Family Planning Birth Control

Note: Hormonal Contraceptives

(Maternal pg. 149-150)Contraceptive vaginal ring—a ring is inserted into the vagina for 3 weeks; removed for 1 week, then a new ring is inserted. (Maternal pg. 149)Transdermal contraceptive patch—applied once a week-has both estrogen and progestin. (Maternal pg. 149)Hormone IM injections—Requires injections only 4 times per year (every 11-13 weeks). IMPORTANT—Do not massage the site after the injection because it may speed up absorption and decrease duration of effectiveness; effectiveness rate is comparable to that of oral contraceptives.; helps with menorrhagia, prolonged bleedingàanemia, and dysmenorrhea Disadvantages to Depo-Provera: weight gain, prolonged amenorrhea, and breakthrough uterine bleeding; Long-term use may decrease bone density—need to encourage calcium intake and exercise. (Maternal pg. 150)Hormone implants—up to 3 years of contraception. Most common side effect: irregular bleeding. Requires a small incision in the inner aspect of the non-dominant upper arm with a local anesthetic. Time releases progestin over the years to prevent ovulation •(Maternal pg. 151)Emergency contraceptive—Plan B—2 doses of progestin. Available without prescription for women of all ages. Should be taken within 120 hours of unprotected sex. Take Plan B One-Step® or a generic version as soon as possible within three days (or 72 hours) after unprotected sex. •For the two-dose version (Next Choice®, LNG tablets 0.75 mg), take one pill as soon as possible within 3 days and the second pill 12 hours later. •Take ella® (ulipristal acetate) as soon as possible within five days (or 120 hours) after unprotected sex. Must know LMP—harm to fetus if given while pregnant. Progestin only most common- more effective and fewer side effects. Prevents fertilization. No evidence that it works after fertilization. Wil

More Emergency Contraception

1.Ulipristal Acetate (UPA) - PO progesterone receptor agonist-antagonist (Ella) 2.Levonorgestrel (LNG)-PO progestin (plan B one-step) 3.Copper intrauterine device (Cu-IUD) 4.Off-label combined OCPs (Yuzpe method)

Note: EMERGENCY CONTRACEPTION

Abortion PILLS - mifepristone and misoprostol are different than emergency contraceptives. Is Plan B a form of abortion and affected by the ruling? No, Plan B is still available. Plan B, one of the brand names for over-the-counter, FDA-approved emergency contraception, can prevent a pregnancy. Plan B equals emergency contraception. It is not an abortion. "It will not work to stop a pregnancy that is already established," Berry-Roberts said. The abortion pill is typically two medications: mifepristone, which stops the pregnancy from growing, and misoprostol, which causes the uterus to empty. It's designed for a first-trimester pregnancy, and its effectiveness goes down the later in the first trimester. Currently, it can be prescribed to a person in Texas before six weeks gestation. It's unclear what will happen if the trigger law goes into effect. It might be possible for a woman to do a telehealth appointment with someone in another state and receive the abortion pill, but a lot is still not known, Berry-Roberts said.

More on Barrier Methods

Cervical cap ▪Smaller than diaphragm ▪Up to 36 hrs. before & 6 hrs. after ▪Provides protection for 48 hrs. ▪Replaced YEARLY ▪Must be fitted by HCP

Barrier Method

Chemical barriers—Spermicides ▪Creams, gels, foams, foaming tablets, suppositories & vaginal films ▪Must be applied before intercourse & wait 15 min but NOT > 60 min. Mechanical barriers - ▪Male condom—Watch for latex allergy ▪Female condom—(Vaginal Pouch) ▪Sponge—Contraception for 24 hrs. ▪Diaphragm—soft latex or silicone - Up to 2 hrs. before & at least 6 hours after ▪Refit for weight loss or gain of 10 lb. or more. ▪Should be replaced every 1 to 2 years ▪Must be prescribed & fitted by HCP ▪Newer single-size diaphragm released in 2018 (SILCS) Note: Spermicides- Must reapply if intercourse is to be repeated. Frequent use is associated with an increased risk of cancer.

