What should be asked on sexual history? (Acronym)
Sexual History – SEX ASAP
- Sexual active? Male, female or both?
- EXes – how many partners in the last 3 months
- Activities – types of sexual encounters – anal, S&M
-
STIs
- Any symptoms that make you worried about having an STI now
- Have you had any previous STIs?
- What are you doing to avoid STIs?
-
Abuse
- Sexual Abuse
- Drug use? IVDU?
-
Pregnancies
- What are you doing to avoid pregnancy? Barrier methods?
- Have you had any pregnancies before?
- When was your LMP
What is important to know on history before starting a patient on OCP? (AFP)
- Menstruation
- Pregnancy, breastfeeding, recent intercourse
- Chronic disease (e.g. hypertension), drug allergies
- Risk factors for VTE
- Future pregnancy intention
- Contraceptive experiences and preferences
- Sexual health
- Sexual practices, current and recent partners, condom use
- Previous STIs
For patients being prescribed a contraceptive for the first time, what are 5 measures that should be done on physical examination?
- Blood Pressure – follow-up visit in 6 weeks to re-check
- Breast exam
- Pelvic exam (if sexually active, otherwise do later)
- Fibroids can grow
- GC/C swabs if sexually active
- Pap is needed if sexually active and >21 years old
According to the CDC, what is the only measure that should be done on physical examination prior to prescribing a contraceptive? (AFP)
- Blood pressure
- Pelvic examination before IUD (Bimanual exam and Cervical inspection)
As part of the Choosing Wisely Campaign, what does the AAFP recommend for the physical exam prior to prescribing OCPs? (AFP)
- Do NOT require a pelvic exam or other physical exam
- ONLY measure Blood Pressure
How can you be reasonable certain that a woman is not pregnant and what is the NPV for pregnancy? (AFP)
NOT pregnant if BOTH conditions met (99% NPV = routine pregnancy testing NOT needed)
- The patient has no signs or symptoms of pregnancy
- The patient meets AT LEAST ONE of the following:
- Is 7 days or less after start of her normal menses
- Has not had intercourse since the start of her last normal menses
- Has been correctly and consistently using a reliable method of contraception
- Is 7 days or less after a spontaneous or induced abortion
- Is within 4 weeks postpartum
- Is fully or nearly fully breastfeeding (exclusively breastfeeding or most feeds (>85%) are breastfeeds, amenorrheic, and less than 6 months postpartum)
What are 5 physiologic contraceptive methods and their effectiveness?
- Abstinence – 100% effective
- Chance – 10% effective
- Calendar/Rhythm – 75% effective
- Withdrawal – 75% effective
- Lactational amenorrhea – 98% effective if breastfeeding q4h and no menses
*** No STI protection with any except abstinence ***
What are 4 barrier contraceptive methods and their effectiveness?
- Condom – 90% effective, 95% effective with spermicide
- Female condom – 80% effective
- Sponge – 90% effective
- Poor STI protection
- Diaphragm – 90% effective with spermicide
- Must be left in for 6 hours after intercourse
- Poor STI protection
What is the effectiveness of the combined oral contraceptive pill?
- 97% effective with typical use
- No STI protection – advise to use concurrent condoms
What are the absolute and relative contraindications to estrogen use?
Absolute
Relative
Head
Migraine with aura*
Migraine and >35
Previous Stroke
Breast
Cancer or undiagnosed lump
Heart
CAD
Valvular heart disease
Abdominal
Severe Cirrhosis or Liver Tumor
Mild Cirrhosis
Pregnancy
Gallstones - currently
<6 week PP & breastfeeding
Undiagnosed vaginal bleeding
Vascular
HTN SBP >160 or DBP >100
Controlled HTN
Diabetes with end-organ
Smoker >35 (<15 cig/day)
Previous DVT
Sickle Cell, SLE, IBD
Smoker >35 (>15 cig/day)
*aura of visual scintillations <1h can be acceptable
What are 4 conditions in which an OCP is contraindicated in a patient with a past history of migraine? (DFCM Open)
- Smoker
- Migraine worse on OCP
- Migraine with aura or neurological symptoms
- Other risk factors:
- Hypertension
- Age >35
- DM
- Atrial fibrillation
- Cardiomyopathy
- Thrombophilia
- Dyslipidemia
What are 6 adverse effects of estrogen excess and 5 adverse effects of progesterone excess from OCP?
- Estrogen
- Menorrhagia
- Dysmenorrhea
- Breast cystic change
- Headaches
- Nausea
- Hypertension
- Progesterone
- Low mood
- Fatigue
- Libido decreased
- Breast pain
- Weight gain and appetite increased
When do adverse effects of the combined OCP typically resolve?
