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Contraception Flashcards

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1
Q

What should be asked on sexual history? (Acronym)

A

Sexual History – SEX ASAP

  • Sexual active? Male, female or both?
  • EXes – how many partners in the last 3 months
  • Activities – types of sexual encounters – anal, S&M
  • STIs
    • Any symptoms that make you worried about having an STI now
    • Have you had any previous STIs?
    • What are you doing to avoid STIs?
  • Abuse
    • Sexual Abuse
    • Drug use? IVDU?
  • Pregnancies
    • What are you doing to avoid pregnancy? Barrier methods?
    • Have you had any pregnancies before?
    • When was your LMP
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2
Q

What is important to know on history before starting a patient on OCP? (AFP)

A
  • Menstruation
  • Pregnancy, breastfeeding, recent intercourse
  • Chronic disease (e.g. hypertension), drug allergies
  • Risk factors for VTE
  • Future pregnancy intention
  • Contraceptive experiences and preferences
  • Sexual health
    • Sexual practices, current and recent partners, condom use
    • Previous STIs
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3
Q

For patients being prescribed a contraceptive for the first time, what are 5 measures that should be done on physical examination?

A
  • Blood Pressure – follow-up visit in 6 weeks to re-check
  • Breast exam
  • Pelvic exam (if sexually active, otherwise do later)
    • Fibroids can grow
  • GC/C swabs if sexually active
  • Pap is needed if sexually active and >21 years old
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4
Q

According to the CDC, what is the only measure that should be done on physical examination prior to prescribing a contraceptive? (AFP)

A
  • Blood pressure
  • Pelvic examination before IUD (Bimanual exam and Cervical inspection)
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5
Q

As part of the Choosing Wisely Campaign, what does the AAFP recommend for the physical exam prior to prescribing OCPs? (AFP)

A
  • Do NOT require a pelvic exam or other physical exam
  • ONLY measure Blood Pressure
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6
Q

How can you be reasonable certain that a woman is not pregnant and what is the NPV for pregnancy? (AFP)

A

NOT pregnant if BOTH conditions met (99% NPV = routine pregnancy testing NOT needed)

  1. The patient has no signs or symptoms of pregnancy
  2. The patient meets AT LEAST ONE of the following:
    1. Is 7 days or less after start of her normal menses
    2. Has not had intercourse since the start of her last normal menses
    3. Has been correctly and consistently using a reliable method of contraception
    4. Is 7 days or less after a spontaneous or induced abortion
    5. Is within 4 weeks postpartum
    6. Is fully or nearly fully breastfeeding (exclusively breastfeeding or most feeds (>85%) are breastfeeds, amenorrheic, and less than 6 months postpartum)
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7
Q

What are 5 physiologic contraceptive methods and their effectiveness?

A
  • Abstinence – 100% effective
  • Chance – 10% effective
  • Calendar/Rhythm – 75% effective
  • Withdrawal – 75% effective
  • Lactational amenorrhea – 98% effective if breastfeeding q4h and no menses

*** No STI protection with any except abstinence ***

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8
Q

What are 4 barrier contraceptive methods and their effectiveness?

A
  • Condom – 90% effective, 95% effective with spermicide
  • Female condom – 80% effective
  • Sponge – 90% effective
    • Poor STI protection
  • Diaphragm – 90% effective with spermicide
    • Must be left in for 6 hours after intercourse
    • Poor STI protection
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9
Q

What is the effectiveness of the combined oral contraceptive pill?

A
  • 97% effective with typical use
    • No STI protection – advise to use concurrent condoms
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10
Q

What are the absolute and relative contraindications to estrogen use?

