qUIZ 2.docx

Contraceptives: - Contraceptive counseling: remember the most effective method is the one that the patient will use - Take a good medical history, family history, and use the U.S. Medical Eligibility Criteria for Contraceptive use: heart disease, VTE, CVA, liver disease, gallbladde...

Contraceptives: - Contraceptive counseling: remember the most effective method is the one that the patient will use - Take a good medical history, family history, and use the U.S. Medical Eligibility Criteria for Contraceptive use: heart disease, VTE, CVA, liver disease, gallbladder disease, migraines WITH aura, HTN, clotting disorder, or cancer - PATH questions: PA is for parenting/pregnancy attitudes - T in PATH is for timing, when do you think you want to have kids? - H in PATH is for how important it is to prevent pregnancy until then - What is the action of contraceptive hormones: 1. Progestins: thicken cervical mucus, prevent ovulation by inhibiting gonadotropin release, suppresses endometrial activity 2. Estrogens: decrease FSH and maintain endometrium ( decrease breakthrough bleeding) - Contraceptive that works really, really well: 1. The implant: the single rod with 68 mg etonogestrel; it is highly effective and long-term; fertility returns rapidly after removal; can be used while breastfeeding; can help with dysmenorrhea and endometriosis sx; reduces risk for PID. Disadvantages are it requires minor procedure, irregular bleeding (most common and worse in first months to 1 yr of use), no protection form STD. Patient educations: bleeding irregularities are common and will improve within 3-6 months; procedure counseling will need pressure dressing x24 hrs and will let steri-strips fall off on its own after removal; still need to use condoms to protect from STDs 2. Hormonal IUD's: these work by inhibiting fertilization and preventing implantation. Advantages include: highly effective and long-term, fertility returns rapidly after removal, can help with heavy menstrual bleeding, dysmenorrhea, and endometriosis symptoms, reduce endometrial hyperplasia, PID, and cervical cancer. Disadvantages are it's a minor procedure and no protection against STD. Bleeding is worse in the 1^st^ 3-6 months of use; could become shorter and lighter, amenorrhea common, and infrequent periods common Patient education: expect spotting for 4-6 weeks after insertion; check strings monthly (if not felt use a back-up method); timing (back-up method for 7 days for LNg IUD). Discomfort Post procedure counseling: nothing in the vagina for 24 hrs, cramping likely last for 24-48 hrs, continue NSAIDs for cramping. Red flags: heavy bleeding, severe pain, foul smelling discharge, fever. Return to clinic in 1-3 months for IUD check and use condoms to protect against STD 3. Copper IUD: 99% effective for up to 12 years; most effective reversible non-hormonal method. Can be used as Emergency Contraceptive if inserted within 5 days. Advantages: highly effective and long-term, fertility returns rapidly after removal, few medical contraindications, can be used while breastfeeding, no hormones, decreases cervical cancer risk. Disadvantages: minor procedure, increased risk for PID, no protection against STD. How does it work? Copper decreases sperm motility and is toxic to sperm. Bleeding worse in the 1^st^ 6 months of use usually heavier and longer, dysmenorrhea possible. 4. Sterilization - Contraceptive that works pretty well: 1. The pill: combined oral contraceptives come in multiple formulations 2. The patch: contraindicated in women with BMI \>30 3. The ring: new ring every month (up to 35 days) 4. The shot: "Depo-Provera" given every 12-14 weeks. Advantages: rapidly and highly effective, decreases heavy menstrual bleeding, dysmenorrhea, and endometriosis symptoms, protects against endometrial hyperplasia and endometrial CA, reduces risk of PID and ectopic pregnancy, decreases sickle cell crisis, possible decrease in seizures. Disadvantages: delayed return of fertility 6-18 months, 9 months on average; decreases bone density, increases risk of diabetes and insulin resistance, increases risk of HIV acquisition, does not protect against STD. Adverse effects: bleeding irregularities are the most common (first 3 