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39 Cards in this Set
- Front
- Back
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In the US:
- What % pregnancies are unintended? - What % of unintended pregnancies are terminated? - What % of unintended pregnancies are due to contraceptive failure? |
- 50%
- 50% - 50% |
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Describe the "ideal" contraceptive.
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- 100% effective
- 100% non-toxic - No coitus-related activity required - Reversible - Inexpensive - Easy to use - Acceptable to all groups of people |
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What is the Pearl Index?
- Main limitation? |
Estimation of BC efficacy:
= number of failures per 100 woman-years of exposure (i.e., 100 women over 1 year; or 10 women over 10 years) --> lower pearl index = less chance of unintended pregnancy - Limitation: doesn't describe effect of duration of use on efficacy |
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What is the Life-Table Analysis?
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Estimation of BC efficacy:
- Based on failure rate for each month of method use - Often used to measure survival in oncology studies |
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What is method-effectiveness?
What is use-effectiveness? |
Method-Effectiveness - efficacy with correct (idea) use of the contraceptive - i.e., highly motivated and closely-supervised patients
Use-Effectiveness - normal unsupervised use by unselected patients - i.e., the "real world" - For some methods, method- and use-effectiveness are ~ equal (e.g., sterilization) - For some methods, they are not equal (e.g., condom, diaphragm) |
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What are two important trends related to type of BC use and AGE?
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- BC Pill = most common in all ages!
- Sterilization increases with age |
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What is the mechanism of action of Combination Hormonal Contraception?
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Overall: prevent ovulation by inhibiting gonadotropin secretion through effects on hypothalamus and pituitary
(act both in CNS and UG tract) Estrogen: - suppresses FSH secretion, so prevents emergence of dominant follicle - helps stabilize endometrium - provides "normal" cyclic menses Progestin: - suppresses secretin of LH, so prevents midcycle surge, thus prevents ovulation - helps stabilize endometrium ... inhibits implantation of blastocyst - forms thick cervical mucus and affects tubal motility; affects sperm motility and migration - makes it difficult for sperm to fertilize egg |
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What do most modern oral contraceptives (OC) consist of?
What is the main way that the different OC options differ? |
- Synthetic Estrogen: ethinyl estradiol or mestranol
- Synthetic Progestin - (many choices) - norethindrone, norethindrone acetate, ethynodiol diacetate, norgestrel levonorgestrel, desogestrel, drospirenone, norgestimate **Differ in dose of E/P and nature of P |
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Why are synthetic, rather than natural, hormones used?
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Natural hormones are rendered inactive when taken orally
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What is break-through bleeding?
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When taking OC, if the stabilization of the endometrium and "normal" cyclic menses initiated by Estrogen is inadequate, patient bleeds during cycle
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What are the different E/P compositions that can make up OC?
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Monophasic - E/P composition remains constant for all 21 days
Biphasic and Triphasic - lower doses of during earlier parts of cycle Progestin-Only: - either Norgestrel (25cg) or Norethindrone (35 mcg) - For breastfeeding women or those with contraindications to estrogens - **Effectiveness requires consistent administration |
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What is the metabolism of E/P in OC?
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Estrogen:
- ethinyl estradiol and mestranol absorbed efficiently in GI, and 60% excreted in urine after 24 hours - can be absorbed transdermally or transvaginally - **mestranol must be converted to ethinyl estradiol to become active - ethinyl estradiol is converted to estrone and estriol in the liver Progestin: - more complex metab than estrogen - > 30 metabilites - quickly metabolized by liver |
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What are relatively minor side effects of OC?
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- nausea
- breast discomfort - break-through bleeding (all due to E) - weight gain - changes in carb metab (due to P's androgenic effects) |
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What are potentially serious side effects of OC?
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- venous thrombosis/thromboembolism
- arterial thrombosis - CVA, MI, etc. - changes in coagulation profile - hypertension - headache - hepatic adenoma - gall bladder disease - change in lipid profile - increase risk of breast cancer is controversial (prob small increase in early-onset, decrease in late-onset) |
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What symptoms can be related to side-effects of BC causing underlying HTN, etc.
