Contraception

Question 1

3 Types of Sterilization

Answer 1

1 - Vasectomy - ligate vas deferens (takes 3 mo b/f effect)

2 - Female Tubal Occlusion - mechanical blockage of fallopian tubes at isthmus (ligate, clips, bands, cauterize, remove)

- Failure rate = .5% (not perfect) 
- Dec risk of ovarian cancer

3 - Hysteroscopic Tubal Occlusion - micro-insert placed into proximal fallopian tubes right after menses –> scarring –> sterilization in 3-6 months
*** Do HSG to confirm tubal blockage - inject dye into uterus and image; should not see dye leaving uterus

Question 2

LNG IUDs

Answer 2

• levonorgestrel (progesterone only)
• MAO: thickening of cervical mucus so that sperm cannot penetrate
• Diff sizes and durations (3-5 yrs)
• Contraindications - current or recent upper genital tract infection (last 3 mo), some uterine anomalies, breast cancer, SLE w/ pos anti-phospholipids antibodies
• Risks - perforation (rare), expulsion/falls out (more common in beginning), irregular bleeding/spotting at start, LIGHTER period
• Adv - long-acting and no effect on fertility

Question 3

Copper IUD

Answer 3

• (ParaGard)
• copper ions wound around polyethylene T
• MAO: copper ions inhibit motility and viability of sperm and ovum (not hormones)
• FDA-approved for 10 yrs of use BUT slightly higher fail rate than other IUDs (.8%)
• Contraindications - current or recent upper genital tract infection (last 3 mo), some uterine anomalies, Wilson’s Disease; FINE FOR BREAST CANCER B/C NON-HORMONAL
• Risks - same perforation, expulsion, may see inc blood loss or HEAVIER period (manage w/ NSAIDS)
• Adv - long-acting and no effect on fertility; can also be used for emergency contraception

Question 4

Implant

Answer 4

• (Nexplanon)
• MAO: inhibition of ovulation w/ progestin only (etonogestrel)
• FDA-approved for 3 yrs of use
• Placed over tricep w/ insertion device
• Failure rate - .05%
• Contraindications - breast cancer, SLE w/ pos anti-phospholipids antibodies
• Adv - long-acting
• Disadv - irregular bleeding (pattern of bleeding in first few months is indicative of what long-term bleeding pattern will be; AKA does not get better), small scar and pain at insertion site

Question 5

COCs in General

Answer 5

• MAO: inhibition of ovulation (progestin suppresses GnRH and thus LH surge while estrogen suppresses FSH)
• Most commonly ethinyl estradiol and mult diff progesterones
• Monophasic, biphasic, triphasic
• Progestin also inc cervix mucus thickness
• Fail rate - 8 to 9% (mainly b/c user error)
• Contraindications - uncontrolled HTN, hx stroke or MI, breast cancer, DM w/ vascular complications, smoker > 35, SLE w/ anti-phospholipid antibodes, migraines w/ auro, hx VTE, liver disease, hepatic adenoma, inc risk MI or stroke in smoker > 35 yo
• Risks - VTE (2x relative risk), dec libido, HCC (rare), nausea, headache, breast tenderness, mood swings
• Adv - improve acne and hirsutism (more SHBG to bind extra testosterone), dec risk ovarian and endometrial cancers, regulate menses and reduce blood loss

Question 6

Pill

Answer 6

• Classic is 21 days active and 7 days placebo but effectiveness inc if shorten or eliminate placebo time (4 days or no days)
• Specific Contra- drug interactions (rifampin), and malabsorptive gastric bypass (roux en y)

Question 7

Patch

Ring

Answer 7

• Patch
  
  • Place new patch ea wk for 3 wks then 1 patch-free wk
  • Less effective in women > 90kg
• Ring
  
  • Placed for 3 wks then remove for 1 wk (or keep in cont for 4 wks)
  • Releases etonorgesterol and ethinyl estradiol daily
  • Can remove for up to 3 hrs for intercourse

Question 8

Progestin Only Pills

Answer 8

• (“mini-pill”)
• MAO: thicken cervical mucus
• Two formulations - norethindrone or norgestrel
• Fail rate - 8-10%
• Much more dependent on user (MUST BE SAME TIME EVERY DAY)
• Often used in breastfeeding women (inc risk DVT after pregnancy) or other contraindications
• Contraindications - breast cancer, SLE w/ anti-phospholipid antibody, liver disease or liver tumors, malabsorptive gastric bypass
• Risks/ Disadv - irregular bleeding, vaginal dryness, strict adherence required
• Adv - safe when breastfeeding, may dec menstrual loss, dec endometriosis

Question 9

Depo- Provera

Answer 9

• Only method that can contribute to delay in fertility once stopped; stays in system for awhile (7-9 month delay)
• MAO: inhibits ovulation
• IM or subQ injection every 3 mo
• Fail rate - 3%
• Risks - wt gain, irregular bleeding, temporary dec in bone mineral density
• Contraindications - breast cancer
• Adv - improve endometriosis, amenorrhea, dec seizures in those w/ epilepsy and sickle cell crises; dec risk endometrial cancer; safe for breastfeeding

Question 10

Barrier Methods (5)

Answer 10

• Latex condoms - failure rate of BUT also protects against STDs
• Female condoms - not latex (good for allergy) and protects against some STDs
• Diaphragm - leave for 6 hrs and use along w/ spermicide; protects against some STDs
• Fertility awareness - (“rhythm method”) really only works if regular periods
• Withdrawal - high fail rate b/c some pre-ejaculatory

Question 11

Lactational Amenorrhea

Answer 11

• AKA using breastfeeding as birth control
• Only for 6 mo after delivery
• Amenorrhea required - any bleeding may indicate ovulation
• Must feed or pumping every 3 hrs (can go 6 hrs overnight)
• High levels of prolactin inhibits GnRH