Contraceptive Options

Oral Contraceptives Advantages

" benefits, such as fuller sexual satisfaction, and may help regulate abnormal menstrual cycles and reduce menstrual blood flow. Additional advantages of OCs include decreased menstrual cramps and pain, and improvement in menstrual In addition to providing some therapeutic benefits, OCs have been proven to protect against · ovarian and endometrial cancers, ectopic pregnancy, pelvic inflammatory disease (PID), functional ovarian cysts, endometriosis, and uterine fibroids

A patient using the calendar method for contraception has determined that her shortest cycle lasts 28 days, her longest cycle lasts 32 days, and that her cycle stats on day 5 of the month. During which range of days of the month should she abstain from intercourse to best avoid pregnancy? a. Day 14 to day 27 b. Day 21 to day 27 c. Day 15 to day 28 d. Day 19 to day 28

1. C A patient using the calendar method whose cycle begins on day 5 of the month, whose shortest cycle lasts 28 days and whose longest cycle lasts 32 days, should avoid intercourse between days 15 and 28 of the month to best avoid pregnancy- When using the calendar method, the patient should subtract 18 days from her shortest cycle and 11 days from her longest cycle. Both those totals should be added to the day of the month her cycle begins, counting that day as part of the totals, thus determining the window of fertility

what effect does Depo-Provera have specifically on the endometrium? a. Creates a thin, atrophic lining b. Thickens the cervical mucus c. Promotes local foreign body inflammatory responses d. Causes lysis of implanted blastocysts

10. a Depo-Provera alters the endometrium by creating a thin, atrophic lining. Depo-Provera also thickens the cervical mucus, but this mechanism of action does not directly alter the -endometrium: rather, it interferes with sperm transport and penetration. Intrauterine devices.not DepoProvera, prevent implantation either by causing lysis of the blastocyst before it implants or by promoting local foreign body inflammatory responses.

Depo-Provera and NuvaRing share all of the following mechanisms of action except: a. Release of synthetic estrogen and progestin b. Thickening of cervical mucus c. Suppression of follicle-stimulating hormone d. Suppression of luteinizing hormone

11. a Although NuvaRing acts by releasing synthetic estrogen and progestin, Depo-Provera is a progestin-only formulation. Both methods of contraception act to prevent fertilization via suppression of follicle-stimulating hormone and luteinizing hormone, as well as promote thickening in the cervical mucus

12. For which of the following types of condoms is use of oil-based lubricants most strongly discouraged? a. synthetic condoms b. Polyurethane condoms c. Natural membrane condoms d. Latex condoms

12.d Oil-based lubricants, such as baby oil, lotions, and petroleum jelly, should not be used with latex condoms, as these can increase the risk of condom breakage. The other types of condoms, such as synthetic, natural membrane, and polyurethane, do not significantly weaken when exposed to oil-based lubricants as compared to latex.

13. Although progestin-only contraceptive pills are not as effective in suppressing unscheduled bleeding, these are a more viable option for patients with certain conditions that are exacerbated by estrogen. Which of these conditions does not usually warrant the need for progestin-only pills? a. Migraine headaches b. Hypertension c. Endometriosis d. Obesity

13.c A combination of estrogen and progestin contraceptives actually decreases the pain resulting from endometriosis; therefore, the use of estrogen is often recommended for endometriosis. Patients who have migraine headaches, hypertension, or obesity would most likely benefit from progestin.

14. Which of these most strongly reflects the theory behind natural family planning? a. pregnancy is less likely when the cervical mucus is thin b. Pregnancy is less likely when the female's temperature drops and rises prior to ovulation. c. Pregnancy is less likely when there are "strawberry patches" on the cervix. d. Pregnancy is less likely when the female is lactacting

14.d The lactational amenorrhea method of natural family planning holds that pregnancy is less likely when the female is not menstruating and fully breast feeeding her infant. The cervical mucus method indicates that pregnancy is more likely when there is a lot of clear, stretchy mucus; fertility is low when there is a scant scant amount of thick, white mucus. The basal body - temperature method of contraception instructs couples seeking to prevent pregnancy to obstain from sexual intercourse during the expected rises and drops in basal body temperature. Lastly, "strawberry patches" on the cervix usually indicate thrichomoniasis and are not used in natural family planning.

15. All of the following are definitive reasons to examine and possibly replace a diaphragm as a contraceptive method except: a. use of oil-based lubricants b. Wear and tear c. Being diagnosed with vulvovaginitis d. Gaining weight exceeding 20 lb

15. с Although use of a diaphragm may increase the risk of contracting vulvovaginitis, contraction of the disease is not an absolute reason to reexamine or replace the device Diaphragms should regularly be checked for tears and holes resulting from repeated use. Furthermore, latex diaphragms should be examined and possibly replaced following use of oil-based lubricants, as such lubricants may weaken the latex. Finally. although precise figures vary, diaphragms should also be examined for refitting if a patient gains or loses weight in excess of 20lbs

16. Which of the following contraceptives has two products commonly named ParaGard and mirena? a. Diaphragm b. Disposable barriers c. The patch d. Intrauterine device

16. d ParaGard (copper-releasing) and Mirena (progestin releasing) are two brands of intrauterine devices. Diaphragms, disposable barriers, and the patch do not have two products with these names.

17. Which of the following is not a typical advantage of contraceptive rings? a. Alleviation of depression symptoms b. Lighter menstrual periods c. Fewer mood swings than oral contraceptives d. Decreased menstrual cramps

17. a Although the NuvaRing may provide fewer mood swings than oral contraceptives, it may worsen, not alleviate, symptoms of depression and should be used with caution in patients with pre- P existing cases of the condition. The NuvaRing may also lead to lighter menstrual periods and decreased menstrual cramps.

18. Undesirable side effects of oral contraceptives such as depression, fatigue, and decreased libido such as depression, fatigue, usually primarily result from: a. Excessive estrogen b. Estrogen deficiency c. Excessive progesterone d. Progesterone deficiency

18. с fatigue, and decreased libido through its are related to estrogen use include nausea are related to estrogen use include nausea, hypertension, @and increased propensity to -develop deep vein thromboses. Some adverse effects, such as breast tenderness, headaches, and hypertension, may be caused by a combination of both hormones.