- 3 months
What % of women experience irregular bleeding when starting a combined OCP? (DFCM Open)
- 10-30% in the 1st month
What should be rule out if irregular bleeding persists for >3 months in women started on a combined OCP? (DFCM Open)
- Rule out:
- Poor compliance
- Uterine/Cervical pathology
- Malabsorption
- Pregnancy
- Smoking
- Other meds
- Infection (especially Chlamydia infection if new onset spotting in regular OCP user)
How should irregular bleeding be managed in women started on a combined OCP? (DFCM Open)
- 7-day trial of oral estrogen OR switching to OCP containing different type of progestin
How should breast tenderness and nausea be managed in women started on a combined OCP? (DFCM Open)
- Switch to lower estrogen OCP
How should no withdrawal bleed during pregnancy be managed in women started on a combined OCP? (DFCM Open)
- Rule out pregnancy
- Switch to OCP containing different type of progestin (levonorgestrel) or higher dose estrogen
What are 4 serious adverse effects of combined OCP use?
- VTE: 3-4-fold risk (1 in 10,000)
- Stroke: 2-fold risk
- Breast Ca: 0 to 1.5-fold risk (3 in 1,000)
- Hypertension
By how much do higher risk contraceptives increase the risk of VTE? (TFP)
- 1 extra VTE per year for 2000 women (e.g. 2000 patients would need to switch to lower risk combined OCP to prevent 1 VT per year)
- Limited evidence as no RCTs
- Uncertain whether risks vary with different hormonal contraceptives
How does the risk of VTE compare for non-users, IUD with progestin, progestin only pills, transdermal estrogen, vaginal ring, 3rd generation progestins and OCP? (TFP)
- 4-5/10,000 woman years (non-users, progestin-only pills, progestin IUD)
- 10/10,000 woman years (combined OCP with 2nd generation progestin – levonorgestrel or norethisterone)
- 2x
- 20/10,000 woman years (transdermal estrogen, vaginal ring, OCP with 3rd generation progestin – desogestrel, gestodene, drospirenone, cyproterone)
- 2x
- 29/10,000 woman years for pregnancy
What are 3 other factors that influence VT risk in women on OCP? (TFP)
- Age = age 45-49 6x risk age 15-19
- Obesity = BMI 35+ 4x risk BMI 20-25
- Smoking = 2x risk
What are 8 potential non-contraceptive benefits of the combined OCP?
- Cycle regulation
- Decreased dysmenorrhea
- Decreased bleeding/anemia
- Decreased acne/hirsutism
- Increase bone density
- Decreased Ovarian Ca (50%)
- Decreased Endometrial Ca (50%)
- ?Colorectal cancer protection
What are 6 potential drugs that can interact with OCPs and cause failure?
- Anticonvulsants – Topamax, Carbamazepine, Phenytoin
- St. John’s wart
- SSRIs – Fluoxetine, Fluvoxamine
- Fluconazole
- Grapefruit juice
- Antibiotics – Erythromycin, Rifampin, Ritonavir
How do estrogen and progesterone act as contraceptives physiologically?
- Estrogen
- Suppresses FSH
- Progesterone
- Thins endometrium
- Thickens cervical cap
- Alters tubal transport
- At high dose (Depo) suppresses ovulation
- Causes FSH suppression
On average when does fertility returns after cessation of OCPs?
- 3 months
What are 3 different combined OCPs and their differences?
-
Yaz (20mcg, 24/4) and Yasmin (30mcg,21/7) have a progestin (Drospirenone) with anti-androgenic properties
- Better weight control, less acne and good for hirsuit women
- Must monitor K+
- VTE studies: perhaps 2x higher risk
- VTE risk in pregnancy is double that of Yaz VTE risk
- Alesse (20mcg, 21/7)
-
Seasonale (30mcg, 84/7)
- Seasonique (30mcg, 84/7) – with 10mcg during placebo period
- LoSeasonique (20mcg, 84/7)
What combined OCP can be given for perimenopausal women?
- Mircette (20mcg, 21/2/5) has 10mcg estrogen during 5 placebo days to reduce hot flashes which typically recur in perimenopause
- Also reduces the chance of ovulation if patient misses first active pill
What are the different types of combined OCPs? (DFCM Open)
- 21/28 cycle = 21d of OCP + 7d of placebo
- Monophasic (same dose of estrogen+progestin for 21d)
- Biphasic (same dose of estrogen but 2 different dose of progestin during 21d)
- Triphasic (same dose of estrogen but 3 different dose of progestin during 21d)
- Continuous Regimen
- 84d of OCP + 7d of placebo
- e.g. Seasonale or Seasonique
What are 6 advantages of a continuous regiment of combined OCP compared to a 21/28 cycle? (DFCM Open)
- Fewer withdrawal bleeds
- Decreased:
- Pelvic pain
- Headache
- Bloating
- Breast tenderness
- Better control of endometriosis/PCOS
What are 3 different ways to start an OCP? (DFCM Open)
-
1st day start (start 1st day of cycle)
- No back-up contraception requires, more SEs
-
Quick start (start immediately)
- Back-up contraception required for 1 week, less SEs
-
Sunday start (start 1st Sunday after menses)
- Back-up contraception required for 1 week if starting >5d since LMP
Why should combined OCPs be deferred until at least 6 weeks postpartum? (AFP)
- Increased risk of VTE
- Progestin-only methods can be safety started immediately postpartum
How should a patient be started on an OCP based on the first day of their last menstrual period (LMP)?
What would you recommend for a patient that missed taking their OCP?
