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Contraception
Part 2: Non-Hormonal Methods and Emergency
Contraception
09/12/12
Objectives
By the end of this lecture, participants will be able to:
• Discuss appropriate candidates for the various types of nonhormonal contraception
• Reinforce patient education on the appropriate use of nonhormonal contraceptive agents
• Explain the various forms of emergency contraception
• Describe the nurse’s role in caring for women seeking
contraception
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Non-Hormonal Methods of
Contraception
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Non-Hormonal Methods
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ParaGard© IUD
Condoms
Diaphragm
Cervical Cap
Spermicide/Sponge
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Non-Hormonal Intrauterine Contraception:
ParaGard© Copper T 380A IUD
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380 coils of copper
Efficacy of 99.4%
Duramed Pharmaceuticals,
Effective up to 10 years
Inc. a subsidiary of Barr
Pharmaceuticals, Inc.
Inserted in office setting
Inhibits sperm motility, fertilization and implantation
Side effects
− Increased bleeding/pain with menses
− Vaginal discharge
• Obtained through Prosthetics
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ParaGard©
• Advantages
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Long-term method requiring no maintenance
Overall, the most cost-effective method
“Reversible sterilization”
Useful for women who can’t take estrogen or don’t want
to use hormones
− Can be inserted at any time during menstrual cycle
• Disadvantages
− Not suitable for women with copper allergy
− Doesn’t protect against HIV/STDs
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ParaGard © Visit
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Rule out pregnancy
Obtain ParaGard© from prosthetics
Pre-insertion med: 600-800 mg of ibuprofen one hour prior
Equipment needed for insertion:
− Betadine or hibiclens, poured into pack of 4x4 gauze
− Sterile gloves
− Sterile equipment on sterile tray
• Uterine sound, vaginal speculum, ring forceps, suture
scissors (long), single tooth tenaculum, sterile IUD package
• Patient received written info? Signed consent form? Questions?
• Remove IUD on or before expiration date with ring forceps
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Male Condom
• Used especially by teens, 20–24 year-olds, childless women,
never-married women
• Typical use failure of 15%
• Advantages:
− Non-prescription, inexpensive, easily obtained
− STD protection (except lambskin condoms - pores allow
viruses and cells to pass through)
• Disadvantages
− Break, slip
− Latex allergy (use polyurethane condoms instead)
− Tied to intercourse
• Check with your facility for procurement
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Female Condom
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Polyurethane sheath with inner and outer ring
Typical use failure of 21%
Used by some sex workers
Advantages
− Under the woman’s control
− Greater STD protection (partly covers the labia)
• Disadvantages
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Tied to intercourse
Noisy
Expensive ($2.50 to $5.00)
High displacement rate
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Diaphragm
• Latex or silicone dome filled with spermicide
• Typical use failure of 16%
• Advantages
− Under the woman’s control
• Disadvantages
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Tied to intercourse
Spermicide only effective for 2 hours
Fitting is necessary
Allergy/UTI risk
Doesn’t protect against HIV/STDs
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Patient Education for Diaphragms
• How to insert
• Insert only up to 2 hours before sex; spermicide effective only 2
hours
• If inserted more than 2 hours before intercourse, leave diaphragm
in place and add more spermicide directly into vagina with
applicator. For further intercourse, add more spermicide.
• Leave diaphragm in place for 6-8 hours after intercourse.
• Do not leave diaphragm in vagina for more than 24 hours - can
increase risk of toxic shock syndrome
• Must also use condoms for STD protection. Irritation from
spermicide may increase risk of acquiring HIV.
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Cervical Cap
Courtesy of
FemCap
• Typical use failure of 20%
• Spermicide inserted into a silicone cup placed on cervix
• Disadvantages
− Tied to intercourse
− Wear 6 hours before and after sex (48 hours max)
− 3 sizes, fitting is necessary (refit after childbirth, abortion,
miscarriage, or gaining 15 pounds)
− Can be dislodged during sex
− Increased risk of cervical inflammation
− No STD protection. Spermicide irritation may increase risk of
acquiring HIV.
• FemCap available in US; mostly marketed in 3rd World countries
• Costs $60–$75 and lasts 2 years
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Spermicides
• Typical use failure of 29%
• Available in cream, foam, gel, film, suppository
• No STD protection
• Possible increased risk of HIV transmission when Nonoxyl-9 is
used alone
− Can irritate vagina and rectum, thus potentially increasing
risk of getting HIV from infected partner
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Sponge
Today Sponge.
Used with
permission from
Mayer Labs.