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- visual sx
- unilateral parasthesia - chest pain (L-sided) - RUQ pain; liver capsule swelling - severe headache - leg swelling |
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What are ABSOLUTE contraindications to OC?
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- hx DVT
- vascular disease (current/past) - hyperlipidemia - significant cardiac disease - E-dependent cancer - pregnancy - active liver disease/tumor - unexplained uterine bleeding - uncontrolled HTN |
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What are relative contraindications to OC? What should the patient do if she has one?
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- HTN, well-controlled
- diabetes - seizure disorder - smoking - factor V leiden deficiency (thrombophilia) - gallbladder disease - breastfeeding - prolonged immobilization - immediate postpartum pd **doc and pt must decide if benefits > risk |
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What are the non-contraceptive benefits OC?
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Decreased relative risk of:
- iron-deficiency anemia - dysmenorrhea - abnormal menstrual bleeding - PMS - endometrial carcinoma - ovarian neoplasm - benign breast disease - rheumatoid arthritis - PID |
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NuvaRing
- MOA? - how fast does fertility return once stop? |
- activated by woman's body temp --> releases daily ethinyl estradiol and etonogestrel
- worn for 3 out of 4 weeks --> only enough hormones for 3 weeks!! - rapid return of fertility! ovulation resumes during first recovery cycle after discontinuation |
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Ortho Evra
- what is? - MOA? - why increased risk? |
= patch
- new patch applied each week for 3 weeks; no patch on 4th week --> withdrawal bleeding - higher risks than OC bc of increased estrogen in patch in order to keep dosage stable over the 3 weeks (rather than phasic) |
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What is withdrawal bleeding?
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Bleeding that occurs after 3 weeks of contraception use during the 4th week without hormones (sugar pills, removal of patch/ring, etc.)
- sole purpose of letting the patient know she's not pregnant!!! |
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Are continuous contraceptive hormones safe?
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YES! BUT women get more breakthrough bleeding with increased duration of hormones... this is why seasonale has withdrawal bleeding after 3 months - to prevent breakthrough bleeding
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Depo-Provera
- what is? - MOA? - side effects... how long do they last? |
= IM shot of progestin-only birth control - given once every 12 weeks
MOA: - blocks LH surge - inhibits ovulation - increases viscosity of cervical mucus - impairs sperm transport - produces endometrial atrophy **No menstrual bleeding --> good for people with dysmenorrhea Side effects: - osteoporosis (P competes with E at ER --> osteoclast activity increased --> increased osteoporosis.... not permanent; must take Ca!) - weight gain - breast tenderness - irregular bleeding/eventual amenorrhea ...... persist for 90-180 days after stopping |
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Emergency Contraception
- names of options you can take/how? - % pregnancies reduced - MOA - contraindications - side effects |
- Plan B = 2 tablets of levonorgestrol (OTC if >18)
- Preven - 2 tablets of levonorgestrel/ethinyl estradiol - Any OC at adequate dose - Insert IUD within 72 hours of intercourse - reduce risk of preg by at least 74% - MOA: - delay/inhibit ovulation - alter endometrium to interfere with implantation? - effects on sperm/ovum transport? - no contraindications; exc. pregnancy! - side effects: nausea (less with progestin-only pills) - withdrawal bleed ~48 hrs after pill |
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IUD
- aka? - what is? - MOA - different types? |
= IUC: intrauterine contraception
= LARC: long-acting, reversible contraception - small, plastic device containing 1+ chemicals or metals --> placed in uterus thru cervix in brief procedure - can leave in for up to 10 years - removal OK; completely reversible MOA - causes sterile inflammatory response in endometrium - involving various cytokines --> creates toxic environment for sperm and prevents implantation of blastocyst - adverse effect on tubal motility - some with progestins - adverse effects on cervical mucus; decrease ovulation TYPES - Copper-T - Progesterone T - Levonorgestrel IUD = Mirena |
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IUD
- advantages? - side-effects? - contraindications? |
Advantages
