Transcript Presentation Title Here

Contraception
Part 1: Hormonal Methods
Objectives
By the end of this lecture, participants will be able to:
• Explain major issues regarding contraception for women
• Discuss appropriate candidates for different types of hormonal
contraception
• Reinforce patient education regarding appropriate use and side
effects of hormonal contraceptive agents
• Describe the nurse’s role in caring for women seeking
contraception
A second lecture will review non-hormonal methods and
emergency contraception.
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6.7 Million US Pregnancies, 2006
Intended vs. Unintended
Intended
Pregnancies
(51%)
Birth
41%
Abortion
20%
Birth
22%
Unintended
Pregnancies
(49%)
Miscarriage
7%
Miscarriage
10%
Data from: The Alan Guttmacher Institute. Facts on unintended pregnancy in the United
States. January 2012.
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Contraceptive Use During the Month of Unintended
Pregnancy
Elective Abortions
Unintended Births
54% used contraception
48% used contraception
46% didn’t use contraception
52% didn’t use contraception
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Contraceptive Use in the U.S.
Male
C
o
n
d
o
m
IUD
Withdrawal
Other
19%
Data from Facts on Contraceptive Use in the United
DMPA
States
Ideal vs. Typical Use: Pregnancy rate in 1st year of use
Implant
Male sterilization
LNG IUD
DepoProvera
Female sterilization
Rates
diverge
Copper IUD
Pill, patch, ring
Condom (male)
Withdrawal
Diaphragm
Periodic abstinence
Spermicides
No method
Ideal Use
0.05 %
0.1 %
0.2 %
0.3 %
0.5 %
0.6
0.3
2.0
4.0
6.0
9.0
18.0
85.0
%
%
%
%
%
%
%
%
Typical Use
0.05 %
0.15 %
0.2 %
3.0 %
0.5 %
0.8
8.0
15.0
27.0
16.0
25.0
29.0
85.0
%
%
%
%
%
%
%
%
Trussell J. Contraceptive efficacy. In: Hatcher et al. Contraceptive Technology, 19th rev
ed. New York: Ardent Media, 2007
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The Contraceptive Visit
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Nurse Intake
• First day of her LMP?
• Currently using contraception?
− If so, what method?
− Regular use?
• Could she be pregnant?
− If so, she may need urine pregnancy test
• Any specific concerns?
• Any specific methods in mind?
• Current weight and blood pressure?
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Giving and Gathering Information
• Allow patient to make informed decision based on
−
−
−
−
−
−
−
Prior methods used
Safety
Efficacy
Ease of use/Privacy of use/Initiation of use
Side effects
Hormonal versus natural
Reversibility
• Avoid influencing patient’s decision with personal bias
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Patient Education
• Any additional questions regarding her chosen
method?
• Printed information regarding the chosen method in
her hand as she leaves the office
• How to contact the provider with questions
• Clear understanding of when she is to return
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Hormonal Methods of
Contraception
11
The Menstrual Cycle
Isometrik, 12/08/2009. Licensed under the Creative Commons Attribution-Share Alike
3.0 Unported license.
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Hormonal vs. Non-Hormonal Methods
Hormonal
1. Combined hormonal
Non-hormonal
− ParaGard IUD
− Oral contraceptives
− Ortho Evra Patch
− NuvaRing
− Diaphragm
− Cervical cap
− Condoms
2. Progestin-only
− Sterilization
− Depo-Provera injection
− Implanon / Nexplanon
− Mirena IUD
− Natural Family Planning
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Combined Hormonal Contraceptives
Use estrogen and progestin to prevent pregnancy
• Combined oral contraceptives
• NuvaRing©
• Ortho Evra© Patch
Typical efficacy of about 93% for all methods
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Side Effects of Combined Hormonal Contraception
•
•
•
•
•
•
Breakthrough bleeding
Nausea
Headaches
Breast tenderness
Decreased libido
Vaginal discharge, irritation, infections (NuvaRing)
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Patient Education for Oral Contraceptives
• Quick Start method to initiate use
− Take the first pill on the day of prescription
• Backup birth control for first 7 days
• Habit formation
− Try to take pill at same time each day
− Use cell phone alarm as reminder
• What to do if one or more pills are missed
• Pill doesn’t protect against HIV/other STDs
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Patient Education for Oral Contraceptives
• Common side effects
• Address weight gain concerns
− Multiple systematic reviews conclude that the available
evidence is insufficient to determine the effect of oral
contraceptives on weight, but no large effect is evident
• Common things that can affect contraceptive
effectiveness
− Medications such as antibiotics
− Herbal remedies such as St. John’s Wort
− Vomiting and diarrhea
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NuvaRing©
• Contraceptive vaginal ring
− 2 inches in diameter, 4 mm thick
− Worn for three weeks out of four
• Replaced every four weeks
• No need for fitting/special placement
• Kept in place by muscles in vaginal wall
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Patient Education for the NuvaRing©
•
•
•
•
Insertion
Four-week schedule
Backup birth control for first 7 days
Other use issues
− Ok to use if it’s broken
− Rinse with cool water and reinsert if it falls out
− If out for >3 hours, use backup birth control for 7 days
− Store for up to 4 months at 59-86°
− Tampons, spermicides, vaginal yeast products ok
• Same side effects as other combined hormonal methods. In
addition, expect vaginal discharge; avoid douching
• Doesn’t protect against HIV/other STDs
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Ortho Evra© Patch
• Transdermal delivery system
• Worn 3 weeks out of four
• Changed once per week
• Adheres through bathing, swimming, exercising
• Efficacy affected by body weight ≥198 lbs
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Ortho Evra© Patch Risks
• Same risks as other combined hormonal
contraceptives EXCEPT… Ortho Evra use results in
higher blood levels of estrogen than equivalent oral
contraceptives, thus potentially increasing the risk
for venous thromboembolism (VTE) and stroke
− Jick et al, 2010: no increased risk of VTE
− Cole et al, 2008: increased risk for VTE
− Much lower risk than pregnancy
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Patient Education for Ortho Evra© Patch
• Use:
− Four-week schedule
− Wear on upper-outer arm, upper torso, abdomen, buttock.