A

Absolute

Relative

Head

Migraine with aura*

Migraine and >35

Previous Stroke

Breast

Cancer or undiagnosed lump

Heart

CAD

Valvular heart disease

Abdominal

Severe Cirrhosis or Liver Tumor

Mild Cirrhosis

Pregnancy

Gallstones - currently

<6 week PP & breastfeeding

Undiagnosed vaginal bleeding

Vascular

HTN SBP >160 or DBP >100

Controlled HTN

Diabetes with end-organ

Smoker >35 (<15 cig/day)

Previous DVT

Sickle Cell, SLE, IBD

Smoker >35 (>15 cig/day)

*aura of visual scintillations <1h can be acceptable

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11
Q

What are 4 conditions in which an OCP is contraindicated in a patient with a past history of migraine? (DFCM Open)

A
  • Smoker
  • Migraine worse on OCP
  • Migraine with aura or neurological symptoms
  • Other risk factors:
    • Hypertension
    • Age >35
    • DM
    • Atrial fibrillation
    • Cardiomyopathy
    • Thrombophilia
    • Dyslipidemia
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12
Q

What are 6 adverse effects of estrogen excess and 5 adverse effects of progesterone excess from OCP?

A
  • Estrogen
    • Menorrhagia
    • Dysmenorrhea
    • Breast cystic change
    • Headaches
    • Nausea
    • Hypertension
  • Progesterone
    • Low mood
    • Fatigue
    • Libido decreased
    • Breast pain
    • Weight gain and appetite increased
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13
Q

When do adverse effects of the combined OCP typically resolve?

A
  • 3 months
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14
Q

What % of women experience irregular bleeding when starting a combined OCP? (DFCM Open)

A
  • 10-30% in the 1st month
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15
Q

What should be rule out if irregular bleeding persists for >3 months in women started on a combined OCP? (DFCM Open)

A
  • Rule out:
    • Poor compliance
    • Uterine/Cervical pathology
    • Malabsorption
    • Pregnancy
    • Smoking
    • Other meds
    • Infection (especially Chlamydia infection if new onset spotting in regular OCP user)
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16
Q

How should irregular bleeding be managed in women started on a combined OCP? (DFCM Open)

A
  • 7-day trial of oral estrogen OR switching to OCP containing different type of progestin
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17
Q

How should breast tenderness and nausea be managed in women started on a combined OCP? (DFCM Open)

A
  • Switch to lower estrogen OCP
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18
Q

How should no withdrawal bleed during pregnancy be managed in women started on a combined OCP? (DFCM Open)

A
  • Rule out pregnancy
  • Switch to OCP containing different type of progestin (levonorgestrel) or higher dose estrogen
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19
Q

What are 4 serious adverse effects of combined OCP use?

A
  • VTE: 3-4-fold risk (1 in 10,000)
  • Stroke: 2-fold risk
  • Breast Ca: 0 to 1.5-fold risk (3 in 1,000)
  • Hypertension
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20
Q

By how much do higher risk contraceptives increase the risk of VTE? (TFP)

A
  • 1 extra VTE per year for 2000 women (e.g. 2000 patients would need to switch to lower risk combined OCP to prevent 1 VT per year)
    • Limited evidence as no RCTs
    • Uncertain whether risks vary with different hormonal contraceptives
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21
Q

How does the risk of VTE compare for non-users, IUD with progestin, progestin only pills, transdermal estrogen, vaginal ring, 3rd generation progestins and OCP? (TFP)

A
  • 4-5/10,000 woman years (non-users, progestin-only pills, progestin IUD)
  • 10/10,000 woman years (combined OCP with 2nd generation progestin – levonorgestrel or norethisterone)
    • 2x
  • 20/10,000 woman years (transdermal estrogen, vaginal ring, OCP with 3rd generation progestin – desogestrel, gestodene, drospirenone, cyproterone)
    • 2x
  • 29/10,000 woman years for pregnancy
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22
Q

What are 3 other factors that influence VT risk in women on OCP? (TFP)

A
  • Age = age 45-49 6x risk age 15-19
  • Obesity = BMI 35+ 4x risk BMI 20-25
  • Smoking = 2x risk
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23
Q

What are 8 potential non-contraceptive benefits of the combined OCP?

A
  • Cycle regulation
  • Decreased dysmenorrhea
  • Decreased bleeding/anemia
  • Decreased acne/hirsutism
  • Increase bone density
  • Decreased Ovarian Ca (50%)
  • Decreased Endometrial Ca (50%)
  • ?Colorectal cancer protection
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24
Q

What are 6 potential drugs that can interact with OCPs and cause failure?

