as soon as you remember even if you take 2 on the same day (back up) Drug interactions: Rifampin, anticonvulsants, St John’s Wort Ability to become pregnant returns after you stop taking the pill Changes in period are common. Combined Oral Contraceptives More than 75 million women around the world rely on COC Safe for healthy reproductive aged women (nonsmokers) First pills (1960s) had very high doses of hormone. Today many have much smaller doses (< 35 mg) All contain estrogen (mestranol or ethinyl estradiol [EE]) and a progestin 18  9/12/2017 Mechanism of Action Repeatedly proven – Thickening of cervical mucous to prevent sperm entry into the upper genital tract – Suppression of ovulation by providing negative feedback to the hypothalamic-pituitary system (suppression of LH and FSH production and inhibition of mid-cycle LH surge Other effects not substantiated – Slowing of tubal motility and disruption of transport of ova – Endometrial atrophy – Alterations in endometrium (inhibit implantation) Contraindications to CHCs Cigarette smokers over age 35 Personal history of thrombosis, stroke or MI Migraine with focal neurologic sx Active liver problems Estrogen sensitive malignancies Screen family history of unexplained clots Combined Oral Contraceptives Formulations Monophasic – Each active pill contains the same dose of estrogen and progestin Biphasic – Have two different combinations of estrogen and progestin in the packet of pills Triphasic – Three different combinations – Some may increase progestin in stepwise fashion, others may also alter the estrogen. One formulation holds progestin constant while only altering the estrogen 19  9/12/2017 Hormonal Contraceptives: Monophasic Same amount of estrogen and progesterone for 21 days, 7 placebo Advantages: less break through bleeding, good for women sensitive to hormonal fluctuations Have your patients log any side effects – what days does it happen Pharmacotherapeutics for Nurse Practitioner Prescribers, 3rd Edition Non-contraceptive Benefits ▪ Decreased dysmenorrhea, menstrual irregularities, and menstrual blood loss, DUB ▪ Improved menstrual migraine ▪ Lessening of acne and hirsutism ▪ Fewer ovarian cysts ▪ Significantly reduced endometrial and ovarian cancer risk ▪ Lower incidence of benign breast conditions such as fibrocystic changes and fibroadenoma ▪ Favorable bone impact ▪ Suppression of endometriosis for women who do not currently desire pregnancy ▪ Decreased fibroid risk Copyright © 2012 F.A. Davis Company COC: Disadvantages Daily dosing and expense Does not protect against STI Contraindications (WHO) – Thromboembolic disorder – Cardiovascular disease – Valvular disease – Uncontrolled HTN – Hepatic carcinoma – Breast cancer – Prolonged immobilization – Headaches with focal neurological symptoms 20  9/12/2017 Risk Factors for VTE on Oral Contraceptives Genetic coagulation disorder Smoking Obesity Immobilization: stop estrogen therapy 2 weeks prior to surgery; fractures, bedrest, casting Special Populations Adolescents – Counseling (compliance/STI) Perimenopausal women – Healthy, non-obese, non-smoking women Smokers – Women over 35 (light smoking between 35-40 merits caution) Post partum women – Delay 3 to 4 wks (hypercoagulable state) Breastfeeding women – AAP advises against estrogen containing pills while exclusively breastfeeding but agrees COCs can be used once supplemental feedings are introduced Initiating the COC Counsel and discuss the risks and benefits History/ WHO Medical Eligibility Criteria for Contraceptive Use Check baseline BP Pelvic examination is not needed in the asymptomatic woman Routine screening for thrombotic mutations is not recommend at this time 3 month follow up – Assess for acceptability and side effects 21  9/12/2017 Initiating the Pill Quick Start – Start on the first day of the office visit as long as she is reasonably sure she is not pregnant. Use back up for 7 days. Menses is delayed until she completes the pills and starts the placebo. Most common off-label start. First Day Start – Start on the first day of her next normal period. No back up necessary Sunday Start – Start on the first Sunday of their menses. If menses was started more than 5 days prior, use a back up method for 7 days. Not generally recommended. Initial Pill Selection Estrogen (cycle control effects) Heavier menses: Estrogen 30-35mcg Normal menses: Estrogen 20-25mcg Progestin (contraceptive effects) Levonorgestrel: safe, less BTB Norethindrone: safe, more