Family Planning

Nexplanon Advantages

- 3 yrs - no estrogen - Ok to use in Breastfeeding - immediately reversible - amenorrhea 20%

Surgical Termination

- 99% effective - Pt Ed on cramping, bleeding, birth control, abx - 2 week f/u

Combined Transdermal Patch: ORTHO EVRA

- 99.2% efficacy - Norelgestomin 150ug (norgestimate) and EE 20 ug - Apply Q wk for 3 wks, off 1 wk (Mimic 3 wk active pill w/ 1 wk placebo) - constant serum concentration - site: abdomen, buttock, upper outer arm, torso - 1st day or Sunday start - Not something for newly started pt - Weight has to be < 200 lbs (absorption issue w/ fat)

Poor Candidates for combined contraception

- Active thrombophlebitis or DVT - Acute/chronic obstructive liver disease w/ elevated liver enzyme or compromised liver fx - Known or suspected breast ca - Undxed genital bleeding - Women > 35 who smoke - Known or suspected pregnancy - Arterial Thrombosis/Ischemic heart disease - Migraines w/ focal neurologic signs - Clotting disorders - HTN

Diaphragm C/I

- Allergy to latex, rubber, spermicidal jelly - abnormal anatomy - inability to insert and remove - Hx of TSS or recurrent UTI

Kathy is 19 year old on DepoProvera for 4 months. She calls clinic because she is still experiencing irregular bleeding. How long w/ this last?

- Approx 50% of pt experience amenorrhea after 6 mo - Approx 75% of pt experience amenorrhea after 12 mo

Progesterone-only Methods bad Candidates

- Avoid in pt w/ ACTIVE DVT or PE - pt w/ breast ca (hormone dependent tumor) - pt w/ CHD or stroke - pt w/ active liver disease

COC SE

- BTB - N/V - Ha - breast tenderness - mood changes - *Major Complications: Thrombophlebitis, PE, CVD, Ca, Hepatocellular adenoma

Spermicidal

- Back up method; itself has high FR - good for 1 hr - Foam and Creams/gel formulations are immediately effective - Suppositories and vaginal contraceptive film need to wait 15 min b/4 sex - Typical FR: 29% - Perfect FR: 18%

Vasectomy Disadvantages

- Bleeding - Infection - Permanent - Regret - no std/HIV protection

Combination Estrogen/Progesterone Contraception

- COC, Ortho Evra Patch, Nuvaring, - Emergency Contraception

NFP Cervical Mucus - Billings Method

- Check daily and chart for ↑ mucus production - abstain from beginning of cycle until 4th day after peak mucus - b4 ovulation: yellow/white/cloudy, feels sticky or tacky - ovulation: clear and slippery, stretchy *most fertile days (unsafe) - 4 days after ovulation: ↓ mucus, cloudy, dry (safe)

Progesterone-only Methods Good Candidates

- Cigarette smokers > 35 y.o. - Women w/ hx of blood clots - Women w/ htn - Women w/ extreme migraine ha - Women who are breastfeeding

Copper IUD (Paragard)

- Copper T w/ single filament string - Typical FR: 0.8% - Perfect FR: 0.6% - Efficacy: 10 yrs - Copper is toxic to sperm - uterus and fallopian tubes produce fluid that kills sperm - longer term (up to 12 yr) than other

IUD

- Cost: $2000/IUD + $200-300/insertion - Types: Copper vs Progesterone/Levonorgestrel - Immobilizes sperm and interferes w/ sperm migration, speeds ovum transport, endometrial effects (thinning)

Diaphragm

- Cost: $25-30 - Typical FR: 16% - Perfect FR: 6% - Inserted up to 2 hr prior w/ spermicidal jelly and left in place for 6 hr after sex

Nexplanon

- Cost: $400-800/insertion + $75-$100 removal - most require insurance approval - Typical and Perfect FR: 0.5% - Single rod subdermal contraception w/ 68mg of etonegestrel - good for 3 yrs

Emergency Contraception

- Cost: 100% covered, $35-$50 OTC - FR w/ pill: 25% - FR w/ copper IUD : 0.01%

Coitus Interruptus/Withdrawal

- Cost: Zero - Typical FR: 27% - Perfect FR: 4% - pulling out b/4 ejaculation - Not reliable, but often used - Difficult; high fail rate