A
  • Anticonvulsants – Topamax, Carbamazepine, Phenytoin
  • St. John’s wart
  • SSRIs – Fluoxetine, Fluvoxamine
  • Fluconazole
  • Grapefruit juice
  • Antibiotics – Erythromycin, Rifampin, Ritonavir
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25
**How do estrogen and progesterone act as contraceptives physiologically?**
* Estrogen * Suppresses FSH * Progesterone * Thins endometrium * Thickens cervical cap * Alters tubal transport * At high dose (Depo) suppresses ovulation * Causes FSH suppression
26
**On average when does fertility returns after cessation of OCPs?**
* 3 months
27
**What are 3 different combined OCPs and their differences?**
* **Yaz** (20mcg, 24/4) and **Yasmin** (30mcg,21/7) have a progestin (**Drospirenone**) with anti-androgenic properties * Better weight control, less acne and good for hirsuit women * Must monitor K+ * VTE studies: perhaps **2x higher risk** * VTE risk in pregnancy is double that of Yaz VTE risk * **Alesse** (20mcg, 21/7) * **Seasonale** (30mcg, 84/7) * **Seasonique** (30mcg, 84/7) – with 10mcg during placebo period * **LoSeasonique** (20mcg, 84/7)
28
**What combined OCP can be given for perimenopausal women?**
* Mircette (20mcg, 21/2/5) has 10mcg estrogen during 5 placebo days to reduce hot flashes which typically recur in perimenopause * Also reduces the chance of ovulation if patient misses first active pill
29
**What are the different types of combined OCPs? (DFCM Open)**
* 21/28 cycle = 21d of OCP + 7d of placebo * Monophasic (same dose of estrogen+progestin for 21d) * Biphasic (same dose of estrogen but 2 different dose of progestin during 21d) * Triphasic (same dose of estrogen but 3 different dose of progestin during 21d) * Continuous Regimen * 84d of OCP + 7d of placebo * e.g. Seasonale or Seasonique
30
**What are 6 advantages of a continuous regiment of combined OCP compared to a 21/28 cycle? (DFCM Open)**
* Fewer withdrawal bleeds * Decreased: * Pelvic pain * Headache * Bloating * Breast tenderness * Better control of endometriosis/PCOS
31
**What are 3 different ways to start an OCP? (DFCM Open)**
* **1st day start** (start 1st day of cycle) * No back-up contraception requires, more SEs * **Quick start** (start immediately) * Back-up contraception required for 1 week, less SEs * **Sunday start** (start 1st Sunday after menses) * Back-up contraception required for 1 week if starting \>5d since LMP
32
**Why should combined OCPs be deferred until at least 6 weeks postpartum? (AFP)**
* Increased risk of VTE * Progestin-only methods can be safety started immediately postpartum
33
**How should a patient be started on an OCP based on the first day of their last menstrual period (LMP)?**
34
**What would you recommend for a patient that missed taking their OCP?**
* One Pill * Take when remember, even if take 2 pills on the same day * No backup protection needed * Two Pills in first 2 weeks * 2 pills the day you remember, 2 pills the next day * Backup protection for 7 days and consider emergency contraception * Two Pills during 3rd week or 3 Pills at any time * Throw out pack and start a new pack * Backup protection for 7 days and consider emergency contraception
35
**Other than the combined OCP, what are 6 other contraceptive methods?**
* Patch * Ring * Progestin-only Pills * Progestin Depot * IUD * Surgical
36
**What is the contraceptive patch, its contraindications, adverse effects and use?**
* EVRA Patch (35mcg/day) * Same contraindications as OCP * Same side effects as OCP * Also have skin reactions * As effective as the pill for contraception and non-contraceptive benefits * Apply ONE patch each week x3, then 1 patch-free week * Apply to buttock, upper/outer arm, upper/outer torso – not to breast * Always use the same day for patch change over – i.e. Monday * If forget to apply a new patch * \<48h – no need for backup * \>48h – start today and use backup contraception for 1 week * Consider emergency contraception if unprotected sex * If forget to remove patch * Remove when you remember and apply a new patch on the regular day
37