- requires no action once inserted, so little failure - if P, reduces amt blood lost during menses - protects against uterine hyperplasia - reduced risk of endometrial cancer - less progestin than P-only pill Side-Effects - dysmenorrhea, menorrhagia, intermenstrual bleeding, expulsion, uterine perforation (low), low incidence of preg (ECTOPIC = 10% of pregs with IUD) ; PID (low) Contraindications: - uterine anomalies - blood dyscrasias - undiagnosed abnormal uterine bleeding - acute/hx PID - vaginitis, cervicitis, bact vaginosis (or mult sex partners - increased risk of infection --> can ascend) - pregnancy (suspicion of) - carcinoma of cervix/endometrium (unresolved abnormal pap) - Wilson's Disease/Cu allergy - immune deficiency - genital actinomycosis |
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Spermicide
- name? - types of application? |
= Nonoxynol-9
- foam, film, suppository **inactivates HIV - used with diaphragm |
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Barrier Methods of Contraception
- Advantages - Disadvantages |
Advantages:
- low toxicity - reduction/protection against STDs Disadvantages: - low use-effectiveness - diaphragms/cervical caps must be prescribed and fitted by doc - refitted and replaced every 1-2 years and/or with wt change > 10 lbs |
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How long must diaphragm be in before intercourse?
How long can it be worn? What else must you do for protection? |
Must be in for min 6 hours
Can wear for 6-24 hours Use spermicide!! **If going to have sex again, must put in more spermicide |
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Fertility Awareness/Rhythm Methods
- effectiveness? - % failure |
- very effective when used correctly without exception
- use-effectiveness poor - 25% women get pregnant during first year |
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Fertility Awareness/Rhythm Methods
- methods to determine fertile days? |
- calendar method
- basal body temperature - cervical mucus testing - symptothermal methods - combo! - usually BBT and cervical mucus |
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Female Fertilization
- what is? - techniques? - advantages? - disadvantages? - failure rate? |
= irreversibile occlusion of fallopian tubes
- surgical partial salpingectomy, tubal electrocautery, application of clips/rings, hysteroccopic tubal occlusion - laparoscopically (thru belly button) or at time of c-section - general anesthesia - out-patient Advantages - low failure rate = 0.5-2% Disadvantages - Irreversible - regret (10% of young women); reversal has moderate success rates - operative morbidity/mortality - relatively high proportion of ECTOPIC pregnancies |
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What is Hypteroscopic Tubal Occlusion?
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Mode of female sterilization thru uterus - put a device in each tube
- aka: Essure |
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Male Sterilization
- name? - technique? - advantages? - side effects? |
= vasectomy
- surgical occlusion of vas deferens - outpatient procedue - local anesthesia - much safer than female sterilization - both short and long-term complications - reversible (but poor when >3 years post-operation) - Main side-effect: local hematoma **Still has sperm for a few months - must wait for a negative semen analysis before stopping other contraception |
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Abortion statistics
- age - race - % first abortion |
- most <25
- most white - 50% = first time abortion |
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First Trimester Abortions:
- medical? - surgical? |
MEDICAL
- Mifepristone (RU 486 = competitive antagonist to P; softens cervix) followed by Misoprostol (PG; uterotonin - contracts uterus) 48 hours later - methotrexate followed by misoprostol SURGICAL - vacuum aspiration |
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Second Trimester Abortions:
- medical? - surgical? Risks compared to first trimester? |
MEDICAL
- induced labor - KCl into fetal heart, then uterotonin SURGICAL - vacuum - D&E **Increased risk of bleeding and infection over 1st trimester abortions |
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What is the efficacy of an abortion?
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96% in pregnancies less than 49 days of gestation
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What is the complication rate of surgical abortions?
- what increases risk? - short-term complications? - long-term complications? |
1 in 200 cases
= lower than that for term pregnancy and most other elective srugery - risk increases with gestational age and underlying medical problems Short-term: - anesthesia complications - infection - intrauterine blood clots - incomplete abortion - continued pregnancy - intrauterine trauma - hemorrhage Long-term: RARE!! - impairment of fertility - psychological sequelae |