19. In which of the following patients would the NuvaRing be contraindicated? a. A 32-year-old female who has just undergone a first trimester abortion b. A 33-year-old female who gave birth 8 ago and is not breastfeeding c. A 34-year-old female who uses tampons A 36-year-old female who smokes

19. d NuvaRing is contraindicated in smokers 35 years of age and older, as these patients are at an increased risk for arterial or venous thrombotic diseases that may be exacerbated by the content of the NuvaRing. Females may start the NuvaRing within the first 5 days after a first trimester miscarriage or abortion, or after weeks postpartum if not breastfeeding. Studies show that tampons do not affect the placement or hormonal agents of the NuvaRing.

20. What is the typical initial dosage of ethinyl estradiol for combined oral contraceptives? a. Dose of 35 meg or less 2. Dose of 40 mcg or less c. Dose of 45 mcg or less d. Dose of 50 mcg or less

20. a The typical initial dose of ethinyl estradiol (estrogen) in a combined oral contraceptive is 35 mcg. Products containing less than 50 mcg of estrogen are considered "low-dose" and are considered less likely to cause significant adverse events. Higher doses do not typically invoke a higher efficacy rate in most women, but may cause more adverse effects associated with hormonal contraceptives; as such, initial doses greater than 35 mcg are not typically prescribed

21. Which of these methods of natural family planning uses both the basal body temperature graph and cervical mucus test? a. Lactational amenorrhea method b. Symptothermal method c. Calendar method d. Billings test

21.b The symptothermal method of natural family planning uses both the basal body temperature graph and cervical mucus test as mechanisms. These two mechanisms are not typically used in either the calendar method, which records serial cycles, or the lactational amenorrhea method, in which patients rely on breastfeeding for natural family planning. Lastly, the Billings testis another name for the cervical mucus test.

If the sponges left in place for too long, a patent is typically at serious risk for which of the following conditions? a. Toxic shock syndrome b. Trichomoniasis c. Anemia d. Amenorrhea

22. a A patients at serious risk for toxic shock syndrome if the sponge is left in place for too long. Using the sponge may also increase risk for candidiasis. Intrauterine devices, not the sponge, may increase the risk of anemia due to increased menstrual bleeding, whereas DepoProvera can increase the risk of amenorrhea.

High amounts of estrogen may cause several adverse effects associated with oral contraceptive use. Which of the following adverse effects is not typically caused by h amounts of estrogen? a. Nausea b. Acne c. Edema d. Breast tenderness

23. b The development of or worsening of facial acne is typically a result of excess androgens, not a higher dose of estrogen. Although earlier progestins commonly promoted androgenic activity, some modern progestins have antiadrenergic activity. These progestins are often used alongside estrogen to combat severe acne and other adverse androgenic effects High amounts of estrogen may cause nausea, edema, and breast tenderness.

Which of the following choices is not a standard advantage of using a diaphragm or cervical cap? a. It is relatively safe and easy to use b. It provides immediate protection. c. When used with spermicidal gel, it may protect against sexually transmitted diseases. d. it remains in place during intercourse

24.d Remaining in place during intercourse is not a standard advantage of using either a diaphragm or a cervical cap, as both can be disturbed during the act; rather, it is an advantage of using the sponge contraceptive. The advantages of being relatively safe and easy to use, providing immediate protection, and guarding against sexually transmitted infections (STIS) when used with spermicidal gel are advantages from using the diaphragm. Likewise, the cervical cap is relatively safe, easy to use, and provides immediate protection. Although the cervical cap's activity against STIs is limited, it may provide some protection from gonorrhea and chlamydia.

Which of the following contraceptive methods should not typically be suggested to a woman who weighs more than 90 kg? a. Depo-Provera b. Implanon C. The patch d. Mirena

25.c C The patch is often less effective than other contraceptive methods in women weighing more than 90 kg, which is possibly related to pharmacokinetic differences associated with increased adipose tissue. Obesity is also a predisposing factor for the development of venous thromboembolism and may therefore increase the risk for this adverse effect of hormonal contraception. Intrauterine devices, implanted contraceptives, and injected contraceptives do not routinely demonstrate significantly reduced efficacy in obese women. As such, Depo-Provera, Implanon, and Mirena are contraceptive options better suited for women who are obese

A patient arrives for a regular injection of DepoProvera. However, in consulting Your records, you find that it has been 14 weeks since the patient received her last injection. When You ask when her cycle begins, she says, "I don't know. After administering the injection, You should caution her to use backup contraception for how long. a. During the first 2 days after injection b. During the first 5 days after injection c. During the first week after injection d. During the first 2 weeks after injection

26. d For full efficacy, the Depo-Provera shot must be administered every 12-13 weeks; should the patient miss this window, she is encouraged use backup contraception for 2 weeks after the shot is administered-For patients who receive the Depo-Provera shot within the first 7 days of the menstrual cycle, or within the first 5 days following abortion or miscarriage, the drug should typically provide immediate protection from pregnancy. For all others, backup contraception is recommended for 1 week following administration.

Which of the following contraceptives almost always contains the chemicals nonoxynol-9 and octoxynol? a. The sponge b. condoms c. Diaphragms d. Spermicides

27.d Spermicides may contain the chemicals nonoxynol-9 and octoxynol for the purpose of destroying sperm cells. The sponge typically contains nonoxynol-9, but does not typically contain octoxynol. Some condoms come with spermicides, but most do not, and the diaphragm regularly requires outside administration of spermicides to be fully effective

Ashley, a 22-Year-old female, is discussing various forms of contraception with You. She says she has heard some great things about intrauterine devices (IUDs) but would like to be informed about the disadvantages of such devices. Which of the following disadvantages is most commonly associated with IUDs? a) Increased risk of pelvic inflammatory disease Increased risk b. Annual need for maintenance and reinsertion c. Increased risk of Asherman's syndrome d. High levels of adverse estrogenic effects

28. a Patients who use intrauterine devices (IU Ds) commonly have a risk of pelvic inflammatory disease for some time after insertion because of the effect of the IUD on the microbiologic environment of the vagina. Although some reports linkIUDs with the development of the intrauterine adhesions characteristic of Asherman's syndrome, such device sare more commonly used to prevent the formation of such adhesions. Annual maintenance or reinsertion is not a common concern, as some IUDs can remain in the uterus for up to 10 years without. need for adjustment. Lastly, hormonal IUDS typically release levonorgestrel, a progestinlike compound, instead of estrogen, meaning estrogenic side effects are not a common , concern.