**What is the contraceptive ring, its contraindications, adverse effects and use?**
* Nuva Ring (15mcg/day) * Same contraindications as OCP * Same side effects as OCP * As effective as the pill for contraception and non-contraceptive benefits * Left in place for 3 weeks, removed for 1-week ring-free * Can stay in during sex, but can be removed for up to 3h * If forget to remove ring at end of week 3 * Remove when you remember and re-insert after 1 week
38
**What is an example of a progestin-only pill and how effective is it?**
* Micronor (0.35mg Norethindrone) * 90% effective
39
**What are 3 indications for the progestin-only pill for contraception?**
* Lactating women * Contraindications to estrogen * Smoker \>35 years * Migraine with focal neurological symptoms * Intolerant to estrogen AE
40
**What are 3 absolute and 3 relative contraindications to progestin-only pills?**
* Absolute * Pregnancy * Unexplained vaginal bleeding * Current diagnosis of breast cancer * Relative – LIVER disease * Severe cirrhosis * Active viral hepatitis * Benign hepatic adenoma
41
**What are 4 potential benefits of the progestin-only pill?**
* Amenorrhea – 50% with injection, 10% with pill * Reduced dysmenorrhea and bleeding * Decreased endometrial cancer * Reduced symptoms of endometriosis, PMS and chronic pelvic pain
42
**What are 8 potential AE of progestin-only pills?**
* Irregular bleeding (Inter-menstrual) * Amenorrhea * Functional ovarian cysts * Headache * Decreased libido * Nausea * Breast tenderness * Weight gain in 50% (10 lbs) * 50% lost weight or maintained
43
**What is the effect on weight for progestin-only contraceptives according to the Cochrane review? (AFP)**
* Little evidence * Mean weight gain was \< 2kg (4.4 lb) for up to 12 months
44
**What are 2 risks specific to progesterone injections for contraception?**
* 9-month delay in fertility * Decreases BMD
45
**Are their placebo pills for progestin-only pills?**
* No – take continuously
46
**What are 4 disadvantages of progestin-only pills compared to combined OCP?**
* Slightly higher failure rates * More breakthrough bleeding * Does not reliably suppress ovulation – not as good for dysmenorrhea * Must take at the SAME TIME each day * 3-hour delay requires backup contraception
47
**What should a patient do if they miss taking a progestin-only pill?**
* 1 pill \>3-hours – take pill as soon as remember and use backup for 48h * 2 pills – take 2 pills per day for 2 days and use backup for 48h
48
**What is an example of a progestin depo, how effective is it and how does it work?**
* Depo-Provera 150mg IM q12weeks * 99.7% effective * High dose progestin suppresses LH surge and ovulation
49
**How should a patient be started on Depo-Provera?**
* 1st day of menses to avoid inadvertently giving when pregnant
50
**What should a patient do if they miss an injection of Depo-Provera?**
* \<14 weeks – can still give injection * \>14 weeks – no sex in last 10 days and negative beta-hCG – give injection * Requires a backup method for 2 weeks * If she has had sex, can still give injection (not teratogenic) * Repeat beta-hCG in 2 weeks
51
**What are 3 indications to an IUD for contraception?**
* Contraindications to OCP * Long-term protection (5-years) * Do NOT have to remember to take
52
**What are 7 absolute and 3 relative contraindications to an IUD?**
* Absolute * Pregnancy * Current or recurrent of \<3 months of PID or STI * Distorted uterine cavity * Unexplained vaginal bleeding * Cervical or Endometrial cancer * Breast Cancer (Mirena) * Copper allergy (Nova T) * Relative * Risk factors for HIV * 48h – 4 weeks postpartum * Ovarian cancer
53
**What are 9 potential adverse effects of levonorgestrel-releasing IUDs? (AFP)**
* Headaches * Nausea * Hair loss * Breast tenderness * Depression * Decreased libido * Ovarian cysts * Oligomenorrhea * Amenorrhea
54
**What % of women using the 20mcg LNG-IUD report oligomenorrhea or amenorrhea after 2 years of use? (AFP)**
* 70%
55
**How effective are the Mirena IUD and Nova T IUD for contraception?**
* Mirena = 99.9% * Nova T = 99.3%
56
**What is the difference between a NovaT IUD, Jaydess IUD and Mirena IUD? (DFCM Open)**
* NovaT = Copper * Mirena = Levonorgestrel 20 mcg/day * Jaydess = Levonorgestrel 6 mcg/day