BEHAVIORAL

D8-19 MOST fertile ▪Abstinence ▪Fertility awareness-based (FAMs) - Cost very little to use. ▪Calendar (Rhythm) ▪Standard days method ▪Avoid days 8-19 of cycle ▪Basal body temperature (BBT) ▪Cervical mucus—Ovulation ▪Withdrawal (coitus interruptus) - 18-20% Failure ▪Lactational amenorrhea method (LAM)

Injectable Contraceptive

Depo-Provera - 3-month IM - progesterone- ONLY •Suppress production of FSH & LH by pituitary gland •Suppress ovulation •Thicken cervical mucus •Cause endometrial atrophy •FDA warning - Over 2 years - BMD • Side effects •Menstrual cycle disturbances •Depression •Acne •Weight gain •Loss of bone mineral density

Note: Injectable Contraceptive

Depo-Provera works by suppressing ovulation and the production of FSH and LH by the pituitary gland, increasing the viscosity of cervical mucus and causing endometrial atrophy. A single injection of 150 mg into the buttocks acts like other progestin-only products to prevent pregnancy for 3 months at a time (Fig. 4.13). The primary side effects of Depo-Provera are menstrual cycle disturbances, depression, acne, weight gain, and loss of bone mineral density. It should also be noted that cycles may not be restored fully for up to 9 months following the last Depo-Provera injection. Recent clinical studies have raised concerns about Depo-Provera's impact on bone mineral density. This evidence has prompted the manufacturer and the FDA to issue a warning about the long-term use (over 2 years) of Depo-Provera and bone loss

Estrogen

Estrogen Secreted from: Ovaries (developing follicle) Function: - Development of endometrium - Stimulates LH secretion (follicular phase) - Inhibits LH and FSH (luteal phase)

FSH

FSH Secreted from : anterior pituitary Function: - Stimulates follicular growth - Stimulates estrogen secretion (from developing follicles)

Note: BEHAVIORAL

Fertility awareness - knowing and recognizing when the fertile time (when a woman can get pregnant) occurs in the menstrual cycle. Ovum released 14 days before the next menstrual period. It lives approximately 24 hours. Women using this method must have regular menstrual cycles for it to be effective. Sperm can live up to 5 days after intercourse. The fertile period during the menstrual cycle is thus approximately 6 days—3 days before and 3 days after ovulation. Because body changes start to occur before ovulation, the woman can become aware of them and not have intercourse on these days or use another method to prevent pregnancy. •Standard Days method - If your cycle is between 26 days and 32 days long, the Standard Days method considers days 8-19 to be the most fertile days. •Cervical mucous method - To prevent pregnancy, you should avoid sexual intercourse or use a barrier method of birth control from the time you first notice any cervical mucus. As ovulation approaches, the mucus becomes more abundant, clear, slippery, and smooth; it can be stretched between two fingers without breaking. Under the influence of estrogen, this mucus looks like egg whites. It is called spinnbarkeit mucus (Fig. 4.5). After ovulation, the cervical mucus becomes thick and dry under the influence of progesterone. Near ovulation, the cervix feels soft and is high and deep in the vagina, the os is slightly open, and the cervical mucus is copious and slippery. •Basal body temperature (BBT) method - In most women, the body's normal temperature increases slightly during ovulation (0.5-1°F) and remains high until the end of the menstrual cycle. The most fertile days are the 2-3 days before this increase in temperature. To monitor your BBT, take your temperature every morning after waking up, before any activity, getting out of

more LARCs

IUC (IUD, IUS) - Hormonal or Nonhormonal ▪T-shaped inside uterus ▪Inhibit endometrium implantation ▪Inhibiting sperm & ovum meeting ▪Periods lighter, shorter, & less painful ▪Copper or progesterone ▪Copper ParaGard-TCu-380A - 10yrs. ▪levonorgestrel-releasing IUS ▪(Mirena & Kyleena) - 5 yrs. ▪LNG-IUD (Jaydess) - Low-dose - 3 yrs.

LARCs

Implants - Nexplanon (4 cm long & 2 mm dia.) ▪68 mg of progestin-Subdermal time-release ▪Delivers 3 yrs. of cont'd ▪Inhibit ovulation & thickens cervical mucus ▪Fertility restored quickly after removal ▪Require a MINOR surgical procedure ▪NO STI protection Side effects - ▪Medical - Irregular Bleeding, Headaches Weight Gain, Acne, Increased Appetite Breast Tenderness, And Depression. ▪Surgical - Peripheral nerve Injury

Note: Think before you choose

Informed Consent—Because some methods have potentially dangerous side effects, it is necessary for the woman to sign an informed consent form to show that she received and understands information about the risks and benefits. Surgical sterilization, IUD's, hormone injections and some facilities require it for BCP's. In your Ricci Maternal Book, there is a table 4-4 (pg. 136-139) which is a summary of all contraceptive methods.The chart goes over description, failure rate, pros, cons, and sti protection