Abstinence

- Cost: zero - Failure rates: 0% - Encourage empowerment

Contraceptive Options for Obese pt

- DepoProvera can cause up to 20 lb wt gain - BMI > 25 is risk factor for VTE w/ OCP use (be extra careful w/ smokers) - OrthoEvra patch is less effective in obese women and recommended to be used in women <200lbs - Nuvating, POP, IUD, nexplanon, condom are good option

Good candidates for combined contraception

- Dysmenorrhea/PMS - Mittelschmerz (painful ovulation) - Endometriosis (benign gynecologic condition; painful) - Acne/hirsutism (help clear skin; decrease testerone) - Perimenopausal bleeding - Ovarian cyst (monophasic pill best) - FHx ovarian ca - Menstrual migraine (c/i if visual aura )

Depo-Provera Advantages

- Easy - immediate efficacy - Postpartum - Spontaneity - amenorrhea

Emergency Contraception Advantages

- Effective - low cost - safe

Any progesterone can cause irregular bleeding and can be tx w/

- Estrogen 0.625mg (premarin), Estradiol 1mg Q21days - COC w/ 21 days then 7 day break - NSAIDS 5-7 days (provide vasoconstrictive prostaglandins)

Combined Vaginal Ring: NUVARING

- Etonogestrel 120 ug and EE 35ug - FR: 0.9% - 2" diameter flexible ring inserted b/w 1st and 5th day of LMP, intravaginally for 3 wk, out for 1 wk - absorbed via vaginal mucosa - Great option for difficulty pill taker

COC Disadvantages

- Expense - Daily - BTB - glucose intolerance - gall bladder disease

Essure

- FDA approved 11/04 - Transcervical sterilization - Efficacy 96.5% in 3 mo, 100% 6 mo - Need HSG to confirm occlusion

Tubal Ligation

- FR: TL-0.5% - Reversal: 43-80% depending on type of procedure and amt of tube damaged

Emergency Contraception Disadvantages

- Failure - N/V

Natural Family Planning (NFP)

- Fertility Awareness method - Identify fertile days -> Assess cycle length -> Avoid sex on most fertile days - Observable signs of ovulation: Cervical mucus and temp - 76-88% effective - Typical FR: 25% - High failure rate as reliability of menses is hard to predict

NFP Temp

- First AM temp - abstain from beginning of cycle till 3 days after rise in temp - 96-98 F typical temp b4 ovulation - resting temp will rise 0.4-0.8 F right b4/during/after ovulation and remain elevated for rest of cycle

COC pt Ed

- First Day or Sunday Start - Missed Pills - ACHES - Back-up method for STD/HIV and 1st mo - Smoking cessation - 3-6 month f/u (Meet 4-6 wks after for pill check initially) - Reassure pt on SE (Ha, sx of DVT/PE)

Medical Termination: Mifepristone (RU-486) and Misoprostol

- Given w/in 10 wks of pregnancy - Mifepristone: acts by blocking progesterone (Progesterone agonist) - Misoprostol: causes uterine contractions and bleeding (given 6-48 hr after Mifeprex) - bleeding typically starts 1-4 hr after Misoprostol and can last for several days - F/u to evaluate w/ u/s and discuss birth control options

Tammy is 35 year old presenting to clinic for string check. She had Mirena IUD inserted 6 weeks. She reports some irregular bleeding, and mild cramping. She is unable to check for string herself. On exam you do not see string. What is next step?

- HCG and u/s to check for proper placement

Emergency Contraception insertion time frame

- IUD must be inserted w/in 5 days - Plan B must be started w/in 72 hr after unprotected sex - Ella w/in 5 days

When should pt stop taking OCP?