• Barrier + spermicide method (1,000 mg of nonoxynol-9)
• Typical use failure of 29%
• Side effects:
− Spermicide allergy
− Increased risk of yeast infections, UTIs
• Patient education points
− Run under water until thoroughly wet. Insert against cervix.
− Can be inserted up to 24 hours before intercourse
− Must be left in place for at least 6 hours afterward
− Do not wear for more than 30 hours in a row - may result in toxic
shock syndrome if left in too long
− No HIV/STD protection. Irritation from spermicide may increase
risk of acquiring HIV.
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Other Methods of Contraception
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Natural Family Planning / Withdrawal
Natural Family Planning
• Effective in select cases for:
− Motivated, educated patients
− Women with regular cycles
• Some sources quote 95% efficacy but typical use failure is likely
higher
• No contraindications, risks, side effects other than failure
Withdrawal
• Not recommended - failure rate of 27%
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Natural Family Planning: Various Methods
• Cervical mucous or ovulation method
• Sympto-thermal method
− Based on cervical mucous and basal body temperature
• “Timed abstinence” or Rhythm/Calendar Method
− Not recommended - high failure rate 25%
• Lactational amenorrhea
− Time between feedings must be no longer than 4 hours during
the day and 6 hours at night
− Most effective during first 6 months of exclusive breastfeeding
− Works better for older women who are less fertile
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Sterilization
• Males: vasectomy
• Females: tubal ligation and Essure
• Counseling Points
− >99% effective, but failures can occur
− Should be considered IRREVERSIBLE
− In U.S., spouse or partner is not required to give consent
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Female Sterilization
• Contraindications
− Severe medical problems not allowing anesthesia
• Side effects
− Heavier menses, more dysmenorrhea
• Risks
− Surgical risks
− Regret/questionable reversibility
− Ectopic pregnancy: Among 10,685 women, risk of ectopic
pregnancy within 10 years of sterilization was about 7/1,000
• Does not protect against HIV/STDs
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Tubal Ligation
• Done postpartum or as an “interval” procedure
− Two small cuts made in abdomen, usually around navel.
Instruments to tie tubes sent thru laparoscope. Tubes are either
cauterized or shut off with small clip. Patient usually returns
home in a few hours.
• Failure rate of 0.8 - 2%
• Counseling Points
− Avoid strenuous exercise for several days
− Return to work within a few days
− Sexual intercourse usually within a week
− Rates of regret: 20% in women under 30!
− Does not protect against HIV/STDs
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Essure©
• Hysteroscopic placement of soft, flexible
micro-inserts
− Growth of scar tissue results in blocked
fallopian tubes
• Advantages: no incisions, minimal
anesthesia, failure rate <1%
• Disadvantages:
− 3-month wait for confirmatory testing
with hysterosalpingography (HSG)
− Not for women with nickel allergy
− No protection against HIV/STDs
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Courtesy of Conceptus, Inc
Emergency Contraception
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Emergency Contraception (EC)
• Plan B/Next Choice (Levonorgestrel)
• Ella (Ulipristal)
• Offer in advance because…
− Increases the likelihood that EC is used
− Decreases the time interval to use
− Does not decrease contraception use
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Counseling Points for Plan B
• Not the same as RU-486
• Non-prescription costs:
− Pharmacy: Plan B One-Step $50 (generic $45)
− Planned Parenthood $37
• Use within 5 days of unprotected intercourse
− Taking within 72 hours decreases chance of getting pregnant
by 89% (from 8% without Plan B to 1% with Plan B)
− Even more effective if taken within 24 hours
− Effectiveness decreases with time
• Common side effects: nausea (23%), abdominal pain (18%),
fatigue (17%), headache (17%), and menstrual changes
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Ella
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Ulipristal single dose (30mg). Not on VA formulary.
Take within 5 days
Efficacy similar to Plan B
Mechanism
− Delays ovulation
− Inhibits implantation
• Similar side effect profile to levonorgestrel
• Advanced provision required; not available without prescription
• Counseling points similar to Plan B
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Other Methods of Emergency Contraception
• Yuzpe regimen
− High doses of levonorgestrel OCP woman already has on hand
− More nausea/vomiting, less effective
• ParaGard© IUD
− Place within 5 days of unprotected intercourse
− Failure rate of 0.1 - 0.7%
− Can be removed after next period, or left in for long-term birth
control
− More effective for overweight and obese women
− Consider antibiotic prophylaxis while awaiting cultures
− Screen as always for STD
− Not FDA approved for this purpose (counsel appropriately)
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Case Studies
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Case 1
Grace, a 26-year-old woman, calls your office:
“I just started birth control and I’m bleeding.”
