Term
| what % of pregnancies in the US are unintended? |
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Definition
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Term
| what % of a woman's life is spent avoiding pregnancy? |
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Definition
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Term
| what is the avg time from 1st intercourse to marriage? |
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Definition
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Term
| what % of women will become pregnant after one episode of unprotected intercourse? |
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Definition
| 8% (2nd + 3rd week of cycle) |
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Term
| which age group is the highest for unintended pregnancy? |
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Definition
| teenagers, followed by women over 40 |
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Term
| how is it shown that contraception does not increase risk of birth-related deaths? |
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Definition
| more pts die that have no fertility control than any other group (except those who smoke over 35) |
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Term
| what are the most common causes of unintended pregnancy? |
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Definition
| lack of contraception, contraception method failure, and contraceptive user failure |
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Term
| what is the only 100% contraceptive method? |
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Definition
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Term
| what are properties of contraceptives desired by women? |
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Definition
| effective, reliable, easily reversed, privacy of use, absence of amenorrhea, and protection against STIs |
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Term
| how are contraceptives evaluated for efficacy? |
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Definition
| the pearl index: divide the # of unintended pregnancies by each women's total months/cycles of exposure from the time she begins until completion of study/unintended pregnancy/discontinuation of method. this is then multiplied by 1200 if months and 1300 if cycles. most OCPs are 1.5-2.5 and the closer to 1 - the better the contraceptive method (indicates fewer failures). |
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Term
| is there a discrepancy between patients who have never used contraceptives before, and those who have used them before? |
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Definition
| yes - the learning curve is about 6 months |
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Term
| what is the key to contraceptive methods? |
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Definition
| decrease in motivational acts = easier compliance w/contraception (for ex: natural family planning method has a lot of motivational acts, pt has to determine if they are ovulating etc) |
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Term
| what risks and benefits exist w/OCPs which can be addressed w/pts? |
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Definition
| risks: OCPs can increase risks of blood clots. benefit: lower risk of ovarian/endometrial CA, less anemia (flow during menstruation is lighter), improvement of acne, and advantage against osteoporosis. |
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Term
| what does need to be done medically before prescribing OCPs? |
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Definition
| past medical hx, family hx w/attention to CV risks (if they exist, then do thrombophilia study), and blood pressure (r/o high BP) |
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Term
| are pelvic exams and PAP/STD screenings necessary before prescribing OCPs? |
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Definition
| no, but if unable to perform on the 1st visit - this is good to do on the 2nd visit |
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Term
| what was the generation we will be treating taught in school in terms of birth control? |
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Definition
| abstinence - due to title V funding |
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Term
| what characterizes the periodic abstinence/rhythm/natural family planning method of birth control? |
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Definition
| the menstrual cycle is about 28 days long and ovulation is usually from about day 12 to day 18, so the pt needs to abstain from day 8 until day 21. this is difficult to maintain discipline to adhere to and still has a high degree of risk (40/100 pregnancy rate). |
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Term
| what characterizes withdrawal as a birth control method? |
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Definition
| this requires a lot of control as most men will ejaculate a small amount of semen before awareness - which has the highest sperm concentration. 18-20% failure rate. |
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Term
| what characterizes secondary abstinence? |
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Definition
| pts who have had unintended pregnancies at a young age can benefit from attempting abstinence from that point on. this should increase self worth, self confidence, and self control |
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Term
| what is the most common method of reversible birth control? |
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Definition
| OCPs: 27% of women age 18-44 are on them and 80% of women age 18-44 have used it at some point. |
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Term
| when do most women discontinue OCP use? |
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Definition
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Term
| why do 1/3 of pts discontinue OCP use? |
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Definition
| side effects (irregular bleeding, etc) |
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Term
| how do combination OCPs generally work? |
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Definition
| progestin primarily suppresses LH and estrogen suppresses FSH - which *prevents ovulation. |
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Term
| what is the action of synthetic progestin (synthetic progesterone) found in OCPs? |
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Definition
| progestin acts through progesterone receptors (which estrogen increases the number of - increases efficacy) to suppress LH, *inducing endometrial atrophy (over time: lighter periods), *altering the cervical mucus (keeps cervical mucus from thinning out at ovulation, stays thick and prevents sperm from entering - may prevent ascending infections), and *diminishing endometrial receptivity. |
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Term
