Contraception

Question 1

Examples of combined hormonal contraceptives

Answer 1

• Combined oral contraceptive
• Patch (ortho evra, xulane)
• Vaginal ring (nuvaring)

Question 2

How do combined hormonal contraceptives achieve contraceptive effect?

Answer 2

Via progestin and estrogen

• Progestin inhibits ovulation by suppressing LH → thickens endocervical mucus and thins endometrium
• Estrogen inhibits FSH and LH → alters endometrial cellular structure

Question 3

Noncontraceptive benefits of combined hormonal contraceptive use

Answer 3

• Lower rates of benign breast tumors
• Dysmenorrhea
• Decreased rates of endometrial, ovarian, colon cancers
• Acne, hirsutism, ovarian cysts

Question 4

Absolute contraindications for combined hormonal contraceptive use

Answer 4

• Current breast cancer
• Postpartum <21 days
• Acute hepatitis, hepatic adenoma
• Migraine with aura
• Major surgery with prolonged immobilization
• Age >35 years and smoking >15 cigarettes/day
• Hypertension (>160/100)
• History of DVT/PT
• Known thrombotic mutations
• History of ischemic heart disease or stroke
• Moderate or severely impaired cardiac function

Question 5

Combined hormonal contraceptive adverse effects

Answer 5

• Reports of breakthrough bleeding in first 3 months
  
  • Usually due to inconsistency of use (should be taken within the same 4 hour period every day)
• Nausea
  
  • If vomiting occurs within 2 hours of taking pill, retake the dose
• Interaction with antiepileptics
  
  • Phenytoin, carbamazepine, topiramate, primidone
• Decreased absorption for patients with history of bariatric surgery

Question 6

What should be done if a woman misses her COC pill within 12 hours of the time it should have been taken?

Answer 6

Take today’s pill immediately

• No additional or emergency contraception needed
• Continue with the rest of the pack

Question 7

What should be done if the woman misses one COC pill for more than 12 hours but only one pill is missed?

Answer 7

Take today’s pill immediately

• No additional or emergency contraceptive needed
• Continue with the rest of the pack

Question 8

What should be done if more than one COC pill is missed in a day?

Answer 8

Take today’s pill and the last forgotten pill now (two in one day)

• Use emergency contraception if she had unprotected sex in the last 7 days
• Use condoms or abstain from sex for 7 days

Question 9

What population of patients would benefit from progestin-only pills versus combined oral contraceptives?

Answer 9

• Risk factors for atherosclerotic CVD
• Vascular disease
• Prolonged history of DM (>20 years)
• History of migraine with aura

Question 10

True/false: Progestin only pills and DMPA (depo provera) do not alter the quality or quantity of breast milk

Answer 10

True - can be helpful option for nursing mothers

Question 11

DMPA (depo provera) is best suited for what type of patients?

Answer 11

Those who do not wish a pregnancy for at least 18 months

• Resumption of fertility frequently delayed by 6-12 months after d/c

Question 12

DMPA (depo provera) patient education

Answer 12

• May experience amenorrhea
• Weight gain (about 11 pounds after 3 years of use
• Loss of bone density (should not receive therapy any longer than 2 years)
  
  • Calcium supplementation
  • Weight bearing exercises
  • Vitamin D supplementation

Question 13

Examples of long acting reversible contraception (LARC)

Answer 13

• IUDs
  
  • Cu-IUD (paragard)
  • Levonorgestrel releasing IUD → mirena, skyla, liletta
    
    • Helpful for women with menorrhagia
• Progestin implants (Nexplanon)

Question 14

Absolute contraindications of use for LNG-IUDs and cu-IUD (paragard)

Answer 14

• Pregnancy
• Current PID
• Current purulent cervicitis or chlamydia infection or gonorrhea
• Unexplained vaginal bleeding
• Cervical cancer
• Distorted uterine cavity

Question 15

Examples of non hormonal contraceptive methods

Answer 15

• Diaphragm
• Spermicides
• Cervical cap
• Contraceptive sponge
• Condoms

Question 16

True/false: Diaphragm use during intercourse should always be coupled with spermicides

Answer 16

True - should be removed no sooner than 6 hours after intercourse

• Should not be recommended to women with history of recurrent UTI
  
  • Spermicides increase risk of UTI

Question 17

True/false: Cervical caps need to be prescribed by a trained health care provider

Answer 17

True - should remain in place for at least 6 hours with spermicide but no longer than 48 hours

• Not to be used during menstruation

Question 18

How would a patient insert a contraceptive sponge?

Answer 18

Foam-like insert embedded with spermicide should be inserted up to 24 hours prior to intercourse

• Remains in place for at least 6 hours but no longer than 30 hours after intercourse
• Should not be used during menstruation

Question 19

True/false: With all emergency contraceptive methods, menstrual bleeding should be expected within 3-4 weeks of using EC

Answer 19

True - If none occurs, a pregnancy test should be done

Question 20

Examples of progestin-only emergency contraception

Answer 20

Plan B, Plan B one step, next choice, next choice one dose

• Taken within 72 hours of unprotected sex but can be effective up to 120 hours postintercourse

Question 21

What is ulipristal acetate (ella)?

Answer 21

Progesterone agonist/antagonist emergency contraceptive

• Unlike LNG EC, remains effective when administered immediately before ovulation around time of LH surge
• Can be used up to 5 days (120 hours) since unprotected sex
• Repeat dose if vomiting occurs within 3 hours
• Only available through prescription

Question 22

Can the copper IUD (paragard) be used as emergency contraception?

Answer 22

Yes - can be inserted within 5 days after unprotected sex

• Cannot be inserted in women with STI or history of cervicitis