When using intrauterine devices, which of the following mechanisms of action is typically caused bY local foreign body inflammatory responses a. Lysis of the blastocyst b. Thickening of cervical mucus c. Atrophy of the endometrial lining d. Inhibition of sperm binding to egg

29. a Intrauterine devices (IUDS) typically cause lysis of the blastocyst due to local foreign body - inflammatory responses. Progestin-producing IUDs typically induce thickening of cervical - mucus, formation of an atrophic endometrial layer, and inhibition of sperm binding to egg; however, these mechanisms more commonly occur as a result of progestins, not as a direct nflammatory response.

A patient is using the NuvaRing as a contraceptive and asks You how long she is allowed to have the ring in her vagina at one time. As a nurse practitioner, you would know that this contraceptive could typically be left in place for how many days? a. As long as 11 days b. As long as 16 days c. As long as 21 days d. As long as 26 days

3. c The NuvaRing must be taken out after 21 days to allow the menstrual cycle to continue. proper usage of the NuvaRing is to keep it in the vagina for 21 days, then remove it for a 1 week break. The ring is kept in for 21 days so that it may continually release hormonal contraceptives in low doses; to remove it before that time could significantly lower the efficacy of the drugs, and keeping the ring in longer than 21 days could throw off the timeline of administration for the next cycle. If the ring is removed, accidentally or otherwise, within those 21 days, it may be reinserted within 3 hours of removal without losing efficacy, if too much time has elapsed however, the patient should either adopt barrier methods to compensate for reduced efficacy or acquire a new NuvaRing and continue the cycle.

A patient with an intrauterine device learns that she is pregnant. If the device is not removed, which of the complications is most likely to occur? a. Placenta previa b. Ectopic pregnancy c. Spontaneous abortion d. Abruptio placentae

3.c In the event of pregnancy, spontaneous abortion occurs in up to 50% of all users of intrauterine devices (IUDS) if the device is left in the uterus. Ectopic pregnancies, on the other hand, occur in 5% of all pregnancies in IUD users. Pregnant patients with IUDs are at increased risk for abruptio placentae compared to other pregnant patients, but this outcome does not occur in patients, but this outcome does not occur in 50% of all such patients. Placenta previa is not associated with use of an IUD.

A patient taking oral contraceptives may be at increased risk for which of the following t increased risk for which of the following conditions as the patients age, dose, and length of therapy increase? a. Hypertension b. Type 2 diabetes c. Abnormal menstrual bleeding d. Hypercholesterolemia

30. a The risk of hypertension in patients taking oral contraceptives often increases with age, dose, and length of therapy. Concomitant use of oral contraceptives in patients with type 2 diabetes and hypercholesterolemia has not been significantly shown to increase the exacerbation of these conditions. Although abnormal menstrual bleeding is also a potential adverse effect of oral contraceptives, this effect does not increase specifically because of age or course of treatment.

.Jennifer, an 18-year-old female, arrives at your clinic seeking emergency contraception. She claims that she was engaging in intercourse with her boyfriend last night and the condom broke during the act. You believe that levonorgestrel during the act. You believe that levonorgestrel would best address her concerns. Which of the following statements would be most accurate? a. "You will likely need a prescription to get the drug." b. This pill works by terminating an implanted fertilized egg. c. "You may experience menstrual irregularities during Your next cycle." d. "The drug should work up to 4 days after intercourse

31.c Oral levonorgestrel as an emergency contraceptive or "Plan B," may result in changes to the patient's menstrual flow and the development of other irregularities, such as spotting, during the next cycle. Patients of child-bearing age can purchase it over-the-counter. Levonorgestrel does not terminate an implanted fertilized egg; rather, it works bY preventing release of eggs from the ovary, preventing fertilization of the egg by sperm, and by altering the uterine lining to prevent implantation. Levonorgestrel is often effective for up to 72 hours following conception, not 96 hours

Nancy, a 24-year-old female, was engaging in intercourse with her boyfriend 3 days ago when the condom broke. She seeks emergency contraception; however, in the past, she has experienced severe nausea and vomiting after using levonorgestrel products. Which of the following products would be best suited for Nancy at this time? a ParaGard b. Implanon c. Mirena d. The patch

32. a Copper-releasing intrauterine devices (IUDs), such as ParaGard, may be used as an alternative form of emergency contraception within 5 days of intercourse. Mirena, a progestinreleasing IUD, is not useful for emergency contraception and would not be recommended for a patient with levonorgestrel hypersensitivity. Implanon, an etonogestrel-containing implant, and the patch that releases ethinyl estradiol and norelgestromin, are similarly ineffective as emergency contraceptives.

How should a spermicide be applied in conjunction with use of a diaphragm for maximum efficacy? a.The spermicide should be applied to the vagina immediately following intercourse while leaving the diaphragm in place. b. The spermicide should be placed around the outside of the diaphragm, which is then removed immediately after intercourse. c. The spermicide should be placed inside the diaphragm, which is then removed at least 6 hours after intercourse d. The diaphragm should be removed immediately following intercourse so that immediately following intercourse so that spermicide cam be applied.

33.c Spermicide should be placed inside, rather than outside, of the diaphragm before it is inserted inserted into the vagina preceding intercourse; once intercourse is complete, the diaphragm should remain inside the vagina for at least 6 hours. Spermicide can be applied inside the vagina without removing the diaphragm, but this is only recommended for repeated intercourse, not first encounters.