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Clarifying Questions
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Could you be pregnant?
What form of birth control are you using?
When did you start it?
How are you using it?
When did you start bleeding?
How long have you been bleeding?
How much blood is there?
What was the first day of your last menstrual period?
Are you experiencing pain with the bleeding?
Have there been any prior episodes of bleeding?
Have you undergone any recent gynecologic procedures?
Is the bleeding related to sex?
Have you experienced any trauma?
Have you recently had any vaginal discharge?
Do you have chills or fever too? 29
Triage: Differentiate urgent from emergent situation
1. Is she hemodynamically stable?
2. Could she be pregnant?
3. Is she experiencing a high-risk complication from her contraceptive?
If she could be pregnant…
• Which test is available (urine vs. 2 types of serum) and how to order?
Contraceptive high-risk complications …
• Recent IUD insertion: fever, lower abdominal pain
• Hormonal contraceptive:
− Deep vein thrombosis (skin pain/swelling/discoloration especially in an
extremity, low back pain)
− Pulmonary embolism (chest pain when taking a deep breath, shortness of
breath, coughing up blood, heart racing or pounding, lightheadedness or
fainting)
When to contact a provider? Based on…
• Available protocol or team dynamics
• Your comfort level and your provider ‘s comfort level
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Determine Appropriate Disposition of Patient
1. When to send to ER
2. When to discuss/refer to a provider
3. Patient education (what to tell her, how to tell her, what she
needs to tell us)
4. How test results will be communicated
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Case 2
Janine, a 22-year-old veteran, calls your clinic.
“The condom broke.
What if I’m pregnant?
I don’t know the guy all that well.”
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Clarifying Questions
• In addition to the possibility of pregnancy, do you have
any other concerns?
• When did the condom break?
• Are you on another form of birth control?
• Was the sex consensual?
• Have you had any other episodes of unprotected sex
recently?
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Assess Janine’s Risk Factors for an STI
• Unprotected sex
• Illicit drug use
• Young age
• Contact with sex workers
• Unmarried
• Multiple sexual partners
• New sex partner in past 60
days
• History of a prior STD
• No HPV vaccination
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You need to address….
Potential pregnancy
• Know which test is available (urine vs. 2 types of serum); how to order
Possible STD exposure
• Know her STD risk factors, screening tests available, how to offer them
to her, how to order tests, her HPV vaccine status
Emergency contraception options
• Plan B: Know VHA policy, availability, and how it works. Educate her on
efficacy, side effects, and use.
• ParaGard: Know how it works and its availability. Educate her on
insertion, efficacy, and side effects.
• Yuzpe method: Know how it works and if she has oral contraceptives
at home. Educate her on efficacy, side effects, and how to do it.
Educate her on pregnancy symptoms, potential teratogenic medications
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Determine Appropriate Disposition of Patient
1. When to send to ER
2. When to discuss/refer to a provider
3. Patient education (what to tell her, how to tell her,
what she needs to tell us)
4. How test results will be communicated
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For more information:
1. Association of Reproductive Health Professionals. Patient Resources.
http://www.arhp.org/patienteducation/index.cfm
2. CDC. United States Medical Eligibility Criteria (USMEC) for Contraceptive
Use.
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC
.htm
3. Johnson BA. Insertion and removal of intrauterine devices. Am Fam
Physician. 2005;71(1):95-102.
4. Weissmiller, D. Emergency contraception. Am Fam Physician. 2004;
70(4):707-14,717-8.
5. McKinley Health Center, University of Illinois at Urbana-Champaign.
Thinking about birth control. [excellent summary for nurses and
patients] http://www.mckinley.illinois.edu/Handouts/birth_control.html
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Primary author:
Sherry Nordstrom, MD
Jesse Brown VA, Chicago, IL
Contributors:
Linda Baier Manwell, MS
University of Wisconsin-Madison
Rose Birkmeier, DNP, FNP
Aleda E. Lutz VA Medical Center, Saginaw, MI
Amanda Johnson, MD, FACOG
Cheyenne VA Medical Center, Cheyenne, WY
WH Nurse Reviewers: Barbara Robinson, RN
Katrina Goldby, RN, BSN, JD
Susan Johnson-Molina, RN, BSN, MAOM
Connie LaRosa, RN, MSA, CPHQ
Barbara Polak, RN, MSN
Mary Ann Reale, MS, RN
Lisa Roybal, MSN, WHNP