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Contraception Basics NURS 541 Winter 2015 (adapted from Carie Bussey, CNM lecture) Objectives 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 try. Where to do you begin? Non-Hormonal Contraception WHY NO METHOD 33% felt they could not get SPERMICIDES Gel, foam, suppository, tablet, cream, film Nonoxynol-9 Effectiveness decrease if IC too soon or too late after application Messy, increase BV in some, local irritation Does not prevent STIs pregnant 30% percent did not really mind 22% partner did not want to use contraception **side effects, thought sterility, access to BC Non-Hormonal Contraception COITUS INTERRUPTUS Men to withdraw from the vagina before ejaculation Failure occurs if withdrawal is not timed accurately or if the preejaculatory fluid contains sperm FERTILITY AWARENESS Standard days method, ovulation method, symptothermal methods Rely on: The periodicity of fertility and infertility 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 given DIAPHRAGM • 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 hours SPONGE Production was stopped in 1995 and resumed in 2005 Contains nonoxynol-9 Moisten with water before insertion no fitting required Less effective and higher discontinuation than diaphragm Better efficacy for nullips Increase risk toxic shock syndrome Non-Hormonal Contraception CONDOMS LAM Male or female <6 months PP Latex or non-latex Exclusively breastfeeding Only method with STI Amenorrheic protection Combined Hormonal Contraception Birth Control Pills Mechanisms of Action Suppress ovulation Alter endometrial receptivity Inhibit sperm Estrogen-Progestin (COC) 20-35mcg ethinyl estradiol/one of 7 different progestins 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) Hypertension Migraines with aura (or age 35 or above without aura) Liver adenoma or tumor Certain medications (anti-convulsant drugs, some antibiotics, some sedatives) 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 DMPA Depot medroxyprogesterone acetate (Depo Provera) Deep IM every 3 months (there is an SC version) Mech of Action Inhibits ovulation Inhibits endometrial proliferation 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 TAKE EVERY DAY! Mech of action Thickened cervical mucus Timing very important! >3 hrs late, BUM x 2-3 days Progestin-Only Contraception Nexplanon Etonogestrel Screen carefully Mech of Action Suppresses ovulation Increase viscosity of cervical mucous Inhibit endometrial proliferation Side effects include unscheduled bleeding, headache, acne LARC: Long-Acting Reversible Contraception Paragard (T380A) fine copper wire Approved to remain in place x 10 yrs Spermicidal activity Also a non-hormonal method LNG-IUS 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 Essure Bilateral Tubal Ligation Surgical sterilization Usually done by Laparoscopic techniques - different surgical techniques Biggest disadvantage is that it is a surgical procedure Vasectomy Most effective mode male contraception 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 confirmed) Higher risk of unilateral tubal occlusion than with BTL Patient Education/Counseling How to start combined hormonal contraception (pills, ring, patch)? 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, patch)? 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 week 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, DMPA)? 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 DMPA 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 contraception. How would you conduct her visit? Returning to our 19 y.o college student… How would you approach this visit? Questions?