Contraception Alicia A Stone RN MS FNP Assistant

Contraception Alicia A. Stone RN, MS, FNP Assistant Professor of Nursing

Birth Control: Comparing the Choices Using effective birth control helps people to stay in control of their lives. Contraceptive needs may change throughout the reproductive years Family planning is the attempt to control the number and spacing of children. A couple may use contraception to avoid pregnancy temporarily or sterilization to avoid pregnancy permanently. Abortion may be used to end a pregnancy when contraception has failed.

What is the “best” contraceptive method? The best contraceptive method for an individual woman is a method that is: medically appropriate effective in preventing pregnancy used consistently and correctly satisfactory to the woman at her stage of life

Hormonal Interventions Oral contraceptives: Progestin alone Progestin and estrogen Stop ovaries from releasing eggs and keep mucus thick Contraindications Benefits Side effects

Combination Contraceptives (Estrogen & Progestin) GENERAL ADVANTAGES • Highly effective in preventing pregnancy when taken correctly • Not related to coitus • Rapid return to fertility after discontinuation • Very safe when prescribed for appropriate users • Can be used throughout the reproductive years

Combination Contraceptives (Estrogen & Progestin) HEALTH BENEFITS • Fewer pregnancies = fewer maternal deaths • Reduction in risk of ectopic pregnancy • Decrease in dysmenorrhea • Decrease in menorrhagia • Reduction in PMS symptoms • Elimination of Mittelschmerz • Decreased anovulatory bleeding • Fewer ovarian cyst problems

Combination Contraceptives (Estrogen & Progestin) HEALTH BENEFITS • Endometrial and ovarian cancer risk reduction • Decreased risk of benign breast conditions • Suppression of endometriosis • Improvement of androgen-sensitivity or androgenexcess conditions (such as PCOS) • Improvement in hot flashes and hormonal fluctuation symptoms in perimenopausal women

Combination Contraceptives (Estrogen & Progestin) GENERAL DISADVANTAGES • Must be taken consistently and correctly to be effective • Storage, access, lack of privacy • Can interfere with lactation • No protection against STIs • Common side effects include: nausea, vomiting weight gain decreased libido headaches breast tenderness skin hyperpigmentation

Combination Contraceptives (Estrogen & Progestin) COMPLICATIONS • Venous thromboembolism • Myocardial infarction and stroke • Hypertension DO NOT Rx TO WOMEN AGE > 35 WHO SMOKE!

Combination Contraceptives (Estrogen & Progestin) CONTRAINDICATIONS • Personal history of thrombosis; known clotting disorder (factor V Leiden mutation, etc. ) • Personal history of stroke or MI • Labile hypertension • Estrogen-sensitive malignancy (such as breast CA) • Active liver disease • Migraines with focal neurologic symptoms

How to Take Birth Control Pills The 28 -day pack contains 21 active pills + 7 placebo pills. Getting started: • “First day” start • Sunday start • “Quick Start” Continuing: one pill per day, every day. Withdrawal bleeding will occur during the placebo week. ≈ $35. 00 per cycle

Patches Norelgestromin and ethinyl estradiol transdermal system (Ortho Evra) Applied once a week for 3 weeks, followed by a patch-free week Buttocks, stomach, upper outer arm, upper torso Advantages 95 – 99% effective Disadvantages

Injectables Depo-Provera once every three months ok for nursing mothers lead to irregular periods, weight gain Lunelle given monthly, q 2830 d decreased side effects.

Nuva Ring Placed in the vagina for 3 weeks which gives protection for month. Remove for one week Exact position is not critical for ring to work.

“Extended Use” Regimens Monthly withdrawal bleeding is NOT necessary! Seasonale provides 84 active pills followed by 7 placebo pills for 4 “periods” a year. Any monophasic pill, the patch, or the ring can be used on an extended basis. ≈ $100. 00 per pack

Progestin-Only Contraceptives

Progestin-Only Contraceptives Mechanisms of action: • Inhibition of ovulation • Prevention of sperm penetration by thickening and decreasing the quantity of cervical mucus • Endometrial atrophy

Progestin-Only Contraceptives ADVANTAGES OF ALL METHODS • No estrogen • Reversible • Amenorrhea or scanty bleeding • Improvement in dysmenorrhea, menorrhagia, PMS, endometriosis symptoms • Decreased risk of endometrial or ovarian cancer • Decreased risk of PID • Compatible with breast-feeding

Progestin-Only Contraceptives DISADVANTAGES OF ALL METHODS • Menstrual cycle disturbances • Weight gain • Depression • Lack of protection against STIs

Progestin-Only Pills Cycle consists of 28 active pills; there is no “placebo week” Vulnerable efficacy! Each pill must be taken on time at 24 hour intervals. BRAND NAMES: Micronor Nor-QD Ovrette ≈ $45. 00 per cycle Compatible with breast-feeding & recommended in combination with lactational amenorrhea.

