Contraceptives PDF

8. Contraception, sterilization & infertility Stats: o 45% of all pregnancies in the U.S. are unintended. o Most occurred in women who didn’t use contraception or used it incorrectly o * Pill, OCPs, OCs, or BC pills = most effective pregnancy prevention...

8. Contraception, sterilization & infertility Stats: o 45% of all pregnancies in the U.S. are unintended. o Most occurred in women who didn’t use contraception or used it incorrectly o * Pill, OCPs, OCs, or BC pills = most effective pregnancy prevention ▪ Includes injectable preparations: Implantable rod, IU systems, patches and rings Hormonal Contraceptive Side Effects (discontinue and start a nonhormonal method) o Loss of vision, diplopia; unilateral numbness, weakness; severe chest/neck pain; severe leg pain/tenderness; hemoptysis, acute SOB; hepatic mass, tenderness. Hormonal Contraceptive Side Effects (continue but access why its occurring) o Amenorrhea (possible pregnancy); breast mass (possible cancer); RUQ pain (cholecystitis, cholelithiasis); Severe headache (stroke, migraine headache); galactorrhea (pituitary adenoma) Contraceptives- combo pills What is it? o Most contain combo of estrogen and progesterone o Prevents ovulation, but if ovulation does occur... ▪ Progesterone will thicken the cervical mucus, which inhibits sperm migration, creating an atrophic endometrium (difficulty implanting) ▪ Estrogen will increase the efficacy of the progesterone & stabilize the endometrium o Classic regime is 21 days of active hormones, 7 days of placebo pills. Some pts do a continuous regime giving them only 1 period 3 or 12 months. o Breakthrough bleeding occurs in 30% of women on low dose OCs (usually resolves spontaneously) Counterindications (CI): o * women >35 yrs who smoke; Hx of thromboembolism; Hx of CAD, CHF, CVA; Hx of migraine w/ or w/out aura. Discontinue combo contraceptive pills if: o increased BP or worsening migraines Benefit of the combo pill: o Shorter, less painful periods o lower incidence of endometrial and ovarian Ca, benign breast and ovarian diseases, pelvic infection, ectopic pregnancies, Progestin Only Pills “mini pill” What is it/what does it do? o Makes the cervical mucus thick and relatively impermeable o Take it at approx. the same time every day. If >3hrs late another form of BC must be used for 48 hrs Indicated for: o lactating women; women >40 yrs; when estrogen formulas are CI Transdermal Patch What is it? o combo patch that lasts for 1 week o Start during first 5 days of menses replace weekly X 3 weeks, 4th week is patch free o Place on clean, dry skin (butt, upper outer arm, or lower abd) o * Has decreased efficacy in those >198 lbs Rings  What is it? o Releases the same amount of hormones daily o used once a month (place in vagina at start of menses and left in place for 3 weeks) o Withdrawal bleeding occurs w/ removal of ring Diaphragms What is it? o Barrier method and dependent on proper use; o Dome shaped latex device; fits over anterior vaginal wall & cervix. o Inserted 6 hrs prior to sex & left in place for 6-8 hrs after intercourse. However, don’t leave in >24 hrs o * no talcum powder but use the diaphragm in combo w/ contraceptive jelly/cream. o Requires fitting from healthcare Side effects: o higher rate of UTIs Cervical caps What is it? o Barrier method and dependent on proper use; o Covers only the cervix; o easier to displace and harder to fit. o Must remain in place 6 hrs post sex but not >48 hrs. o * Higher incidence of toxic shock syndrome (TSS) and cervicitis Sponges What is it? o Barrier method and dependent on proper use; o Small, pillow-shaped sponge that fits over cervix containing spermicide o Can remain in place for 24 hrs, more effective in nullip women Side Effects: o increased risk of TSS if left >30 hrs Long acting reversible contraceptives What is it? o Includes IUDS and hormone eluting subdermal implants o Very effective (99%) but higher up-front costs Indicated for: o Pts w/ contraindications to estrogen containing compounds o Those who desire rapid return to fertility IUDS * All must be checked for placement in weeks Ideal Candidate: o * Adolescents are ideal candidates per AAP Contraindicated for: o congenital/acquired anatomical distortions of uterus, current AUB, active pelvic infection, pregnancy Risks: o * Increased incidence of PID, spontaneous expulsion, uterine perforation, embedded in uterine wall (10-16%) Types of IUDS: o 4 hormonal types which release levonorgestrel  Thickens cervical mucus, place w/n 7 days of LMP or during menses Side Effects: irregular bleeding/spotting (amenorrhea, increased risk of ovarian cysts) Copper IUD- ParaGard Interferes w/ sperm motility & fertilization; may inhibit implantation Creates cytotoxic response in endometrium Injection- depot medroxyprogesterone (Depo-Provera) What is it? o Injectable progesterone! o Need every 3 months w/in 1st 5 days of menses (last at least 14 weeks: “safety margin”) Side Effects: o * FDA warning: decreased bone density so limit is 2 years. However, ACOG does not recommend limiting yrs of DMPA as the effects on bone mineral density are intermediate and reversible. o Always consider risk to benefit ratio for the individual pt Implants- etonogestrel (Nexplanon, Implanon) What is it? o Place w/n 1st 5 days of LMP, approved for up to 3 years. o Place on the inner side of upper arm. o Helpful for Side Effects: o Similar to IUDs o Irregular bleeding/amenorrhea o Some weight gain Indicated for: o pts w/ dysmenorrhea from endometriosis, pts who cannot use IUDs, pts with HTN; pts who smoke and are >35 yrs; pts w/ seizure disorders, sickle cell anemia; pts who can’t take estrogen containing preps. Counter-Indicated: o * Pts with hormone responsive conditions (breast ca), unevaluated vaginal bleeding, breast malignancy, H/O thromboembolism or cerebrovascular disease, liver dysfunction Emergency contraception What is it? o Used for unprotected sex within 72 hrs and if there aren't any medical CI. o Not a form of medical abortion and do not terminate existing pregnancies. o * Works to prevent ovulation and fertilization (has NO effect on implantation) Types of emergency contraception: o Plan B One Step and Next Choice: ▪ Most common prep ▪ OTC med and consist of only one pill o Progestin only regimen: ▪ 2 tablets of levonorgestrel 12 hrs apart, up to 5 days after unprotected sex o Copper IUD- * most effective method if inserted w/n 5 days ▪ There’s some research on effectiveness of hormonal IUDS for emergency contractive and it pairs favorably w/ that of oral emergency contractive however the IUD does NOT decline with increased BMI o Ella – ulipristal acetate ▪ Effective up to 5 days after unprotected sex (effects diminish after 72 hrs  though) ▪ Needs a prescription (single dose) Sterilization What is it? o * MC method of controlling fertility in th US o Permanent (reversal outcomes have poor rates) Male: o Vasectomy- ▪ Occludes the vas deferens (complete is not obtained until 10 wks post op) ▪ Complications in 10-15% of cases ▪ SE: bleeding, hematoma, acute and chronic pain, skin injection, depression/change in body image Female: o Can be done out-pt o Allows for occlusion of fallopian tubes by clips, rings, or cautery o * minilaparotomy is MC surgical approach used o Electrocautery, hulka clip (most reversible), falope ring, filshie clip o Hysteroscopy- access to fallopian tubes via cervix ▪ Essure system- stainless steel & nickel titanium coil is inserted into fallopian tubes ▪ Asiana system: taken off market in 2012 but a silicone insert was placed into each fallopian tube ▪ Complications- infection, bleeding, ectopic preg Infertility What is it? o Inability of conception after 12 months of trying. For women >35 years, after 6 months of trying 3 categories of infertility: o Female factor (65%): * ovulatory dysfunction MC cause = PCOS; fallopian tube obstruction; pelvic adhesions; endometriosis o Male factor (20%): varicocele, oligozoospermia, azoospermia, sperm motility or morphology issues o Unexplained/other (15%) Evaluation of infertility: o Female: H&P: menstrual hx, ovulation predictor tests, basal body temp. Uterus Eval: US, hyperosalpingography, MRI, hysteroscopy, laparoscopy o Male: H&P, semen analysis, F/U urologist or reproductive endocrine specializing in male infertility Assisted Reproductive Technology (ART) Types: o 1) Artificial insemination: aka) IUI intrauterine insemination ▪ Ovarian stimulation: for pts w/ anovulation or oligo-ovulation ▪ * Clomiphene citrate = MC used ▪ Controlled ovarian hyperstimulation (exogenous gonadotropins stimulate follicular development ▪ Intrauterine insemination: washed semen is introduced via catheter into uterus o 2) * IVF: in vitro fertilization (MC method) ▪ >99% of all ART procedures ▪ Involves ovarian stimulation to produce multiple follicles; retrieve the oocytes from the ovaries; oocyte fertilization in vitro in the lab; embryo incubation in the lab; transfer of embryos into the women’s uterus through the cervix. o Couples Counseling includes risk of mult gestations; multifetal pregnancy reduction; stress assoc w/ ART; adoption