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Contraception (alert symptoms for women on CHCs (loss of vision,…
Contraception
treatment options
non-pharmacological
male condoms
CIs: allergy to latex or rubber
prevents direct contact of the vagina with semen, genital lesions, and infectious secretions
female condoms
CIs: allergy to polyurethane, hx of TSS
prevents direct contact of the vagina with semen, genital lesions, and infectious secretions
sponge
CIs: allergy to spermicide, recurrent UTIs, hx of TSS, abnormal gynecologic anatomy
prevents direct contact of the vagina with semen, genital lesions, and infectious secretions
cervical cap
CIs: allergy to spermicide, hx of TSS, abnormal gynecologic anatomy, abnormal pap smear
cannot be used during menses
prevents direct contact of the vagina with semen, genital lesions, and infectious secretions
requires Rx from a clinician who has fitted the patient for the correct size
can be inserted 6 hours prior to intercourse and shouldn't be removed <6 hours after intercourse
ALL of these methods have a high user failure rate!
periodic abstinence (rhythm method)
physiologic changes are used during each menstrual cycle to determine the fertile period
cons: relatively high pregnancy rates, avoidance of intercourse for several days during each menstrual cycle
pharmacological
spermicide
CIs: allergy to spermicide
must be reapplied before each act of intercourse
provides no protection against STDs
chemical surfactant that destroys sperm cell walls to prevent sperm from entering the cervical os
when used >2x/day, nonoxynol-9 may ↑ risk of transmission of HIV by causing small disruptions in the vaginal epithelium
combined hormonal contraceptives (CHCs)
contain estrogen and progestin and work primarily before fertilization to prevent conception
estrogens
suppress FSH release from the pituitary to contribute to blocking the LH surge
mestranol must be converted by the liver to EE before it's active and is 50% less potent than EE
synthetic estrogens found in CHCs available in the US: ethinyl estradiol (EE), mestranol, estradiol valerate
progestins
thin the endometrium to decrease likelihood of egg implantation + thicken the cervical mucus to block sperm entry
adversely affect lipid metabolism (decreases HDL and increases LDL)
reduced endometrial cell growth= reduced cancer risk
CIs: <21 days postpartum, severe liver disease, hx or risk of DVT, prolonged immobilization, migraines with aura, uncontrolled HTN, hx or risk of breast cancer, smoking ≥15 cigarettes/day (if age ≥35YO)
monophasic
OCs contain the same amounts of estrogen and progestin for 21 days,while
multiphasic
OCs contain variable amounts of estrogen and progestin for 21 days
symptoms occurring with early OC use (nausea, bloating, breakthrough bleeding) usually improve by 3rd cycle of use
AEs: N/V, breast tenderness, weight gain, acne, oily skin, depression, fatigue, breakthrough bleeding, application site reaction (patch), vaginal irritation (vaginal ring)
EE levels may be reduced when OCs are taken with tetracyclines and penicillin derivatives (esp. rifampin)
many forms besides oral!
transdermal patch
less effective in women who weigh >90kg
vaginal ring
emergency contraception (EC)
used to prevent unwanted pregnancy after unprotected/inadequately protected sexual intercourse
progestin-only (Plan B One Step) and progesterone receptor modulator (Ella) products are recommended as first-line options
AEs: N/V, irregular bleeding
if a pregnancy already exists, the EC will not disrupt or harm the embryo
effective for up to 3 days after sexual intercourse
progestin-only “minipills”
associated with irregular/unpredictable menstrual bleeding
less effective than combination OCs
must be taken every day of the menstrual cycle at approximately the same time to maintain efficacy
injectable progestins (Depo-Provera)
administered every 3 months either by IM in the gluteal or deltoid muscle or subQ in the abdomen or thigh within 5 days of onset of menstrual bleeding
avoid initiating until 6 weeks postpartum in breastfeeding women
Provera
= medroxyprogesterone
long-acting reversible contraception (LARC)
include IUDs and implants
doesn't require effort or adherence by pt once inserted
not used as frequently in the US
99% efficacy rate is similar to that of surgical options (i.e. tubal ligation)
etiology and pathophysiology
contraception
- prevention of pregnancy following sexual intercourse by inhibiting viable sperm from coming into contact with a mature ovum
~49% of all pregnancies in the US are unintended, and these pregnancies have been associated with adverse pregnancy behaviors and outcomes
postpartum depression
increased rate of preterm birth,spontaneous abortion, and other fetal abnormalities
delayd prenatal care
when estradiol levels remain elevated, the pituitary releases a LH surge, which stimulates the final stages of follicular maturation and
ovulation
most clinically useful predictor of approaching ovulation
occurs 28-32 hours before a follicle ruptures
monitoring and follow-up
annual BP monitoring is recommended for all CHC users
contraceptive users should receive an annual well woman exam (may include a cytologic screening)
women using DMPA should be asked at 3-month follow-up visits about weight gain, menstrual cycle disturbances, and fractures
Women using IUDs should have follow-up visits every 1-3 months to check IUD placement and s/sx of upper genital tract infection
all women should receive counseling about healthy sexual practices including the use of condoms to prevent the transmission of STDs when necessary
treatment goals
prevent pregnancy
prevention of STDs (with condoms)
improvements in menstrual cycle regularity (with hormonal contraceptives)
improvements in certain health conditions (with hormonal contraceptives)
manage symptoms of perimenopause
benefits of using CHCs for women
decreased iron deficiency anemia
reduced risk of ovarian and endometrial cancer. (50% risk reduction in pts using OCs for ≥5 years)
improvement in menstrual regularity
may reduce risk of ovarian cysts, ectopic pregnancy, pelvic inflammatory disease, endometriosis, and uterine fibroids
relief from menstruation-related problems (e.g. decreased menstrual cramps, decreased menstrual blood loss)
vitamin requirements for women of childbearing age
folic acid: 400-800mcg daily (increases in pts w/ seizure disorders)
magnesium: 310mg daily (increases to 320mg for ages 31-50)
iron: 18mg daily
calcium: 1000mg daily
vitamin D: 600IU daily
alert symptoms for women on CHCs
loss of vision
unilateral numbness, weakness, or tingling
severe pains in chest, left arm, or neck
hemoptysis
severe pains, tenderness, or warmth in legs
slurring of speech
hepatic mass or tenderness
exophthalmos
absence of menses