Depo-Provera Advantages: • highly effective • discreet & private • use not linked to coitus • requires user to “remember” only 4 times a year Disadvantages: • weight gain • impossible to discontinue immediately • delayed return to fertility • adverse effects on lipids • decreased bone mineral density Depo-Provera = depot medroxyprogesterone acetate 150 mg IM q 12 weeks

Progestin Implants Advantages: • highly effective • eliminate “user error” • long-term • reversible Disadvantages: • high initial cost • insertion & removal require specialized training • cannot be easily discontinued

Condoms – Male = thin covering which fits over an erect penis. Made out of latex rubber, polyurethane, or animal membrane. Advantages Disadvantages Efficacy

Male Condoms FAILURE RATES: perfect use 2% typical use 15% MINIMIZING USER ERROR • Use with every act of intercourse • Use “from start to finish” • Unroll condom onto penis (do not unroll first; do not test by filling with air or water first) • Hold rim during withdrawal to prevent slippage or leakage • Have several condoms available

Female Condoms made of a thin plastic called polyurethane. This is NOT latex or rubber. Advantages Disadvantages Efficacy

Diaphragms A thin rubber domeshaped cup with a flexible rim. It fits over a woman's cervix and covers part of the inside of the vagina. Come in different sizes and must be fitted by a clinician. Should always be used with spermicide like a contraceptive gel or cream.

Cervical Cap a small rubber cup with a firm, rounded rim. It fits on a woman's cervix. Held in place by suction. Comes in four sizes and must be fitted by a clinician. Must be used with a spermicide, like a contraceptive gel or cream.

Natural Family Planning Egg released 14 days before start of menses. Fertilization can result from intercourse that took up to 4 days before egg release. Methods: calendar rhythm, temperature, mucus, symptothermal

Cycle Beads

Fertility Awareness / Periodic Abstinence Disadvantages: Advantages: • No hormones • No side effects • Enables a woman to understand her body’s cycles • Promotes cooperation between partners • Can also be used to achieve pregnancy or to identify infertility problems • The only method • Methods require varying amounts of training & cost • Detracts from spontaneity, causes friction between partners if not in agreement • Difficult to use if: − recent childbirth − breastfeeding − recent menarche − approaching menopause − recent discontinuation of a hormonal method − irregular cycles − unable to interpret fertility signs

Intrauterine Device Two types: progesterone release and copper release. Side effects Patient education topics Advantages and Disadvantages

Levonorgestrel Intrauterine System (LNG-IUS) (Mirena) ADVANTAGES SPECIFIC TO THE MIRENA: • can remain in place for up to 5 years • protective against endometrial cancer • reduces menstrual bleeding by 90%; 20% of users become amenorrheic • low incidence of progestin side effects (only 10% systemically absorbed) DISADVANTAGES SPECIFIC TO THE MIRENA: • irregular bleeding, especially during the first 6 months

Emergency Contraception Copper T 380 A IUD for up to 5 to 8 days after unprotected intercourse to prevent implantation. This is the most effective method. Morning After Pills (MAPs) are two large doses of ordinary birth control pills taken within 72 hours

Emergency Contraception Indications for use: • contraceptive failure (condom broke, pills forgotten) • error in withdrawal or periodic abstinence • rape • any unintended “sperm exposure” Contraindications: • pregnancy EC could prevent about ½ of unintended pregnancies − 1. 5 million pregnancies in the U. S. every year.

Emergency Contraception: Plan B Contents: 750 µg levonorgestrel per pill If taken within 72 hours as directed, Plan B reduces the risk of pregnancy from a single act of intercourse by 89%. ≈ $35. 00 per pack Directions: Take the first tablet as soon as possible within 72 hours after unprotected intercourse. Take the second tablet 12 hours later. The sooner Plan B is taken, the better. It can be taken up to 120 hours after intercourse.

Emergency Contraception: Plan B Mechanisms of Action • Disruption of development and maturation of ovarian follicles • Disruption of egg maturation and ovulation • Interference with corpus luteum function • Alteration of cervical mucus, blocking sperm • Disruption of development of the zygote, morula, & blastocyst • Impaired transport in the fallopian tube & uterine cavity • Interference with development of the endometrium to impede implantation

Sterilization – Tubal Ligation an operation which blocks the tubes carrying a woman's egg to her uterus. Advantages and Disadvantages Effectiveness

Transcervical Sterilization Essure™ Mechanism of Action: Using a hysteroscopic approach, one Essure micro-insert is placed in the proximal section of each fallopian tube lumen. The micro-insert expands upon release, acutely anchoring itself in the fallopian tube. The micro-insert subsequently elicits a benign tissue response. Tissue in-growth into the micro-insert anchors the device and occludes the FAILURE RATE: in fallopian tube, resulting sterilization. 0. 2% after 3 years

Sterilization - Vasectomy a small cut is made in the scrotum and the vas deferens are blocked. sperm will not be cleared until after 20 ejaculations. Effectiveness

Nursing Implications Assessment Planning Education Interventions Evaluation of effectiveness

Go get΄em!