- In smoker >35 switch to progesterone only - In non-smoker, in absence of other health concerns, COCP can be safely continued to menopause - Check FSH annually on day 6-7 of placebo pills to decide if pill can be discontinued - small ↑ risk of breast ca in pill users - ↑ incidence of VTE and risk factors should be re-evaluated

Essure Advantages

- Incision free - local anesthesia - in office or hospital procedure - Quick recovery 24 hr

Nexplanon Disadvantages

- Irregular bleeding 6-12 mo (varies; hard to predict) - Cost - pain or scarring at insertion site (migration possible) - possible small ↑ wt gain - ha, acne - ovarian cysts - mood changes

Spermicidal Disadvantages

- Irritation - ↑ VVC - Must use within 1 hr time frame

Progesterone IUD

- Levonorgestrel: Mirena 20mg, Kyleena 17mg, Skyla 13.5mg and Lyletta 52 mg - Typical & perfect FR: 0.1% - Efficacy: 5 years; 3 yrs (Skyla) - Pvt fertilization by damaging or killing sperm - Thickens cervical mucus - Thins uterus (endometrium); makes difficult for fertilized egg to implant and grow - Pvt ovulation

Nexplanon Insertion

- Local anesthetic to inner side of arm b/w bicep and triceps muscle - Insertion into subdermal tissue w/ needle-like applicator that advances rod - Bandage on site for 24 hr - Removal after 3 yrs w/ small incision and use of forceps

Contraception in adolescent pt

- Low OCP adherence in adolescents (45% at 3 mo; 33% at 12 mo) - Short acting methods have higher discontinuation/pregnancy rates than long acting contraception - IUD does not ↑ risk of infertility d/t PID

Barrier Methods types

- Male Condoms - Female Condoms - Diaphragm - Cervical Cap - Spermicidal jelly, cream, foam, film

Pregnancy Termination

- Medical and surgical options - State to state regulations regarding parental consent - Ma require parental consent for women under 18 yrs, but judge can excuse this requirement

Progesterone-only Methods Advantages

- No estrogen SE - ↓ menses, amenorrhea - ↓ anemia - can be used in lactating mothers - when estrogen is c/I - Good for pt w/ Endometriosis & ovarian cancer (hx or current)

NFP Disadvantages

- No protection STD/HIV - Difficult w/ long, irregular cycles, or approaching menopause or recent menarche

contraception 3 types

- Non-Hormonal method: Abstinence, Coitus Interruptus , Natural Family Planning, Barrier Methods - Hormonal Methods: POP, Depo-Provera, Nexplanon, IUD, COC Pills, Combined Transdermal patch, Combined vaginal ring, Emergency Contraception - Permanent Options/Abortion

IUD Disadvantages

- PID - Dysmenorrhea - Menorrhagia - expulsion (vaginal discharge, pain, irreg bleeding, string change) - pregnancy complications; ↑ ectopic pregnancy - uterine rupture (during device insertion)

During your discussion you realize that Stacey has hard time keeping up w/ her regular schedule and she admits that she may have hard time remembering to take pills. Options you offer her include:

- Patch (need to be <200lb) - Ring - IUD - Implant - Condoms (STI protection)

Tubal Ligation Disadvantages

- Permanent - no STD/HIV protection - reversal difficult - risk of surgery & anesthesia - mortality/morbidity higher than vasectomy - ↑ ectopic

Selection of contraception

- Personal preferences - Effect of menstrual cycle - Childbearing plans - Pattern of sexual activity - Partner influences and concerns - Social and cultural factors - Ability to acquire and use method successfully - Method specific concerns - Tolerance for daily, vaginal, transdermal, injectable methods - Concomitant need to prevent STI - Supportive care from healthcare provider

28 yr old female calls your office on Monday morning stating that condom broke when she and her partner had sexual intercourse Friday afternoon. Is it too late for her to take postcoital contraception?

- Plan B: must be taken within 72 hr - Ella: must be taken within 120 hr (need prescription) - Copper IUD: must be inserted within 5 days - 99% effective - Menses typically 1 wk late after EC - Can give w/ anti-emetics (nausea common d/t hormonal shift)

Good Candidate for Depo-Provera

- Postpartum pt - Poor pill takers - Pt w/ Endometriosis/Dysmenorrhea

Nexplanon C/I

- Pregnancy - allergy to etonogestrel - liver tumors - undxed vaginal bleeding - severe liver disease - b4 6 wk postpartum

missed NUVARING

- Protective if off for <2 days (48hr) - if fall out; reinsert immediately

COC Drug to drug interaction: Should use condoms 1wk post txments of following drugs

- Rifampin - Vit C - anti-convulsants - abx (reduces normal flora in gut) - St. John's Wort

IUD Advantages

- Safe - highly effective - long acting - Tx Ashermann's w/ hormonal IUD -↓ menstrual flow and pain, amenorrhea w/ hormonal IUD

COC Advantages

- Safe, effective - cycle control - Dysmenorrhea, ovarian cysts, Acne, Mittelschmerz, Anemia - Reversible - prevents ovarian and endometrial ca - bone mineral density - Premenstrual dysphoric disorder

Missed Combined Transdermal Patch

- Still protective if off for < 2days - if not use back up and restart

Surgical Termination: Dilation and evacuation

- Surgical option done after 16 wks w/ dilation and suction

Sally is 42 year old w/ hx of dvt w/ her last pregnancy. What are her best options for contraception?