LH

LH Secreted from: Anterior pituitary Function: - Surge cause ovulation - Development of corpus luteum - Stimulates progesterone secretion

Note: LARCs

LONG-ACTING REVERSIBLE CONTRACEPTIVES (LARCs) An intrauterine contraceptive (IUC) is a small T-shaped object that is placed inside the uterus to provide contraception. It prevents pregnancy by making the endometrium of the uterus hostile to implantation of a fertilized ovum by causing a nonspecific inflammatory reaction and inhibiting sperm and ovum from meeting. Maternal pg. 150-151) Copper IUDs is a non-hormonal form of birth control that is T-shaped and wrapped in a bit of copper. It works as a preventative by releasing copper ions into the uterus, causing an inflammatory response toxic to sperm. IUD's are inserted in the uterus to provide continuous pregnancy prevention without causing permanent sterilization, however infertility issues have been noted with discontinuation. Para Gard effective for 10 years---Mirena effective for 5 years IUD"s can be inserted at any time the woman is not pregnant and does not currently have an STI or pelvic infection. IUD's cause a sterile inflammatory response, which results in a spermicidal intrauterine environment. Usually causes thinning of endometrium and thickening of cervical mucus to inhibit sperm entry Side effects: cramping and bleeding following insertion. Menorrhagia, dysmenorrhea, irregular bleeding and bleeding between cycles. Risk for uterine perforation, ectopic pregnancy and expulsion of IUD. Teaching—Check for the presence of the plastic threads or strings extending from the IUD into the vagina to ensure that the device is present. Report if the threads are longer or shorter than when inserted. Signs of infection. The woman should be advised to watch for influenza like signs which may indicate a septic spontaneous abortion and to have the IUD removed immediately if she becomes pregnant.

Note: Barrier Methods

Mechanical barriers (Med sug-pg. 1673-1674 or Maternal pg. 143-146) Diaphragm-size dependent. The diaphragm may be inserted up to 2 hours before intercourse and must be left in place for at least 6 hours afterward. Diaphragms are available in a range of sizes and styles. The diaphragm is available only by prescription and must be professionally fitted by a health care provider. Women may need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 lb or more. As a general rule, diaphragms should be replaced every 1 to 2 years. must refit by HCP In 2018, released a single-size diaphragm that has been proven to be effective as traditional diaphragms and provide a long-term controlled release of the lead candidate anti-HIV microbicide dapivirine, Condoms best other than abstinence against STI's. Female condom is made of polyurethane, has a flexible ring inside the closed end of the condom which fits over the cervix, another ring extends outside the vagina to partially cover the perineum. Cervical CAP - Contraindications to use of a cervical cap include cervical cancer, recent urinary tract infection, latex allergy, pelvic organ prolapse, and history of toxic shock syndrome (TSS). Using the cervical cap during menstruation may increase the risk of TSS The contraceptive sponge is nonhormonal, nonprescription device that includes both a barrier and a spermicide. The sponge, made of polyurethane saturated with 1 g of nonoxynol-9, releases 125 mg of the spermicide over 24 hours of use. Unlike the diaphragm, the sponge can be used for more than one coital act within 24 hours without the insertion of additional spermicide, and it does not require fitting or a prescription from a health care provider. does not offer protection against STIs. To use the sponge, th

Note: Contraception

Note—The human ovum is capable of fertilization for approximately 24 hours after ovulation. Sperm retain fertilizing ability for 48 hours after coitus. Ovulation typically occurs 12-16 days before the onset of menses if the woman is regular.

Note: Oral Contraceptives

OCs work primarily by suppressing ovulation by adding estrogen and progesterone to a woman's body, thus mimicking pregnancy. This hormonal level stifles GnRH, which in turn suppresses FSH and LH and thus inhibits ovulation. Cervical mucus also thickens, which hinders sperm transport into the uterus. Implantation is inhibited by suppression of the maturation of the endometrium and alterations of uterine secretions Progestin-only pills (POPs) have both advantages and disadvantages when compared to combined pills. The pill-taking regimen is simple and fixed; no pill color changes or days without pill-taking occur. These pills are appropriate for women who cannot or should not take estrogen in combined OCs, for example, a woman older than 35 years who smokes cigarettes. These OCs work primarily by thickening the cervical mucus to prevent penetration of the sperm and make the endometrium unfavorable for implantation. POPs must be taken at a certain time every 24 hours. Breakthrough bleeding and a higher risk of pregnancy have made these OCs less popular than combination Ocs.