57
**Compare and contrast the Mirena IUD and Nova T IUD by contraceptive effects, non-contraceptive benefits and adverse effects.**
**Nova T** (99.3%) **Mirena IUD** (99.9%) **Contraceptive Effects** * Inflammatory response in uterus * Cu is spermotoxic * Thins endometrium * Thickens cervical cap * Alters tubal transport **Non-contraceptive Benefits** * Lower Endometrial Ca * Decreased Menorrhagia * 30% Amenorrhea * Decreased Dysmenorrhea * Decreased endometrial hyperplasia if on tamoxifen **Side Effects** * Increased flow * Increased dysmenorrhea * Irregular bleeding
58
**What are 4 potential risks associated with IUDs?**
* Uterine Perforation – 1 in 1,000 * Unclear risk of PID * Expulsion 5% over 5 years (6.7% copper \> 5.8% progestin) * Ectopic pregnancy
59
**What should be done to the IUD in the case of an ectopic pregnancy?**
* Remove IUD – lowers risk of septic abortion * If cannot remove then get ultrasound to evaluate for perforation
60
**When should an IUD be inserted during the menstrual cycle and when is it easiest?**
* Any point in the menstrual cycle * After pregnancy is excluded * Easiest if during menses * Copper = Any time in the menstrual cycle * Levonorgestrel = First 7 days of menses
61
**Following removal of an IUD, when does fertility return?**
* 3-6 months
62
**What are 3 possible causes for a lost IUD string and what should be done?**
* Causes: Expulsion (5%), Perforation, String in Cervical Canal * Exclude Pregnancy * Get ultrasound * If present, can leave it * If not, get AXR to evaluate for perforation
63
**How should an STI be managed in a patient with an IUD?**
* If LOWER symptoms – treat STI * If suggestive of PID – remove IUD
64
**Is the use of misoprostol recommended before IUD insertion to allow for easier insertion? (AFP)**
* No – no benefit and increased AEs * ACOG makes NO recommendation regarding its use
65
**Are prophylactic antibiotics recommended before IUD insertion? (AFP)**
* No
66
**How long after treatment for an STI should women with an IUD be screened? (AFP)**
* 3 to 6 months after treatment
67
**How long after resolution of an STI should an IUD be inserted? (AFP)**
* 3 months
68
**What are the risks of tubal ligation?**
* Bleeding * Infection * Failure * Low chance at reversing * Risk of damage to bladder/bowel, general anesthetic
69
**What is the annual failure rate for surgical sterilization techniques? (AFP)**
* Abdominal tubal ligation (1 in 100 to 200) * Laparoscopic tubal ligation (1 in 100 to 200) * Male vasectomy = 1 in 100 overall (1 in 2,000 with confirmed azoospermia)
70
**For patients starting long-term contraception what should you always counsel them about?**
* Emergency Contraception
71
**What should be done for a patient that misses a period?**
* Pregnancy test and REPEAT in 2 weeks
72
**What are the contraindications for emergency contraceptives?**
* None
73
**When should you follow-up with a patient after taking an emergency contraceptive?**
* 3-4 weeks * Repeat pregnancy test vs Spontaneous menses * Contraception counseling
74
**What are 3 options for emergency contraceptive use?**
* Yuzpe * Plan B * IUD
75
**How should the Yuzpe regimen be used for emergency contraception and how effective is it?**
* Yuzpe * 2 tablets, then repeat in 12h * 100mcg Ethinyl estradiol and 500mcg Levonorgestrel q12h x2 * Best within 24h (98% effective), can use up to 72h (30% effective) * AE: nausea and spotting
76
**How should Plan B be used for emergency contraception and how effective is it?**
* Plan B * Progesterone only (Levonorgestrel 750mcg q12h x2), PO within 3 days * Alters endometrial lining to prevent implantation * Best within 24h (98% effective), can use within 72h (70% effective) * AE: less N/V, still spotting
77
**How should an IUD be used for emergency contraception and how effective is it?**
* IUD – ONLY with COPPER – up to 99.9% effective * Use within 5 days
78
**What should be done if there is no menstrual bleeding within 21 days of treatment with emergency contraception? (Toronto Notes)**
* Pregnancy test
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