A patient who has recently started on the patch mentions that she is also pursuing an herbal regimen for various health issues. Which of the following herbs would be most likely to affect her following herbs would be most likely to affect her treatment with the patch? a. St. John's Wort b. Ginger c. Echinacea d. Ginseng

34. a St. John's Wort may diminish the therapeutic effect of estrogens while decreasing the serum concentration of CYP3A4 substrates, thus creating the risk of contraceptive failure in treatment with the patch. Ginseng. ginger, and echinacea do not typically have any significant interaction with the patch.

As a practitioner, you know that the approximate theoretical and actual failure rates for oral contraceptives are: a. Perfect use: 0.1%, typical use: 10%-15% b. perfect use: 5%, typical use: 10% c. Perfect use: 1%-3%, typical use: 1.5%-3% d. Perfect use: 0.1%, typical use: 3%-5%

36.d Oral contraceptives (OCs) are one of the most reliable forms of birth control, with a theoretical failure rate of approximately 0.1%; however, due to the need to take OCs at the same time every day and the associated risk of nonadherence, - the actual failure rate ranges from approximately 3% to 5%.

Implanon usually offers continuous birth control for how long? a. Three Years b. Four years C. Five Years d. Six Years

37. a BY suppressing ovulation, altering the viscosity of cervical mucus, and preventing embryo implantation in the endometrium through controlled release of etonogestrel, Implanon usually offers up to 3 years of continuous birth control. After the 3 Years have elapsed, the device loses its effectiveness and may not successfully prevent pregnancy.

A patient arrives at Your clinic to discuss longterm options for contraception. In evaluating her circumstances, you decide that implanon might work best for her. You might tell her all of the [ following regarding the implant except: a. "Odds are you will be able to maintain a "Odds are You will b. "I would hold off on agreeing to Implanon before | tell You everything about it." c. "This drug will be more expensive than the pill at least, at first. d. "The implant may be visible, so take that into consideration.

38. a As the Implanon implant may lead to irregular or absent periods, a regular menstrual cycle cannot be guaranteed for somebody taking the drug. Informed consent from the patient is required before Implanon can be implanted; as such, the nurse practitioner should inform the patient about all aspects of the implant, which include potentially higher initial expenses than other contraceptive methods and the possibility that the implant will be slightly visible under the skin for a short period following implantation.

A 19-year-old patient is using a cervical cap as a contraceptive. She asks you how long must the cervical cap be left in the vagina following intercourse. You should tell her which of the following? a. Two hours at most b. Three hours at most c. At least 4 hours d. At least 6 hours

39. d The general recommendation is that a cervical cap be left in the vagina for at least 6 hours post intercourse. Studies have not shown the cervical cap to be as effective if removed before this recommended time.

An 18-year-old patient comes to your office to inquire about spermicides, and asks about the failure rate of spermicides when used alone. As a nurse practitioner, You tell her the typical first-year failure rate is: a. Approximately 11% b. Approximately 16% c. Approximately 21% d. Approximately 32%

4.c The typical first-Year failure rate of spermicides is approximately 21%. When combined with other barrier contraceptives such as condoms or diaphragms, the failure rate is reduced to approximately 5%. Male condoms have an estimated failure rate of 11%. The cervical has an estimated 16% failure rate in patients who have not given birth, and an estimated 32% failure rate in patients who have

Sharon, a 24-year-old female, calls the clinic inquiring about her NuvaRing. She says that her ring, which had been in place for 2 weeks, fell out about 4 hours prior. She is worried that this will throw off her contraceptive schedule. What instructions would be most effective in helping instructions would be most effective in helping a. Rinse the ring with cool water, reinsert, and use a spermicide or barrier for 1 week b. Reinsert the ring immediately. c. Discard the ring and insert a new ring immediately. d. Wait until the current 21 day period is over and start a new ring.

40. a If the NuvaRing is displaced for more than 3 hours within the first 2 weeks of using it, the best course of action would be to rinse the ring with cool water, reinsert it as soon as possible, and use a spermicide or barrier form of contraceptive in conjunction with the ring for the next 7 days. If the ring is displaced for less than 3 hours, the ring should be re-inserted as soon as possible, as contraceptive effectiveness would not necessarily be decreased: however, the ring should still be rinsed with cool water before re-insertion to minimize the risk of infection. If the ring is displaced for more than 3 hours during the third week of use, the ring should be discarded and a new ring should be inserted immediately. Waiting until the 3 week period is over is not necessary under the circumstances presented.

Which of the following is the least likely undesirable effect to expect in a female patient using spermicides a. Incomplete dissolution of suppositories b. Increased risk for candidiasis c. Vaginal skin irritation d. Unpleasant taste

5. b developing candidiasis, this risk is not significant compared to the risk of other undesirable effects. Instead, spermicides significantly increase a female patient's risk for urinary tract infections. Vaginal or penile skin irritation, incomplete dissolution of suppositories, and unpleasant taste are other common undesirable effects of spermicides.

Which of these patients would most likely need to have her diaphragm refitted, given that all of these patients already have a diaphragm and want to continue to use one? a. A patient who experiences an allergic reaction b. A patient who has gained approximately 25 lb c. A patient who has lost approximately 8 lb d. A patient who has contracted herpes

6.b Although guidelines may vary it is often considered often considered necessary to refit a diaphragm if the patient using it gains or loses weight in excess of 20 lb. Whether or not a patient contracts a sexually transmitted infection would not directly affect whether the patient needs to have her diaphragm refitted. Although an allergic reaction may result from exposure to latex or spermicides, such reactions may require a change of formation or removal of the diaphragm, not a refitting.

Which of the following types of contraceptives may be used to prevent the recurrence of Asherman's syndrome? a. Injected contraception b. Cervical caps c. Disposable barriers d. Intrauterine devices

8.d An intrauterine device can be used to prevent the recurrence of Asherman's syndrome because of the ability to be placed in the uterine cavity to create a barrier between the walls of the uterus. Implantation after the initi &l removal of scar tissue in the uterus may help with healing and facilitate separation of the tissues. Injected contraceptive methods are not a form of physical barriers and would not help prevent Asherman's syndrome. Cervical caps and disposable barriers are placed over the cervix to prevent sperm from entering the uterus, but there is no evidence of their effectiveness in preventing recurrences of Asherman's syndrorne.