| what is the action of ethinyl estradiol found in OCPs? |
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Definition
| ethinyl estradiol *suppresses FSH (preventing emergence of the dominant follicle), *potentiates the actions of progestins by increasing the intracellular progesterone receptors - allowing a reduction of progestin dose in combination hormonal OCPs, and *stabilizes the endometrium to prevent break through bleeding (side effect of progesterone thinning the endometrium). |
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Term
| what are the 2 common estrogen doses in OCPs and the accompanying considerations? |
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Definition
| OCPs used to be 50 mg estrogen, which had more breast tenderness, n/v (estrogen ADRs) and a higher risk of DVTs. 30/35 mg pills are now available which have less estrogen ADRs and less DVT risk. 20 mg pills which are even more common have even less estrogen ADRs, the same DVT risk, but more breakthrough bleeding (the most common reason pts discontinue OCPs). |
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Term
| what are the estrogenic ADRs? |
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Definition
| n/v, bloating, breast tenderness - all of which are short lived, but pts need to be warned of them |
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Term
| how does the risk of DVT compare between a pt on OCP vs one who is pregnant? |
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Definition
| 2x higher for pregnant pts |
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Term
| how do OCPs help with acne and hirsutism? |
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Definition
| testosterone is responsible for acne and hirsutism. estrogen increases the activity of sex binding globulin, which binds testosterone - inactivating it. many OCPs are approved for acne. |
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Term
| if a pt is heavier, how does it affect the efficacy of OCPs? |
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Definition
| OCPs have less efficacy in heavier pts (155 lbs in some studies) - may need to use more powerful OCPs and have a back up method. |
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Term
| can OCPs increase wt gain? |
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Definition
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Term
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Definition
| 99.5-99.8% effective. due to compliance issues, may drop to 97% |
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Term
| is there any known adverse event to continuous OCP use (not taking the 7 day break every 21 days for a withdrawal bleed - *not a period)? |
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Definition
| no, but this is considered off-label (insurance won't cover). there may be some irregular bleeding around 12-15 wks and if patients have irregular bleeding because they missed a few days, you can advise them to continue to allow themselves to bleed and start back up their pills after their bleed off is finished. |
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Term
| what is the risk w/generic OCPs? |
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Definition
| the active drug may be 25-75% of that in brand names |
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Term
| what are the different packaging methods for OCPs? |
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Definition
| *traditional 28 day: 21 active, 7 placebo (during that 7 days, the pituitary starts to release some FSH/LH - if pts forget to start again immediately, the pt may ovulate). *reduced placebo: 24 active, 4 placebo (less likely pt will ovulate during withdrawal period). *prolonged cycle: 84 active, 7 placebo (or low dose estrogen). *continuous: all active estrogen. |
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Term
| what are estrophasic OCPs? |
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Definition
| combination OCPs where only the dose of progestin changes, supposedly to help w/estrogen side effects |
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Term
| what are the benefits of OCPs? |
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Definition
| predictable cycle, decrease flow, decreased cramps (decreased prostaglandins which cause headache, n/v, and heavy cramping), decreased mittelschmerz (pain w/ovulation), decreased ovarian cysts, decreased PID, decreased rheumatoid arthritis, decreased ovarian CA, decreased endometrial CA, increased bone density, decreased benign breast disease, *no change in breast CA risk, decreased acne, and possibly decreased uterine fibroids |
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Term
| what are the ADRs associated with OCPs? |
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Definition
| little/no period, break through bleeding, nausea, 1 kg gain max, mood changes (not clearly supported), headache, and breast tenderness |
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Term
| what risks are associated w/OCPs? |
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Definition
| DVTs (3/10,000 risk), pts w/migraines have a higher incidence of strokes (6x higher risk) |
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Term
| what other medications are affected by OCPs? |
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Definition
| phenytoin (affected by binding hormone which is affected by OCPs), caffeine, alcohol, tricyclic antidepressants -> effects are increased. tylenol, coumadin, benzodiazepines, methyldopa -> effects are decreased. |
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Term
| do OCPs have a negative impact on DM pts? |
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Definition
| no - no effect on glucose management, but there is an increased risk of congenital birth defects because eggs develop while patient has high sugar content. (may occur months before conception) |
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Term
| should smokers older than 35 take OCPs? |
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Definition
| no - think about diaphragms, IUD, non estrogen pills |
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Term
| can pts w/controlled HTN take OCPs? |
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Definition
| if patient is on one agent, they can use low dose pills |
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Term
| can pts w/mitral valve prolapse take OCPs? |
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Definition
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Term
| can pts w/varicose veins take OCPs? |
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Definition
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Term
| can pts w/thrombocytopenia or von willebrands take OCPs? |
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Definition
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Term
| who should avoid just OCPs containing estrogen? |
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Definition