- Tubal ligation - Copper IUD - Barrier methods - LNG-IUD - Essure

Vasectomy

- Typical FR: 0.15% - Perfect FR: 0.10 - Reversal: 16-79%, average 50% - Take 4 mo before sperm b/4 sterile

Cervical Cap

- Typical FR: 20% - Perfect FR:9% - Must remain in place for 6 hr following sex for maximum of 48 hr

Female Condoms

- Typical FR: 21% - Perfect FR: 5% - Can be placed up to 8 hr prior to intercourse - Female Condoms are lubricated but not w/ spermicidal jelly; should be used w/ spermicides

Depo-Provera Injection

- Typical FR: 3% - Perfect FR: 0.3% - Given w/in 1st 5 days of menses, repeated every 12 wk, 150 mg IM - Very good rate as long as pt comes Q time for injection

Male Condoms

- Typical FR: 6-30% - Perfect FR: 2% - Always emphasize use for prevention of STD's - should be used w/ spermicides - Only synthetic condom protect against STI (lamb skin does not; only protect against pregnancy)

COC

- Typical FR: 9% - Perfect FR: 0.1% - inhibits ovulation, ↓ ovum transport, early luteolysis, thickens cervical mucous, alters endometrium - Start w/ lowest dose (10/20 mcg) - Monophasic: 1 dose throuout - Biphasic: 2 different strength - Triphasic: mimic cycle; 3 different doses

POP (minipill, Micronor, Camila)

- Typical FR: 9% - Perfect FR: 0.3% - 28 days of continuous progesterone 0.35mg of norethindrone or 0.075mg of norgestrel - Take 1 pill daily, no placebo week, use backup 1st month - Recommend condom use as it pvt STI, and also pvt unwanted pregnancy when pills are missed

Good Candidates for IUD

- Women w/ one sexual partner - Women at low risk for STD's - Women who w/ menorrhagia, perimenopausal bleeding - Estrogen is c/i

Emergency Contraception C/I

- any person w/ OCP c/i - if unprotected intercourse occurred > 5 days prior

Cervical Cap Advantages

- can be used w/ condoms

Diaphragm Advantages

- can be used w/ condoms - ↓ cervical neoplasia

NFP Advantages

- can plan/prevent pregnancy

A 22 year old G1P1 presents for contraception. She plans to wait 2-3 years before having another child. She has been on PO contraceptives for past 3 years without problems except that she frequently misses pills. She discontinued her pills about 2 months ago and is currently in third day of her period. She is in office for Nexplanon insertion. Instructions for this client on use of Nexplanon should include:

- effective for 3 yr - Most women have regular periods w/ this method - does not need backup method w/ her timing of insertion (inserted w/in 1st 5 days of menses) - same potential adverse effects as POP

Progesterone-only Methods

- ex: Depo-Provera, POP, Nexplanon, hormonal IUD - Inhibit ovulation - ↑ cervical mucus - premature lysis of corpus luteum - cause atrophic endometrium (Thin out uterus wall, so nothing can attached)

Spermicidal Advantages

- good back up method - Accessible, OTC, Inexpensive - STD/HIV protection - lubrication

Good Candidates for Barrier Methods

- high STD risk - can not/do not want to use hormonal methods - need backup contraception - have sex infrequently, especially young adults - want method that is user-controlled

Measure of Effectiveness: Typical use

- how effective method is during actual use (includes inconsistent and incorrect use)

POP Advantages

- immediately reversible - no wt gain - amenorrhea

POP Disadvantages

- irregular bleeding - mastalgia (breast pain)

Progesterone-only Methods Disadvantages

- irregular menses, amenorrhea - wt gain - breast tenderness - mood changes - ha - Should never miss pill; uterus is very sensitive to thinning