A patient starting the contraceptive patch places her first patch on the first Sunday of the month. Assuming she maintains the recommended schedule, she would replace this patch with a new one on each of the following Sundays except: a. Second Sunday b. Third Sunday c. Fourth Sunday d. Fifth Sunday

9.с Proper use of the patch requires changing the patch out once each week on the same day of the week it was first applied; on the fourth **change day, however, the patch is removed and not replaced until 1 week later. The patch would be replaced on the second and third change day. and the fifth change day would mark a new administration of the patch and the start of a new cycle.

Diaphragm/Cervical Cap

A diaphragm or cervical cap is a flexible, domeshaped cup constructed of latex rubber. Its purpose is to prevent pregnancy bY blocking the transport of sperm through the cervical os. The mechanism of action works to make a barrier against sperm transport. n used with spermicidal cream or gel, the cell membrane of the sperm is often destroyed as well, 19

•Condoms Contraindications

Allergies to rubber or spermicide are the major contraindications to condom use 21

The Sponge Disadvantages

Common disadvantages of this contraceptive method include increased risk for candidiasis and slight risk for toxic shock syndrome from leaving the sponge in place too long. The sponge also does not protect against most STDS,22,23

• Condoms Advantages

Condoms are safe and easily available as an over-the-counter birth control option. Condoms provide immediate protection against pregnancy and help to protect against the transmission of most STDS.21

•Condoms

Condoms have sheath-like coverings that are inserted over the penis or into the vagina to act as an obstructive barrier for sperm. Most condoms are made of latex and are available with or without a spermicide. The failure rate is 12% for male condoms and 21% for female

•Condoms Disadvantages

Condoms may interfere with sensation, and it's possible for some condoms to break upon use. Foreplay and sexual activity are often interrupted when putting on the condom Natural skin condoms provide minimal protection against STDS.

Oral Contraceptives Contraindications

Contraindications for OCs include a history -of thromboembolic disorders, CVA, and coronary „artery disease. OCs should not be prescribed to patients with known or suspected breast cancer, or other cancers. Other contraindications include known or 'suspected estrogen-dependent neoplasia, pregnancy, benign or malignant liver tumor or impaired liver function, previous cholelithiasis during pregnancy. and undiagnosed abnormal uterine bleeding

Diaphragm/Cervical Cap Advantages

Diaphragms and cervical caps are barrier methods of contraception that provide immedia te protection against pregnancy and minimal protection against STDs when used with spermicidal gels, 19 Both are safe and easy to use, and neither option interrupts sexual activity because both forms of birth control are inserted into the vagina prior to sexual intercourse

Diaphragm/Cervical Cap Disadvantages/Side Effects

Diaphragms and cervical caps can cause skin irritations in patients who have an allergic reaction to latex or spermicides, and overall increase the risk of urinary tract infections and vulvovaginitis. 19

The mechanism of action in OCs

Estrogen causes progesterone levels to drop and inhibits ovulation via suppression of folliclestimulating hormone (FSH), luteinizing hormone (LH), or both. Estrogen also inhibits implantation via alteration of the endometrium, acceleration of ovum transport, and promotion of luteolysis. progestin promotes the secretion of thick cervical mucus to interfere with sperm transport, and inhibits the process of capacitation. Other progestational effects include the suppression of the endometrium, and hypothalamic-pituitary-ovarian idisturbances that inhibit ovulation

Oral Contraceptives Management Guidelines

General considerations call for OC regimens to begin with low-dose combined or multiphasic pills (35 mcg or less). Progestin-only pills should be considered for women with a history of migraine headaches, who are breast-feeding, or who have some contraindication to combination pills." Additionally, the risk of hypertension increases with age, dose, and length of therapy. interactions with certain antibiotics and anticonvulsants can reduce the effectiveness of OCS. Alternatively, OCs can reduce the effectiveness of warfarin, insulin, and certain oral hypoglycemics. Patients should be educated about the use of OCs and their adverse effects. Breakthrough . bleeding and spotting are common with abnormal menstrual bleeding and would require a higher dose, if necessary? Some OCs are used to manage if necessary.' Some OCs are used to manage progesterone. Immediately discontinue OCs if the patient is pregnant to avoid birth defects caused by excessive estrogen levels.

Diaphragm/Cervical Cap Management Guidelines

General considerations for the use of a diaphragm or cervical cap include periodically urapillaymor cervical cap include periodically loses more than 20 lb. while using the diaphragm, the diaphragm should be refitted. The use of oil-based lubricants should be avoided because these may destroy the latex of the diaphragm or cervical cap. 2 cervical cap must remain in the vagina for it least 6 hours following intercourse. If the patient attempts repeated intercourse, she must again instill spermicide into the vagina without removing the diaphragms

Implant Contraception

Implant contraception (e.g., Nexplanon) is a thin, flexible rod that contains etonogestrel. The rod is implanted in the upper arm and diffuses progestin to prevent pregnancy. The typical failure rate of Nexplanon is 0.01%, and the mechanism of action is -the same as other progestins.®

Implant Contraception Management Guidelines

Implant contraception requires informed consent, with the patient receiving a full briefing on the benefits, risks, effectiveness, and processes associated with the implant.

Sterilization Disadvantages

Indecision regarding future childbearing should be carefully considered because sterilization is meant to be permanent. Procedures to reverse surgical sterilization are both are costly and complicated 13 Sterilization does not provide protection from STDs. Safe sexual practices with a condom should be used to prevent unwanted infections.

Injection Contraception Disadvantages

Injection contraception can cause menstrual irregularities, usually amenorrhea, and can delay fertility for up to 1 Year. The injection must be performed every 3 months , which can make this ethod of birth control inconvenient for some patients."

