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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?