Patches & Rings

PATCHS - Ortho Evra ▪Ethinyl estradiol & norelgestromin ▪Q3 wks. - 4th patch-free week ▪Adherence > OCs. ▪Overweight & obese >198 lb. ▪ Effectiveness & VTE & wt gain RISK Side Effects - VTE RINGS - NuvaRing Ethinyl estradiol & etonogestrel Inserted 3-week & 4th ring-free week Effective cycle control (AUB & PCOS) No need for fitting or HCP Side Effects - Erosion of vaginal wall Ring expulsion vaginal discharge Interference with coitus Unpleasant ring odor Vaginal discomfort

Progesterone

Progesterone Secreted from: Ovaries (corpus luteum) Function: - Thickening of endometrium - Inhibits LH and FSH (luteal phase)

EMERGENCY CONTRACEPTION

Reduces risk of pregnancy AFTER unprotected intercourse or contraceptive failure Educate About - ▪Used within 72 to 120 hrs. ▪Sooner INGESTION more effective ▪NO protection against STIs or future pregnancies. ▪Should NOT be used as a regular birth control method ▪May delay next menses ▪CHECK PREGNANCY if NO menses within 3 wks. after use ▪Report any SEVERE abdominal pain to HCP immediately ▪ECs can be regular birth control pills given at a Higher Dose ▪ECs are contraindicated if pregnant

Note: oral contraceptives

Report - Abdominal pain may indicate liver or gallbladder problems Chest pain or shortness of breath may indicate a pulmonary embolus Headaches may indicate hypertension or impending stroke Eye problems may indicate hypertension or an attack Severe leg pain may indicate a thromboembolic event

Permanent - Contraceptives

Sterilization: Permanent, safe, and highly effective ▪Laparoscopic, abdominal, hysteroscopic ▪REVERSAL surgery is difficult, expensive, & sometimes unsuccessful.

Oral Contraceptives

Suppress ovulation by adding estrogen & progesterone to a woman's body Weigh benefits vs risks Combination—Estrogen/Progestin - Mono OR multiphasic Progestin ONLY (POPs)—"Mini-pill" medroxyprogesterone Teaching: ▪Take at same time everyday ▪Interactions - effectiveness decreased with ABT ▪What to do if a pill is missed? Postpartum & Lactation Considerations ▪Increased risk for VTE ▪Avoid OC for 3-6 wks. ▪progestin does not affect milk production

Note: Permanent - Contraceptives

Vasectomy—surgical ligation and resection bilaterally of the vas deferens. After vasectomy, semen no longer contains sperm. This is not immediate, though, and the man must submit semen specimens for analysis 8 to 16 weeks after a vasectomy until two specimens show that no sperm is present. When the specimen shows azoospermia, the man's sterility is confirmed Table 56-4 in Med Surg book compares sterilization methods Essure is still mentioned briefly in the 4th edition of Maternal. However, in 2019, this procedure and device was taken off the market.

Female Sterilization

•Tubal Ligation •Mini-laparotomies & laparoscopies •Sealed with a cauterizing instrument or with rings, bands, or clips, or cut and tied

Male Sterilization

•Vasectomy - cutting the vas deferens •Complications - infection, hematoma, & pain •Semen analysis 8 to 16 wks. until two show no sperm

Contraception

▪Intentional prevention of pregnancy ▪?? Prevent transmission of STIs & HIV Types - ▪MOST effective: Abstinence, Male & female sterilization, IU contraception, & implant ▪Very effective: Injectable contraceptive, patch, ring, & pills ▪Less effective: Male & female condoms, diaphragm, & fertility awareness

Types of Hormonal

▪Oral Contraceptives (OCPs) ▪Contraceptive vaginal ring - NuvaRing ▪Transdermal contraceptive patch - Ortho Evra ▪Hormone injections - Depo-Provera (Q3 mths) ▪Long-acting Reversible Contraceptives (LARCs) - Nexplanon & IUS ▪Emergency contraceptive - Plan B "the morning after pill"

Think Before You choose

▪Safety ▪Protection from STIs ▪Effectiveness ▪Acceptability ▪Convenience ▪Benefits ▪Side Effects ▪Effect on Spontaneity ▪Availability ▪Expense ▪Preference ▪Religious & Personal Beliefs ▪Informed Consent