Injection Contraception Advantages

Injection contraception is highly effective,dongacting, and convenient. Prolonged amenorrhea is seen in some patients, as well as concomitant effects such as a general decrease in anemia, cramps, and ovulatory pain. This form of contraception is often useful in reducing pain associated with endometriosis and generally does not cause estrogen-related side effects. Injected contraceptives are known to reduce the risk of PID and other endometrial and ovarian cancers

Condoms Management Guidelines

Latex condoms provide a greater degree of protection against STDs than natural or lamb skin ondoms. Patient education is also very important. Patients who use condoms should be informed of the following: to avoid the use of oil-based lubricants, that sensation is increased with lubricant use, that condom breakage risk is reduced by leaving 1/2 inch spermicide use often increases effectiveness

» Emergency Contraception

Mechanisms of emergency contraception commonly work to prevent either fertilization or e implantation of a fertilized egg in the uterus. Preparations do not cause abortion. Two common types of emergency contraception are levonorgestrel (Plan B One Step, Ella), which is also known as "the morning after pill," and the copper-releasing IUD. ~ Emergency contraception pills are commonly sold over-the-counter to women 17 years of age and over. Females younger than 17 years of age need a prescription. Plan B should be taken within 72 hours of unprotected intercourse for greatest efficacy. One should stress that Plan B is not the "abortion pill" (i.e., mifepristone). The typical effectiveness of Plan B is 85% The copper-releasing IUD is an alternative m of emergency contraception that must be nserted within 5-6 days of intercourse 24 The typical effectiveness of the copper-releasing IUD is 99%.

Intrauterine Device Advantages

Mirena has been shown to decrease menstrual loss and dysmenorrhea. This type of IUD can also potentially prevent the severity of Asherman's syndrome, which is the formation of scar tissue in the uterine cavity

« Natural Family Planning

Natural family planning involves planned abstinence from sexual intercourse while the female abstinence from sexual intercourse while the female is most fertile. When used The mechanisms that comprise natural family planning include the calendar method, which consists of recording serial cycles and identifying the longest and shortest cycles. Abstinence occurs during the fertile phase of a woman's menstrual cycle, which is determined by subtracting 18 days from the shortest cycle, which is the earliest day of fertility, and 11 days from the longest cycle, which is the latest day of fertility The basal body temperature (BBT) graph is another method of natural family planning contraception. This method involves a daily record of BBT prior to rising in the morning over a 3-to 4-month period. The temperature commonly drops 12-24 hours prior to ovulation, and increases after ovulation due to production of progesterone. It is strongly recommended that patients avoid intercourse from between 2 and 3 days prior to the expected drop and approximately three days following the rise. The cervical mucus test (Billings ovulation method) involves documenting changes in cervical mucus (i.e.,spinnbarkeit) over a 3- to 4-month period. The patient must also notice when mucus changes from sparse and thick amounts to thin with increasing spinnbarkeit. The patient must abstain n intercourse from the time of mucus change unt il approximately four days thereafter, when mucus will resume its standard thickness. The symptothermal method is a method that uses both the basal body temperature and cervical mucus techniques. The lactational amenorrhea method (i.e., prolonged breast-feeding) is when the patient plans via breastfeeding for natural family planning because breastfeeding often delays ovulation and menstruation for approximately six months.20

Oral Contraceptives Disadvantages

One of the disadvantages of using OCs is that they offer no protection against HIV or other STDs. Pills must be taken every day to ensure full efficacy, and the cost The use of OCs increases the risk of developing The use of OCs increases the risk of developi "breast cancer, as well as rare and potentially dangerous circulatory complications. Possible side "effects include mood changes, nausea, headaches, and breakthrough bleeding .

•The Sponge Advantages

One of the main advantages of the sponge is not feeling its presence during intercourse. it can be inserted up to 6 hours before intercourse, which avoids interrupting foreplay or sexual activity and provides some protection against gonorrhea and chlamydia

Oral Contraceptives

Oral contraceptives (OCs) (i-e., "the pill") a are daily tablets that interfere with fertilization and implantation.

Intrauterine Device Side Effects

Possible side effects of IUDs include spotting, bleeding, hemorrhage, anemia, cramping, and pain. These side effects may also include expulsion of the IUD, with an expulsion rate of up to 10% in the first year. A lost IUD string complicates removal of the device, and pregnancy can still occur while using the IUD. IUDs increase the risk of developing PID, which is often highest in the first 6 weeks after insertion.13

» Emergency Contraception Side Effects

Possible side effects of using Plan B and intrauterine devices include nausea and vomiting, fatigue, headaches, dizziness, diarrhea, breast tenderness, and fluid retention. The timing or flow of the patient's menstrual period could also change, and duration of the menstrual cycle could also increase

Injection Contraception Side Effects

Potential side effects of Depo-Provera include variable and individualized menstrual irregularities, adverse effects associated with progestin, decreases in high-density lipoprotein cholesterol, and possible diminishment of bone density after long-term use.

Intrauterine Device Disadvantages

Side effects of IUDs include pain and cramping up to 40% of all removals of the device are related to pain. An increase in menstrual bleeding that leads to anemia may occur with the use of an IUD. With pregnancy. spontaneous abortions occur in up to 50% of all cases if the IUD is left in the uterus, and ectopic pregnancies occur in up to 5% of all users, 17

Contraceptive Ring Disadvantages

Side effects of the contraceptive ring are similar to those associated with some OCs (e.g., breast tenderness, headaches, weight gain, nausea, mood changes, breakthrough bleeding), but these side effects occur at a lower incidence. The contraceptive ring is known to increase the risk of vaginal discharge, irritation, or infection in some patients. Some methods of contraception, such as diaphragms, cervical caps, and shields, cannot be used simultaneously with the ring. Use of the contraceptive ring is also known to worsen depression in some patients with a history of the disorder. Lastly, the contraceptive ring offers no protection against HIV/AIDS, STDs, or other sexually transmitted infections (STIS).

Implant Contraception Disadvantages

Some of the side effects associated with implant contraception include irregular menstrual periods, prolonged menses, spotting between periods, and absent periods. Cosmetically, the implant may be slightly visible when initially administered. Implant contraception is more expensive than other methods of contraception

•Spermicides Advantages

Spermicides are available for over-the-counter purchase and help to provide immediate protection against pregnancy and transmission of STDs. Spermicides are relatively safe, and can be used with barrier methods of birth control to improve effectiveness

» Spermicides

Spermicides are preparations that primarily use nonoxynol-9 as the main ingredient to destroy sperm cells 20 Spermicides have a typical first-year failure c

Sterilization

Surgical procedures of sterilization are an effective method of birth control and are intended to be permanent. In females, tubal ligation (i.e., "having one's tubes tied") involves closure of the fallopian tubes to prevent fertilization. In males, vasoligation (i.e., vasectomy) is the process in which the vas (i.e., vasectomy) is the process in which the vas oocytes and sperm in semen.

