Download here! - UW Canvas

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Infection control wikipedia, lookup

Maternal physiological changes in pregnancy wikipedia, lookup

Menstrual cycle wikipedia, lookup

Menstruation wikipedia, lookup

Start School Later movement wikipedia, lookup

Prenatal development wikipedia, lookup

Birth control wikipedia, lookup

Contraception Basics
NURS 541
Winter 2015
(adapted from Carie Bussey, CNM lecture)
 Review the basic types of contraception, including risks,
benefits, side effects, and usage
 Describe the process of choosing an appropriate contraceptive
method for a patient, using a woman-centered approach
 Outline the proper patient education/counseling to provide
when prescribing a contraceptive method
Before we start….
 What’s important to our patient when choosing a
contraceptive method?
 Efficacy vs effectiveness
 Side effects
 Ease of use
 Non-contraceptive benefits
 Quality of life
A Contraception Visit
 Comfortable setting
 What does your patient want?
 Review of history for contraindications
 Discuss options
 Develop a plan and implement (Rx, procedure, etc)
 Follow-up
How to Choose an Appropriate Method
 Other factors to consider:
 Ability to use method
 Coitus-based
 Partner support
 Daily use vs weekly vs monthly vs minimal
 Length of desired contraception
 Permanence
 Long-term (1+ years)
 Less than a year
An example:
 34 y.o. G3P2 presents at 6 months postpartum for a barrier
method of birth control (hormones make her “feel funny”). She
is “ok” if she gets pregnant but would like to wait another 12
months before conception. She hasn’t had much IC PP, but she
has used the LAM with occasional condom use (her husband
really doesn’t like condoms).
 Where to you start?
Another example:
 19 y.o. nullip presents during her college winter break for birth
control. She recently got involved sexually with her boyfriend
and they usually use condoms. No significant health history,
she smokes socially when she has alcohol (about 2
cigarettes/wk), menses are regular without any gyn c/o. She has
never had a gyn exam. Due to start menses next week. She’s
heard of a certain pill that her friend’s on that she may want to
 Where to do you begin?
Non-Hormonal Contraception
 33% felt they could not get
Gel, foam, suppository, tablet,
cream, film
Effectiveness decrease if IC too
soon or too late after
Messy, increase BV in some,
local irritation
Does not prevent STIs
 30% percent did not really
 22% partner did not want to
use contraception
 **side effects, thought
sterility, access to BC
Non-Hormonal Contraception
Men to withdraw from the
vagina before ejaculation
Failure occurs if withdrawal is
not timed accurately or if the
preejaculatory fluid contains
 Standard days method,
ovulation method,
symptothermal methods
Rely on:
 The periodicity of fertility and
 A single ovulation each cycle
 The limited viability of ovum
 The limited viability of sperm
 A woman's ability to monitor
cycle length and/or cyclerelated symptoms and signs.
 Labor intensive, little info
• Fitted by Clinician
• Safe, cheap, minimal s/e,
reversible, decrease cervical
cancer risk?
• Availability, messy, skill,
increase UTIs?
• Must use spermicidal
• No STI protection
• Diaphragm – leave in 6-8
hours after IC and remove
• Cap – can leave in for 48
Production was stopped in
1995 and resumed in 2005
Contains nonoxynol-9
Moisten with water before
no fitting required
Less effective and higher
discontinuation than
Better efficacy for nullips
Increase risk toxic shock
Non-Hormonal Contraception
 Male or female
 <6 months PP
 Latex or non-latex
 Exclusively breastfeeding
 Only method with STI
 Amenorrheic
Combined Hormonal Contraception
Birth Control Pills
 Mechanisms of Action
Suppress ovulation
Alter endometrial
Inhibit sperm
 Estrogen-Progestin (COC)
20-35mcg ethinyl
estradiol/one of 7 different
Monophasic or triphasic
Transdermal Patch
• “Ortho Evra”
• 20 mcg ethinyl estradiol
/150 mg norelgestromin
• Apply weekly
Vaginal Ring
• “NuvaRing”
• Avoids 1st pass of liver
• 15 mcg ethinyl estradiol &
120 mg etonogestrel
• 1 ring/month
When is estrogen not safe?
Hx DVT/VTE, clotting disorder, hx CVA, MI, cardiomyopathy
Breast cancer/disease, other reproductive cancers
Smoking + ≥ 35 years of age
Postpartum < 6 weeks (increased risk DVT)
Multiple CAD risk factors (HTN, DM, older age, smoking)
Migraines with aura (or age 35 or above without aura)
Liver adenoma or tumor
Certain medications (anti-convulsant drugs, some antibiotics, some
Risks to estrogen-containing contraception
 Venous thromboembolism (VTE)
 About 3.5:10,000 users will get a clot
 Smoking increases this risk
 Clots may lead to stroke, PE, myocardial infarction, death
 Warning signs: ACHES
 Abdominal pain (severe)
 Chest pain (including shortness of breath)
 Headache (severe)
 Eye problems (visual problems or speech problems)
 Swelling and pain in the legs
Progestin-Only Contraception
Depot medroxyprogesterone acetate
(Depo Provera)
Deep IM every 3 months (there is an