months may experience irregular bleeding, prolonged bleeding), weight change (gain 5 lbs per year), headaches, mood changes. Patient education: irregular bleeding after first injection common, amenorrhea common after second injection, if there is a gap between injections the bleeding irregularities may occur again. Fertility return may take 6-9 months, ensure adequate calcium and vitamin D in diet, use condoms/barriers to protect against STD Non-contraceptive benefits of the CHCs from the progestin: decreased menstrual blood loss, decreased dysmenorrhea, decreased symptoms of endometriosis, decreased menstrual migraines, decreased risk of ovarian cancer non-contraceptive benefits of the CHCs: from the ethinyl estradiol will treat hot flashes and other perimenopausal symptoms, protect bone mineral density for high-risk patients, improve acne, and improve hirsutism Risks of CHCs: increased risk of VTE, increased risk of MI and stroke, several drug interactions, can increase BP and decreased HDL cholesterol. Adverse effects of CHCs: changes in bleeding pattern; typically lighter and shorter, may cause amenorrhea, spotting common Teach patients about ACHES: Abdominal pain, chest pain, headache, eye problems, severe leg pain/swelling of legs/feet (all signs/symptoms of blood clot) Key patient education about COC: - Take the pill everyday at the same time (3 hr window) - Spotting normal in the first 1-3 months - If miss 1 pill take as soon as remember, no back-up needed - If missed 2 or more pills in week 1 or 2, take the most recent missed pill, keep taking pills in pack and used back-up method x 7 days; may need emergency contraceptive if missed pills in week 1 - If missed 2 or more pills in week 3, take the most recent missed pill as soon as possible, finish remaining hormone pills in pack and throw away reminder pills and start a new pack; use back-up method x 7 days Key patient education about patch: - Apply one patch per week for 3 weeks, followed by 1 patch-free week - Use a different site with each new patch - Apply to skin that is clean and dry without powders, lotions, etc. - Wash hands after applying patch b/c hormones - Use condoms/barriers to prevent STD - If there is a delay in beginning 1^st^ patch need to apply patch as soon as remember and use back-up method x 7 days - If there is a delay in beginning 2^nd^ or 3^rd^ patch, if changed within 48 hrs need to apply new patch and no back-up needed; after 48 hrs use back-up for 7 days - If the patch falls off, put on a new patch; this day becomes the patch change day Key Patient Education ring: - Insert ring into vagina as high as possible - Put ring in for 3 weeks and take out for 1 week - May take out for up to 3 hrs - Discard ring in package - If delayed removal (\>5 weeks): remove old ring, place new ring immediately and use back-up x 7 days - If delayed reinsertion (\25, not effective for BMI \>30. Prevents ovulation by blocking LH surge. Adverse effects: change in menses, N/D, breast tenderness, HA, mood changes. Can start hormonal contraceptive immediately. If no menses within 3 weeks then need to do a urine preg. 2. Ulipristal acetate (Ella): effective up to 120 hrs after sex; less than effective for BMI \>35. Adverse effects: HA, dysmenorrhea, nausea, and abdominal pain. Breastfeeding: pump and dump for 24 hrs after taking, recommended to give script in advance, no menses within 3 weeks need to do a urine preg. 3. Copper and LNg 52 IUDs: insert within 5 days (120 hrs); best choice for obese ppl. If no IUD within 3 weeks, take a urine preg test Special Populations: 1. Perimenopause: can use CHC if no other risk factors to help with vasomotor symptoms, use pill with 20 mcg ethinyl estradiol, can use the ring and avoid the patch. Progestin-only methods and copper IUD are acceptable without medical contraindications. Stop contraceptives at age 55 or menopause 2. Immigrants Managing Adverse Effects: - Unscheduled bleeding 1. CHC: provide reassurance; if using continuously take a hormone break or use higher dose of E2. If cyclic use increase E2 dose or switch progestin. Smoking cessation 2. Depo and Implants: reassure because usually take 3-6 months; NSAIDs ibuprofen 400-800 mg TID x 5-10 days; COCs monophasic with \