* Spermicides Disadvantages

Temporary vaginal or penile skin irritation is a common side effect. spermicides that are available in suppository form may not dissolve completely. Lastly, spermicides have an unpleasant taste.

Intrauterine Device Contraindications

The IUD comes with both absolute and strong relative contraindications. Absolute contraindications include active, recent, or recurrent pelvic infection (e.g., gonorrhea, absolute contraindication for the IUD. Strong relative contraindications for IUDs include undiagnosed, ""; irregular, or abnormal uterine bleeding, as well as * risk for PiD."

Implant Contraception Advantages

The advantages of using implant contraception include continuous protection for 3 Years with no estrogen-related side effects. Implant contraceptives produce fewer serious system complications than most other birth control methods. Additionally, scanty or absent menses may occur with decreased anemia." Use of a contraceptive implant could provide some beneficial effects, such as a general reduction in menstrual cramps, ovulatory pain, and risk of endometrial cancer

Contraceptive Ring

The contraceptive ring is a flexible, prescriptive contraceptive that is approximately 2 inches in diameter. The most popular known brand is the nuvaring The four mechanisms of action for the contraceptive ring are: the ring releases synthetic from pregnancy for up to 1 month. Second from pregnancy for up to 1 month. Second, vaginal contact activates the release of hormones ain a sudden burst, with concentration gradually decreasing over the course of use. Third, the ring suppresses ovulation and thickens the cervical mucus to help with preventing fertilization - Lastly, the ring may alter the endometrium to affect implantation

Contraceptive Ring Advantages

The contraceptive ring is convenient to use and provides advantages over other forms to prevent pregnancy: The contraceptive ring is reversible and discreet, and generally cannot be felt by the user or the partner. Use of the contraceptive ring &has a once per month insertion, which allows for uninterrupted sexual activity. associated with causing fewer mood swings than those associated with OC Therapeutic benefits of the contraceptive ring aside from birth control include the possibility of shorter, lighter,and more regular menstrual periods. In some patients, the contraceptive ring has also been associated with decreased menstrual cramps, and an improvement in facial acne, among other benefits.'

Contraceptive Ring Management Guidelines

The contraceptive ring is vaginally inserted once a month; the ring is then left in place for 21 days— no more, No less. The patient should remove the ring after.3 weeks to allow menstruation to occur. As new ring is then inserted for continuous pregnancy protection, but must be inserted on the same day of the week as it was inserted in the last cycle or else pregnancy may occur. If the ring falls out, it must be reinserted within 3 hours; a backup method of contraception must be used if the ring was left out for more than 3 hours. Unopened packages of the ring must be protected from direct sunlight or very high temperatures."

* The Sponge

The contraceptive sponge is a disposable, round barrier of soft polyurethane that fits over the cervix, similar to a diaphragm, and contains spermicides. A common brand name for the sponge is Today. The typical failure rate of the sponge is 10%, but effectiveness is raised if used in conjunction with a condom

Diaphragm/Cervical Cap Contraindications

The diaphragm or cervical cap should not be used if the patient exhibits an allergy to rubber, latex, or spermicide, or is unable to insert the device.19

Intrauterine Device

The intrauterine device (IUD) is an artificial T-shaped device with either a metal wrapping or chemically-impregnated surface that is inserted into the uterus to prevent pregnancy.17 There are two common types of IUDs: the copper-releasing device, known as ParaGard, and e progestin-releasing device, known as Mirena. ParaGard is a plastic device wrapped with fine copper wire that can remain in the uterus for up to *10 years. Mirena (also known as a levonorgestrelreleasing intrauterine system) is a plastic device that can remainin the uterus for up to 5 years.17 The mechanism of action for IUDs involves the immobilization of sperm; IUDS interference with sperm migration from the vagina to the fallopian. tubes. IUDs also accelerate the transport of the ovum through the fallopian tube and inhibits fertilization. Lastly, IUDs often cause lysis of the blastocyst and/or prevent implantation due to local foreign body inflammatory responses, 18

Sterilization Advantages

The main advantage of using the sterilization method is that it is a permanent form of contraception for both males and females with a low failure rates

Intrauterine Device Management Guidelines

The management guidelines for IUDs should 2 include patient education. Patients should be ¹informed on how the IUD works, with instructions that focus on how to check the string, monitor bleeding. and control pain. ~ that the risk of expulsions greater 'during menses. For women who have recently given birth, the device may be inserted 4-8 weeks 'postpartum. Patients should also be taught to recognize danger signs associated with IUDS, such as late menses, abdominal pain or dyspareunia, fever and chills

¢ The Sponge Management Guidelines

The management guidelines when using the sponge includes instructing the patient on how to insert the sponge into the vagina while using a cord loop attachment. Patients should understand that the sponge is inserted up to 6 hours before intercourse, and that the sponge should be left in place for at least 6 hours after intercourse. The sponge provides protection for up to 12 hours. Lastly, patients should know not to leave the sponge in the vagina for more than 30 hours, 22

•Spermicides Contraindications

The only contraindication for the use of spermicides is an allergy,

the Patch Advantages

The patch also does not interfere with sexual activity. The patch is applied only once per week and can be worn for 3 weeks. It is also easily any can be reversible.

The Patch Disadvantages

The patch may cause mild to moderate site reactions and offers no protection from HIV/AIDS and other STDS or STIs. Effectiveness is reduced in women who weigh more than 90 kg, and is not as effective with concurrent use of certain antibiotics, antifungals, and other medications. The patch also increases the risk for serious cardioembolic events (e.g., myocardial infarction, CVA, pulmonary embolus) The risk for estrogenic side effects is also increased because 60% more estrogen is released in the patch than in OCs.