| those w/sickle cell, SLE, or lactating women - may use progestin only contraceptives |
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Term
| what are non-contraceptive uses of OCPs? |
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Definition
| dysfunctional uterine bleeding (DUB - thins endometrium), peri-menopausal (to regulate cycle), dysmenorrhea/endometriosis (reduces symptoms and incidence of further complications), acne, hirsutism, polycystic ovarian disease, and amenorrhea (esp in teens who may need supplemental estrogen - to build bones) |
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Term
| what is the primary indication for progestin-only OCPs? ADRs? |
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Definition
| lactating women, as well as migraine pts, smokers, high DVT risk pts, and those mainly focused on cycle control. they are prescribed continuously (no blanks). ADRs: lots of breakthrough bleeding (estrogen helps stabilize the endometrium), high failure rate (no increase in progestin receptors), and more acne |
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Term
| what is the MOA for progestin-only OCPs? |
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Definition
| suppression of ovulation 50% of the time, *alteration of the cervical mucus, alteration of the endometrium, and alteration of fallopian tube action (decreases cilia action, slows ovum transport, *possible ectopic pregnancy risk) |
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Term
| when is emergency contraception used? MOA? |
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Definition
| w/in the first 72 hrs of intercourse. |
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Term
| what characterizes the emergency contraception "plan B"? |
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Definition
| plan B contains .75 mg of levonorgestrel (no estrogen) and is intended to be taken in 2 doses, 12 hours apart 72 hrs after the incident. it is OTC for pts 18+ and pts are recommended to buy it at a non-critical moment. |
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Term
| what is the MOA for plan B? |
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Definition
| this dose of levonorgestrel (synthetic progesterone) interferes w/follicular maturation, suppresses gonadotropins, suppresses/delays ovulation, keeps cervical mucus thick, discourages sperm migration, decreases corpus luteum sufficiency, decreases endometrial receptivity, and decreases zygote development/transport/adhesion. it is *not an abortifacient. |
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Term
| what is the efficacy for plan B? |
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Definition
| 58% @ 49-72 hours post sex |
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Term
| if a pt still gets pregnant after taking plan B, can they still have the child? |
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Definition
| yes - emergency contraception is not teratogenic |
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Term
| what is the different between plan B and preven? |
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Definition
| plan B is just levonorgestrel and preven is levonorgestrel and estrogen - which will cause the ADRs: n/v and breast tenderness |
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Term
| what are the contraindications for emergency contraception? |
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Definition
| clotting problems, ischemic heart disease, breast bxs, migraine, stroke, and liver tumors. (all contraindications are relative to pregnancy) |
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Term
| what are common side effects of emergency contraception? |
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Definition
| n/v, vomiting, menstrual irregularities, breast tenderness, headache, abdominal cramping, dizziness, fatigue |
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Term
| if a pt cannot afford emergency contraception, how can you provide her w/it using free OCP samples? |
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Definition
| 4 35 mg OCPs 2x w/12 hrs inbetween |
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Term
| what is the MOA for RU 486/mifepristone? |
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Definition
| blockage of intracellular steroid receptors (can be used w/in *120 hours) |
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Term
| what characterizes transdermal contraceptive systems? |
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Definition
| patches such as ortho evra are applied for 3 weeks w/one patch free week (low motivational acts = high compliance) and contain norelgestromin as well as ethynyl estradiol. pts need to push the patch down firmly for full effect and a continuous dose of hormones is then administered w/no first pass systemically (equals ~20 micrograms of ethinyl estradiol). ADRs: some breast discomfort, patch site reactions, etc. risks: *possible increased risk of thromboembolic events due to 2x increase of estrogen in blood. |
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Term
| what characterizes vaginal rings? |
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Definition
| vaginal rings, such as nuvaring contain etonogestrel and ethynyl estradiol and are placed in the vagina (pts do not feel it). vaginal rings are worn for 3 weeks w/one week off (but if out for more than a couple hours over the 7 day break, the egg recruitment process may start. can also use continuously.). pregnancy rate: .65/100 women. if the ring falls out - the pt should wear a back up for 2 weeks. no wt contraindications (supposedly). |
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Term
| are male partners affected by women who use vaginal rings? |
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Definition
| no - fraction of hormones available for penile absorption = 5% |
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Term
| what characterizes depo provera? |
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Definition
| depo provera is an injection of 150 mg medroxyprogesterone acetate every 3 months (no estrogen - fewer ADRs). injection is deep IM, Z track to ensure fluid doesn't leak out. MOA: block LH surge, some FSH suppression, alteration of endometrium, and thickened cervical mucus. |
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Term
| what are advantages of depo provera? |
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Definition
| much lower compliance issues, smoking/sickle cell/lactating women can use it, private (use is undetectable), decreased endometrial AC, decreased menstrual flow/anemia, decreased PID, delayed fertility (up to 9 mos), decreased endometriosis, fewer uterine fibroids, and increased seizure threshold (for epileptic pts). also a good sterilization trial run. |
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Term
| what are disadvantages of depo provera? |
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Definition
| irregular menstrual bleeding (usually in 1st 3 mos), amenorrhea (80%), *wt gain (relative to BMI), bone loss (do not use longer than 2 yrs) |