Spermicidal SE

- irritation

ORTHO EVRA Black Box Warning

- issued 2006 - 60% higher estrogen than in COC

Cervical Cap C/I

- latex, rubber, spermicidal allergy - Hx TSS - inability to insert and remove - abnormal anatomy - abnormal pap smears - cervical infection and vaginal bleeding - can't be used during menses

Depo-Provera SE

- menstrual changes - Ha - weight gain - Mood (irritability) - Black Label warning: ↑ risk of osteoporosis for 2 yrs

Surgical Termination: Vacuum Aspiration

- mild suction used to evacuate contents, done in clinic and up to 16 wk

COC Missed Pills instruction

- missed single pill; double up next day - Missed two pill; double up for 2 days - Missed three pill; not a good method for this pt

Essure Disadvantages

- not immediate - need back up for 6 mo (until complete occlusion from scar in fallopian tube) - can't use IUD or Intrauterine system at same time - may need more than 1 insertion

Bad Candidates for Barrier Methods

- not recommended in cases of allergy to latex or spermicides - Diaphragm & Cervical Cap not recommended for women w/ cervical/vaginal anatomical abnormalities - 1st 6 wks after childbirth; changes w/in cervic and reproductive tract - Hx of TSS

Tubal Ligation Advantages

- permanent - effective

NUVARING c/i

- poor vaginal tone - hx of vaginal prolapse - chronic constipation

Cervical Cap Disadvantages

- possible TSS - ↑ BV, VVC - ↓ spontaneity - can cause abnormal pap smears

Bad Candidates for IUD

- pregnant - allergic to copper (for copper IUD only) - have uterus that is shorter or smaller than IUD - have artificial heart valve - are at risk for getting STI - have recent hx of pelvic inflammatory disease or STDs - have cervical, endometrial, or ovarian cancer that needs txment

Vasectomy Advantages

- safe - effective

Emergency Contraception SE

- same as COC's - can be more severe

NFP Calendar Method

- subtract 10 from longest cycle and 20 from shortest cycle - abstain during those days - sex Q other day if attempting pregnancy as these indicates peak ovulation

Measure of Effectiveness: Perfect use

- when method is used correctly and consistently as directed

Diaphragm should be refitted if...

- wt change >10 lb - post-partum - post-abortion or SAB

Depo-Provera Disadvantages

- wt gain (10-15 lb) - ↓ bone density; ↑ risk of osteoporosis for 2 yrs - not immediately reversible - appointment Q 3 mo

Diaphragm Disadvantages

- ↑ UTI's, Bacterial Vaginosis, Vulva Vaginal Candidiasis - ↓ spontaneity - possible TSS

Linda is 45 year old woman who has been on pill for 12 years. She is taking OCP's for contraception. She is non-smoker, nml BMI and otherwise healthy. Which of following could be good option for her? A. Continue taking OCP B. Place paragard C. Refer for Tubal ligation D. Place Nexplanon E. Tell her to stop pill and not to worry, she probably can't get pregnant

A. Continue taking OCP

Tammy is 28 year old G2P2, in monogamous relationship, who needs contraception. She is 5'5" 235 lbs. and still trying to lose her baby weight. What is least appropriate method for her? A. Copper IUD B. OCP C. Depo Provera D. LNG IUS

C. Depo Provera

Stacey is 17 year old G0P0 presenting for her first gyn visit. She is interested in contraception as she has recently become sexually active w/ her first partner. She is healthy, non-smoker w/ regular menses. What aspect of exam is important for this pt? A. pap smear B. complete gyn exam C. Screening for STI D. Telling her parents

C. Screening for STI

A woman who uses NuvaRing removes ring during sex in evening and realizes next morning that she forgot to reinsert it. If this is week 1 or 2 for this ring she should be advised to: A. Discard this ring and insert new one immediately B. Discard this ring, wait for withdrawal bleed and insert new ring C. Reinsert this ring w/ no backup needed if it has been out for less than 8 hr D. Reinsert this ring and use backup method for 7 days (during week 1&2, reinsert ring and need to use backup)

D. Reinsert this ring and use backup method for 7 days - during week 1&2, reinsert ring and need to use backup) - pt can reinsert this ring w/ no backup needed if it has been out for less than 8 hr IF it is wk 3