SC version)
Mech of Action
 Inhibits ovulation
 Inhibits endometrial
 Thick cervical mucus
 Changes tubal motility
Side Effects
 Menstrual irregularities, wgt
changes, h/a, nervousness,
reduction in bone mineralization
Progestin-only Pills
“Minipill”, POP
0.35mg norethindrone
No hormone-free week, AKA
Mech of action
Thickened cervical mucus
Timing very important!
>3 hrs late, BUM x 2-3 days
Progestin-Only Contraception
Screen carefully
Mech of Action
Suppresses ovulation
Increase viscosity of cervical
Inhibit endometrial
Side effects include
unscheduled bleeding,
headache, acne
Long-Acting Reversible Contraception
Paragard (T380A)
fine copper wire
Approved to remain in place x 10
Spermicidal activity
Also a non-hormonal method
 Mirena
 52 mg levonorgestrel
 Releases 20 mcg/day
 Approved to remain in
place x 5 yrs
 Many more insurances are
covering at almost
complete cost
 Skyla
 13.5 mg levonorgestrelreleasing system
 Good for 3 yrs.
Paragard (copper) IUD
What other method (we’ve already
discussed) is also a LARC?
Patient Education/Counseling
 How to start?
 Coitus-based methods
 Condoms, spermicide, sponge – use entire sexual encounter
 Diaphragms/cervical caps – insert at least 30 minutes prior to
encounter and leave in for at least 6 hours afterwards, up to 24 hrs
for diaphragm, 48 hrs for cervical cap
 Need spermicidal gel!!
Permanent Contraception
Bilateral Tubal Ligation
Surgical sterilization
Usually done by Laparoscopic
techniques - different
surgical techniques
Biggest disadvantage is that it
is a surgical procedure
Most effective mode male
Interruption of occlusion of the
vas deferens
Hysteroscopic sterilization
 No incision
 Less postoperative pain
 Need for contraception for
three months post-procedure
(until tubal occlusion is
 Higher risk of unilateral tubal
occlusion than with BTL
Patient Education/Counseling
 How to start combined hormonal contraception (pills, ring,
 First day start: no BUM required
 Sunday start: first Sunday after menses begins, allows subsequent
menses to fall during week (not weekend); BUM x 7 days
 Quick start: Start method immediately, regardless of timing in
cycle; BUM x 7 days, pregnancy test in 2 weeks IF unprotected
intercourse preceding start
Patient Education/Counseling
 How to use combined hormonal contraception (pills, ring,
 Pills
 21+ days active pills (3 weeks),4-7 days hormone-free/estrogen-
containing spacer pills, withdrawal bleed usually on day 2-3 of fourth
 Ring
 One ring vaginally x 3 weeks, with one week hormone free
 May do calendar method: insert day 1, remove day 25 of each month
 Patch
 One patch weekly on hips, abdomen, shoulders/upper arm x 3 weeks,
one week off
Do we need withdrawl bleed?
 OCPs: take continuously
 Withdrawal bleed 3-4 x per year
 Counseling about bleeding during first 3-4 months
 Nuva Ring: Take days 1-28 each month.
 Easy to remember!
 Not FDA approved
 Patch: not recommended
 Why?
Patient Education/Counseling
 How to start progestin-only hormonal contraception (POP,
 POPs
 Can be started at any time; BUM x 7 days; pregnancy test in 2 weeks
if unprotected intercourse
 No hormone-free week, expect irregular bleeding if any
 Start at visit if pregnancy can be reasonably excluded (neg pregnancy
test and no UP intercourse in preceding 2 weeks); BUM x 7 days
 DMPA re-injections due every 9-13 weeks (12 weeks + 1 week buffer)
Patient Education/Counseling
 Nexplanon, LARCs, permanent methods
 Require visits for insertion and/or pre-operative exam
 Careful screening necessary
 Specialized training for insertion needed
A common scenario…
A 23 y.o. woman calls the office stating that she forgot her pill pack
when she went away for the weekend and missed 4 pills during the
active week. She has unprotected intercourse last night. What can
you tell her?
Emergency Contraception
 Several ways to offer
 Existing oral contraceptive pills
 Many pills at once…not usually reasonable
 Plan B One-Step (1.5mg levonorgestrel)
 One pill taken within 120 hours (72 hours) of UPIC
 Plan B/Next Choice (0.75mg levonorgestrel x 2)
 2 pills taken 12 hrs apart (or at the same time) within 120 hours (72
hours) of UPIC
 Ella (30mg ulipristal acetate)
 One pill taken within 120 hours of UPIC
Missed pills
 Missed 1 pill:
 Take missed pill immediately and continue at regular interval/time with
subsequent pills
 Missed 2 pills during weeks 1 or 2:
 Take 2 pills daily x 2 days, then finish pack on regular schedule. Use BUM
for remainder of cycle
 Missed 2 pills during week 3:
 Take 2 pills daily until active pills completed, then start new pack within
7 days. Use BUM for remainder of first pack and x 7 days with start of
new pack
 Missed 3 or more at any time:
 Stop current pack, restart new pack within 7 days and use BUM through
the first 7 days of the new pack
Returning to our first example…
 34 y.o woman at her postpartum visit, wanting non-hormonal
 How would you conduct her visit?
Returning to our 19 y.o college student…
 How would you approach this visit?