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Term
| what are relative contraindications for depo provera? |
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Definition
| liver disease, breast disease, *severe depression, CV disease, and desire to return quicker to fertility. |
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Term
| what characterizes use of contraceptive implants? |
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Definition
| contraceptive implants such as implanon have the same MOA as depo-provera (suppresses LH/thickens cervical mucus) and will work for 3 years. the capsule is injected between the bicep+triceps while pt is on menses (so you know they're not pregnant) and is easy to remove. |
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Term
| what characterizes use of a diaphragm? |
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Definition
| diaphragms are used w/contraceptive cream/jelly and are fitted specifically for the pt. only 3% of pt use then and the failure rate is 2-23% depending on compliance. diaphragms should be left in 6 hours post intercourse then cleaned. they can be used up to 2 years. ADRs: vaginal irritation, increased UTI risk (drink lots of fluid to counteract). benefits: cheap and decreased cervical gonorrhea, PID and tubal infertility |
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Term
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Definition
| a contraceptive similar to a diaphragm which is fitted for the pt and does not require spermicide. these *may be kept in for 24 hrs (literature says 48). |
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Term
| what characterizes use of spermicides? |
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Definition
| these OTC contraceptives are cheap but w/efficacy ~ 80% they should not be the only form of birth control used by the pt. |
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Term
| what characterizes use of the female condom? |
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Definition
| the female condom lines the vagina w/an inner ring to cover the cervix and an external ring over the labia. *may help w/STD transmission but is one time use. the female condom is potentially awkward to use and cannot be used w/a male condom. |
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Term
| what characterizes use of male condoms? |
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Definition
| latex/polyurethane have possible HIV protection - but lambskin do not. the condom must be put on before penetration and a reservoir needs to be left at the end. failure rate 3%, but in actual use: 48%. |
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Term
| what characterizes use of sponges as contraceptives? |
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Definition
| sponges are cheap, and similar to the diaphragm (they also contain spermicide). they may be used for 24 hours and the partner should not feel it. they offer limited STD protection. |
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Term
| what characterizes use of intrauterine devices (IUD) such as paraguard? |
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Definition
| IUDs contain a metal such as Cu, are effective for up to 10 years, have a hight efficacy (low motivational acts), have low failure rate (3%) - however the pt requires adequate counseling, b/c they may have increased or painful bleeding. |
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Term
| what is the MOA for IUDs such as paraguard? |
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Definition
| the IUD creates a spermicidal intrauterine environment via a sterile inflammatory response b/c the copper releases a free copper/salt. |
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Term
| what is the relationship between IUDs and pregnancy? |
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Definition
| if there is a pregnancy in a IUD pt, it is likely to be ectopic or a spontaneous abortion (40-50%). an IUD needs to be removed in the case of a pregnancy (which will bring abortion rate to 100% - preterm labor/birth). however, do not remove the IUD if infection occurs. there is no increased risk of congenital anomalies. |
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Term
| what characterizes the use of an intrauterine system such as mirena? |
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Definition
| these are not copper, but have levonorgestrel and are good for 5 years. MOA: cervical mucus/endometrial viability/tubal motility is altered. the pt can rapidly return to fertility (1 mo). failure rate: .1/100. when inserted pt should do so on a full stomach, take ibuprofen, and use a one-handed technique. the pt may not have any period or may have increased bleeding. |
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Term
| what characterizes hysteroscopic sterilization? |
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Definition
| this is a soft, flexible tube micro insert (requires no incision) where coils are placed in and then scarring occurs over 3 months. this is permanent contraception. FDA requires confirmation of tube blockage. |
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Term
| what are contraceptive considerations for pts w/manual or dexterity problems? |
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Definition
| barrier methods/pill packs may be hard to manipulate |
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Term
| what are contraceptive considerations for pts w/mental or psychiatric problems? |
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Definition
| they may have problems remembering to take the pill daily (IUD/depo may be better) |
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Term
| what are contraceptive considerations for pts w/SLE? |
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Definition
| progestin-only pills can help prevent lupus flare-ups |
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Term
| what are contraceptive considerations for pts who are chronically anti-coagulated? |
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Definition
| these pts should use non-hormonal methods of contraception |
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Term
| what are contraceptive considerations for pts w/CV issues? |
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Definition
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|
Term
| what are contraceptive considerations for pts w/high cholesterol? |
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Definition
| high triglycerides may be increased by estrogen. pts on high triglyceride rx should not get pregnant. |
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Term
| what are contraceptive considerations for HIV+ pts? |
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Definition
| ensure barrier methods are used to prevent transmission. if they want to get pregnant, make sure viral load is low. |
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