BTB DSP: avoid in unknown family hx or family hx coagulopathy Teaching Drug to drug interactions Warning signs (depression, chest pain, headaches, eye problems, leg pain): ACHES Impending surgery (if immobilization involved stop 30 days prior) Short term anticoagulant therapy (stop 30 days prior) Cycling 22  9/12/2017 BTB Declines over first year Rule out infection (CT) Take same time daily (w/in 4 hours) NSAIDS for 5 days Increase estrogen Switch generic to brand Vaginal Contraceptive Ring Flexible; 3 weeks in and 1 out Continuous use (off label) Minimal effects on lipids No effect on BP No effect on CHO metabolism Low androgenic effects Teaching Ring Use Allow the patient to handle the ring to note size and flexibility Quick demonstration of insertion and removal Assurance that most women find it easy to use 23  9/12/2017 Transdermal Patch Approved in 2001 Replace every 7 days; no patch wk 4 Can shower, swim, bathe If patch comes off, replace Obesity;90 kg limit Risk Factors for Combined Patch Appears to be similar to COC, although some studies show equal risk while others show higher risk Warning re: exposure to estrogen Risk with transdermal patch is still less than that of pregnancy Hormonal Contraceptives – Depo-Provera (DMPA) and Nexplanon IM injection and subdermal implants Advantages – Good for women who are estrogen sensitive, breast-feeding, women with liver disease, HTN, seizures, clot hx. – Easy administration, compliance and efficacy Side effect – Menstrual changes – Delayed return to fertility(DMPA) – Wt gain, HA, mood changes 24  9/12/2017 Depo-Provera (DMPA) Long acting contraceptive Injection every 3 months (150 mg)- between 11-13 weeks Initiate 5 days after start of menses; effective in 7 days If > 17 weeks late, exclude pregnancy Back up contraception. Ovulation does not generally recur for several months PP (not breast feeding – 5 days PP; breastfeeding 6 wks PP) Prescribe EC in event of lateness Black Box Warning: BMD Should not be used longer than 2 years unless other forms are inadequate. Can lose up to 4% BMD Black box warning is not supported by WHO, ACOG & Am Acad of Adolescent Health who generally indicate that concerns should not prevent the clinician from prescribing In adolescents it is not clear if it effects BMD; adolescents regain BMD after cessation Include CA, D3, daily exercise Nexplanon (Etonogesterol Progestin Implant) Inhibits ovulation Effective 3 years Inserted sub-dermally between biceps and triceps Not radio-opaque (MRI or US to locate) Must be inserted by a trained clinician Most common complaint: irregular bleeding (may need to medicate to terminate the bleeding episode) Return to ovulation in about 3 months 25  9/12/2017 LARCS-IUD Copper T380-IUD LNG IUD Approved for 5 years Approved for 10 years Mirena- levonorgestrel- Broader use of copper releasing (LNG)(5yrs) Skyla:smaller; nulliparous IUD to include (3yr) nulliparous and Causes thick, impenetrable adolescents mucus, ovulation is not suppressed Practice safe sex Initial spotting for 4 mo, then 80% reduction of Convenient cost blood loss, less effective and dysmenorrhea; ? Fibroid reduction reversible 5 years of continuous use Poor Candidates for IUC Known or suspected pregnancy Puerperal sepsis (4) Immediate post-septic abortion Unexplained vaginal bleeding – Cervical or endometrial CA Uterine fibroids; depending on location Uterine distortion Current purulent cervicitis, GC/CT Pelvic TB Emergency Contraceptives Types Education/Counseling Plan B™ or PlanB One 1. If period does not start within 3 weeks, see your Step™ (Progestin only PCP for an exam and.75mg) pregnancy test. – May be given up to 120 hours 2. Do not have unprotected or 5 days after unprotected sex during the days and weeks following intercourse treatment. – 2 pills or 1 pill q 12 3. As soon as possible, begin – Give Meclizine for nausea if using a method of birth. using COCs control you will be able to use on an ongoing basis – OTC for ages 17+ 4. Remember this is a Ulipristal (ella) 30mg, 1 difficult time for the person needing to make dose this choice. – Preferred for overweight – Needs Rx – Less effective if BMI > 35 26  9/12/2017 Contraception - Sterilization Permanent, common over 30 yr old Vasectomy-interruption of vas deference – Local anesthesia, out patient Tubal Ligation – Mini-laparotomy technique – Tie, cut or newer transcervical inserts MEC: HIV and Contraceptives CHC/POPs: Cat 1,2 DMPA: 40% increased risk of HIV acquisition IUC: Cat 2 27