Don’t put on breast, irritated skin, same place as last Patch.
− Do not cut in half or alter in any way
− If Patch is off or partially off…
• ≤1 day, try to reapply or put on new Patch immediately
• >1 day, apply new Patch and start a new 4-week cycle.
Use backup birth control for 7 days.
• Doesn’t protect against HIV/other STDs
• Side effects similar to other combined hormonal methods
plus potential skin irritation at application site
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Extended Cycle Use
• Jolessa (Seasonale© equivalent) on VA formulary
• Eliminates or delays placebo week to reduce
frequency or manipulate timing of menses
• Thins uterine lining over time
• Safe and equally (or possibly more) effective than
regular oral contraception
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Duramed Pharmaceuticals, Inc, a
subsidiary of Barr
Pharmaceuticals, Inc.
Patient Education for Extended Cycle Use
• Start on first Sunday after start of menstruation. Take one active
tablet daily for 84 days, then 7 days of inert tablets.
• Habit formation
− Try to take at same time each day
− Set cell phone alarm as reminder
• Side effects similar to other combined hormonal contraceptives
plus vaginal spotting…
− 26 days of unscheduled bleeding per 13 week cycle
compared to 13 days in traditional cyclic use
− Is reduced to 1.5 days per month by 4th 13-week cycle
• What to do if one or more pills are missed
• Doesn’t protect against HIV/other STDs
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Progestin-Only Contraceptives
• Depo-Provera injection
• Oral contraceptive
• Nexplanon/Implanon implant
• Mirena© IUD
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Depo-Provera (DMPA)
• Rule out pregnancy before initiation
• Single injection every 12 -14 weeks. If >14 weeks elapse
between injections, determine pregnancy status.
− 150 mg medroxyprogesterone acetate IM Q 3 months
− SubQ also available but not on VA formulary
• Efficacy of >97%
• Postpartum use
− Within first 5-days postpartum if not breastfeeding
− During sixth postpartum week if fully breastfeeding (no food
or formula)
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Depo-Provera
Advantages
• Dosing schedule
• Effects on cycle
• May decrease risk of
gynecologic cancer or
pelvic inflammatory
disease
Disadvantages
• Injection
• Weight gain, hair loss, mood
changes, headache
• Irregular bleeding first 6-9 mos
• May worsen uncontrolled
depression
• Delayed return of fertility
• Reduces bone density; reverses
upon discontinuation
• Has been associated with
thrombotic events
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Patient Education for Depo-Provera
• Shot every 3 months
• Initial bleeding or spotting; amenorrhea over time
• Weight gain (avg 15 lbs over 5 years)
• Weight-bearing exercise and calcium
• Delayed return to fertility after discontinuation
• Reduction in bone mineral density reverses upon
discontinuation
• Reminder for return visit
• Doesn’t protect against HIV/other STDs
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Oral Progestin
• Efficacy of 93%
• Advantages
− Can stop medication immediately if there are problems
− Inexpensive compared to injectable/implant methods
• Disadvantages
− User-controlled so pills may be missed
− Strict adherence to schedule is required
• Breast-feeding mothers
− If fully breastfeeding (no food/formula), start 6 weeks after
delivery
− If partially breast-feeding, start 3 weeks after delivery
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Patient Education for Oral Progestin
• Requires strict adherence to schedule
− If a pill is missed by more than 3 hours, use backup birth
control for 5 days
• No placebo week with progestin-only pills
• What to do if pill is missed – condoms!