The Patch Contraindications

The patch should be discontinued or not used in patients who are taking certain antibiotics, antifungals. or other medications. Also, women older than 35 years of age should not use the patch. Other contraindications include smoking, high blood pressure, and a history of blood clots or any. cardioembolic disorder, among others.¹³

•The Sponge Contraindications

The sponge is contraindicated in patients who are allergic to spermicides 2

•Natural Family Planning Disadvantages

There are a few disadvantages to using the natural family planning method for contraception. Unintended pregnancy is a possibility. and this contraceptive method offers no protection against contraceptive method offers no protection against be limited to 25% of the month if this method is rigidly followed, 20

Injection Contraception Contraindications

There are two common types of contraindications for the use of Depo-Provera: relative contraindications and absolute contraindications. Relative contraindications involve planning pregnancy within a Year of receiving the injectors 1 inability to cope with menstrual irregularities. Absolute contraindications include pre-existing *allergies to Depo-Provera, unexplained abnormal uterine bleeding, and pregnancy.

The Patch Management Guidelines

This contraceptive method may be applied to the arm, buttocks, torso (but not breast), or abdomen on either the first day of the patient's menstrual cycle (i.e.. day 1) or on the first Sunday following the first day, whichever is preferred. The date of application is known from that point on as patch change day. The patch is removed 7 days later, and another patch is applied to an approved body location . The process is repeated again on the next patch change day. The patch is removed without being replaced on the. following patch change day- After waiting for 7 days, a new patch is applied on the next patch change day. If the patch stays off for more than 24 hours, restarting a new 4-wee cycle often necessary ih addition to using a backup method of contraception

The Patch

Transdermal contraceptive patches releases synthetic estrogen and progestin. The mechanism of action for the patch is to prevent ovulation and works similarly to combination OCS.¹2 The patch has a ical failure rate of less than 1%-2%.

* Natural Family Planning Management Guidelines

When using the natural family planning method, the patient must be properly educated in the mechanisms of action and logistics for this contraceptive method to work

Injection Contraception Management Guidelines

Women should be screened regularly to identify risk factors that would contraindicate use of injection contraception. For instance, a pregnancy test should be performed if menstruation has not occurred more than 2 weeks after the 3-month contraceptive period of effect has ended. The patient receiving the injection should be warned to avoid massaging the site of injection. The injection must be repeated every 3 months. There is a 2-week grace period; any longer, and the patient would have to take a pregnancy test before further administration « For sexually active patients, a backup method of contraception should be implemented during the first 2 weeks after the injection unless the contraceptive was administered by DOC 5.

Oral Contraceptives Side Effects

Women with an estrogen deficiency could present with complaints of no withdrawal bleeding. decreased duration in menstrual bleeding, <Lontinuous spotting a nd/or bleeding, breakthrough » bleeding on day of cycle (DOC) anywhere between days 1 and 9, and atrophic vaginitis. Excessive progesterone could lead to breast tenderness, transient hypertension. depression, fatigue, decreased tibido, decreased duration 1 1 menstrual bleeding, and increased appetite. n menstrual bleeding, and increased appetite -breakthrough bleeding on DOC 10-21 and delayed menses. Signs and symptoms of excessive androgenic side effects include hirsutism, acne, oily skin, edema, and an increased libido. Signs and symptoms of excessive androgenic side effects include hirsutism, acne, oily skin, edema, and an increased libido. Women with a combination of excess estrogen and deficient progesterone could present with dysmenorrhea or menorrhagia, nausea, vomiting headache, irritability, bloating with or without edema, and syncope.Long-term complications associated with OCS include chloasma, cerebrovascular accident (CVA), deep venous thrombosis, thromboembolic disease, pulmonary emboli, telangiectasias, hepatic adenoma, adenocarcinoma, and cervical changes.

Which of these statements is true regarding the use of condoms? a. There is a higher reported failure rate of female condoms than male condoms. b. Natural skin condoms give the most protection against sexually transmitted diseases. c. The failure rate of condoms is the lowest of all barrier contraceptives. d. Leaving empty space at the end of the condom increases the risk of breakage.

a The failure rate of the female condom is substantially higher than the failure rate of male condoms. Latex condoms provide the greatest degree of protection from sexually transmitted diseases (STDs), whereas natural skin condoms do not protect against STDS. Condoms do not have the lowest failure rates of the barrier contraceptives, which include spermicides and the sponge. The sponge has the lowest possible failure rate of these, whereas spermicides used alone have a higher failure rate than male condoms. Leaving a ½-inch of space at the end of the condom decreases the risk of breakage.

Patients are at increased risk for what fungal infection when using the sponge? a. Toxic shock syndrome b. candidiasis c. Skin irritation d. Urinary tract infections

b The risk of candidiasis is increased when the sponge is used as a contraceptive. Toxic shock syndrome may ensue from leaving the sponge in for too long, but this condition is bacterial, not fungal in nature. Although the sponge may produce vaginal irritations and urinary tract infections, these reactions are not typically fungal in nature.

Combination pills (e.g., Ortho-Cyclen, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo)

contain a synthetic estrogen and a progestin. Combination pills suppress ovulation and alter the cervical mucus and uterine lining to prevent "fertilization. Ethinylestradiol is the most common synthetic estrogen in combination pills, followed by mestranol The combination pill and the minipill mainly use norgestimate for progestin

Injection Contraception Depo-Provera

is a longacting progestin administered intramuscularly. The mechanism of action involves a suppression of FSH and LH surge and inhibiting ovulation and altering the endometrium by creating a thin, atrophic lining, 14 progestin thickens cervical mucus, which interferes with sperm transport and penetration.

progestin-only: formulation (¡-e., minipills &gt;

that contains a lower dose of progestin than the dose in a combination pill. The minipillis not as effective as the combination pill because it does not always suppress ovulation; them minipill prevents fertilization by altering the cervical mucus and cervicallining.

Contraceptive Ring Contraindications

uncontrolled hypertension and smoking are two main contraindications for using the contraceptive ring; smoking more than 15 cigarettes a day is a contraindication even in patients with controlled hypertension. A history of blood clots or any cardioembolic disorder (e.g., myocardial infarction, CVA) should be considered as strong contraindications, and the risk of side effects increases in women older than 35 years of age.