• Side effects include spotting or breakthrough bleeding,
amenorrhea, or shortened cycles.
− Irregular bleeding decreases in many users by cycle 12
• Doesn’t protect against HIV/other STDs
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Nexplanon® (replacing IMPLANON®) Implant
• Subdermal implant (size of a matchstick) inserted in groove
between biceps and triceps on non-dominant arm
• Stops ovulation and thickens cervical mucus
• Efficacy of >99%, effective for 3 years
• Safe for immediate postpartum contraception
• May be less effective for women >130% of ideal body weight
• Does not affect bone mineral density
• Side effect: irregular menses that doesn’t get better with time
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Nexplanon® (IMPLANON®) Visit
•
•
•
•
•
•
Obtain implant from prosthetics
Ensure provider trained in insertion is available
Rule out pregnancy
Get user card and consent form from implant packaging
Ensure patient has received written info. Any questions?
Equipment needed for insertion:
− Exam table for woman to lie on
− Sterile surgical drapes, sterile gloves, antiseptic solution, sterile
marker (optional)
− Local anesthetic spray (or 2 mL injection of 1% lidocaine),
needles, and syringe
− Sterile gauze, adhesive bandage, pressure bandage
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Nexplanon® (IMPLANON®) Removal Visit
• Equipment needed:
− Exam table for woman to lie on
− Sterile surgical drapes, sterile gloves, antiseptic solution,
sterile marker (optional)
− Local anesthetic (i.e., 0.5 to 1 mL 1% lidocaine), needles, and
syringe
− Sterile scalpel, forceps (straight and curved mosquito)
− Skin closure, sterile gauze, adhesive bandage, pressure
bandages
• Immediate replacement can be done in same arm, and through
same incision, after removal of previous implant
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Patient Education for the Implant
• Use barrier contraception for 7 days after insertion
• Expect irregular menses
• Care of insertion site:
− Pressure bandage minimizes bruising. Remove in 24 hours.
Remove small bandage over insertion site in 3 to 5 days.
• Implant must be removed no later than end of the third year
− Complete implant user card from packaging. Give to patient
as record of location of implant and when it should be
removed/replaced.
• Doesn’t protect against HIV/other STDs
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Hormonal Intrauterine Contraception:
Mirena© IUD
• Levonorgestrel 20 mcg/day
• Efficacy of 99.9%
• Effective up to 5 years
• Inserted in office setting
• Side effects
− Irregular bleeding/spotting
− 20% amenorrhea at 1 year
• Obtained through Prosthetics
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Courtesy of Bayer
Mirena©
• Advantages
‒
‒
‒
‒
Long-term method requiring no maintenance
Very cost-effective method
“Reversible sterilization”
May be place at any time during cycle
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Mirena© Visit
•
•
•
•
Rule out pregnancy
Obtain Mirena© 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
• Has patient received written info? Signed consent form. Questions?
• Remove IUD on or before expiration date with ring forceps
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Patient Education for Mirena©
• Expect irregular bleeding and/or cramps during first weeks after
insertion
• Can’t be felt during sex (unless string is cut too short, then will
poke partner)
• After every period (or every 2 months if no menses), check that
IUD strings are protruding from cervix. Don't pull!
• Record Mirena expiration date and keep in safe place
• Mirena does not protect against HIV or STDs
• Contact provider if…
− Sex is painful for self or partner
− IUD strings are missing, strings suddenly seem longer, or hard plastic
can be felt at cervix or in vagina
− Normal periods return
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Patient Education for Mirena©
• Contact provider immediately if
− Severe abdominal/pelvic pain with vaginal bleeding
− Extreme lightheadedness or fainting
− Signs or symptoms of heart attack or stroke
− Signs of pregnancy
− Unusually heavy vaginal bleeding
− Abdominal pain or pain during sex
− Unexplained fever
− Unusual or foul-smelling vaginal discharge, lesions or sores
− Very severe headaches or migraines
− Yellowing of the skin or eyes
− Exposed to a sexually transmitted infection
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For additional 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. Lesnewski & Prine. Initiating hormonal contraception. Am Fam
Physician. 2006;74(1):105-112.
4. Lesnewski et al. Preventing gaps when switching contraceptives. Am Fam
Physician. 2011;83(5):567-570 .
5. Bonnema et al. Contraception choices in women with underlying medical
conditions. Am Fam Physician. 2010;82(6):621-628.
6. Grossman Barr, N. Managing adverse effects of hormonal contraceptives. Am
Fam Physician. 2010;82(12):1499-1506.
7. Johnson, BA. Insertion and removal of intrauterine devices. Am Fam
Physician. 2005;71(1):95-102.
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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