- One Pill
- Take when remember, even if take 2 pills on the same day
- No backup protection needed
- Two Pills in first 2 weeks
- 2 pills the day you remember, 2 pills the next day
- Backup protection for 7 days and consider emergency contraception
- Two Pills during 3rd week or 3 Pills at any time
- Throw out pack and start a new pack
- Backup protection for 7 days and consider emergency contraception
Other than the combined OCP, what are 6 other contraceptive methods?
- Patch
- Ring
- Progestin-only Pills
- Progestin Depot
- IUD
- Surgical
What is the contraceptive patch, its contraindications, adverse effects and use?
- EVRA Patch (35mcg/day)
- Same contraindications as OCP
- Same side effects as OCP
- Also have skin reactions
- As effective as the pill for contraception and non-contraceptive benefits
- Apply ONE patch each week x3, then 1 patch-free week
- Apply to buttock, upper/outer arm, upper/outer torso – not to breast
- Always use the same day for patch change over – i.e. Monday
- If forget to apply a new patch
- <48h – no need for backup
- >48h – start today and use backup contraception for 1 week
- Consider emergency contraception if unprotected sex
- If forget to remove patch
- Remove when you remember and apply a new patch on the regular day
What is the contraceptive ring, its contraindications, adverse effects and use?
- Nuva Ring (15mcg/day)
- Same contraindications as OCP
- Same side effects as OCP
- As effective as the pill for contraception and non-contraceptive benefits
- Left in place for 3 weeks, removed for 1-week ring-free
- Can stay in during sex, but can be removed for up to 3h
- If forget to remove ring at end of week 3
- Remove when you remember and re-insert after 1 week
What is an example of a progestin-only pill and how effective is it?
- Micronor (0.35mg Norethindrone)
- 90% effective
What are 3 indications for the progestin-only pill for contraception?
- Lactating women
- Contraindications to estrogen
- Smoker >35 years
- Migraine with focal neurological symptoms
- Intolerant to estrogen AE
What are 3 absolute and 3 relative contraindications to progestin-only pills?
- Absolute
- Pregnancy
- Unexplained vaginal bleeding
- Current diagnosis of breast cancer
- Relative – LIVER disease
- Severe cirrhosis
- Active viral hepatitis
- Benign hepatic adenoma
What are 4 potential benefits of the progestin-only pill?
- Amenorrhea – 50% with injection, 10% with pill
- Reduced dysmenorrhea and bleeding
- Decreased endometrial cancer
- Reduced symptoms of endometriosis, PMS and chronic pelvic pain
What are 8 potential AE of progestin-only pills?
- Irregular bleeding (Inter-menstrual)
- Amenorrhea
- Functional ovarian cysts
- Headache
- Decreased libido
- Nausea
- Breast tenderness
- Weight gain in 50% (10 lbs)
- 50% lost weight or maintained
What is the effect on weight for progestin-only contraceptives according to the Cochrane review? (AFP)
- Little evidence
- Mean weight gain was < 2kg (4.4 lb) for up to 12 months
What are 2 risks specific to progesterone injections for contraception?
- 9-month delay in fertility
- Decreases BMD
Are their placebo pills for progestin-only pills?
- No – take continuously
What are 4 disadvantages of progestin-only pills compared to combined OCP?
- Slightly higher failure rates
- More breakthrough bleeding
- Does not reliably suppress ovulation – not as good for dysmenorrhea
- Must take at the SAME TIME each day
- 3-hour delay requires backup contraception
What should a patient do if they miss taking a progestin-only pill?
- 1 pill >3-hours – take pill as soon as remember and use backup for 48h
- 2 pills – take 2 pills per day for 2 days and use backup for 48h
What is an example of a progestin depo, how effective is it and how does it work?
- Depo-Provera 150mg IM q12weeks
- 99.7% effective
- High dose progestin suppresses LH surge and ovulation
How should a patient be started on Depo-Provera?
- 1st day of menses to avoid inadvertently giving when pregnant
What should a patient do if they miss an injection of Depo-Provera?
- <14 weeks – can still give injection
- >14 weeks – no sex in last 10 days and negative beta-hCG – give injection
- Requires a backup method for 2 weeks
- If she has had sex, can still give injection (not teratogenic)
- Repeat beta-hCG in 2 weeks
What are 3 indications to an IUD for contraception?
- Contraindications to OCP
- Long-term protection (5-years)
- Do NOT have to remember to take
What are 7 absolute and 3 relative contraindications to an IUD?
- Absolute
- Pregnancy
- Current or recurrent of <3 months of PID or STI
- Distorted uterine cavity
- Unexplained vaginal bleeding
- Cervical or Endometrial cancer
- Breast Cancer (Mirena)
- Copper allergy (Nova T)
- Relative
- Risk factors for HIV
- 48h – 4 weeks postpartum
- Ovarian cancer
What are 9 potential adverse effects of levonorgestrel-releasing IUDs? (AFP)
- Headaches
- Nausea
- Hair loss
- Breast tenderness
- Depression
- Decreased libido
- Ovarian cysts
- Oligomenorrhea
- Amenorrhea
What % of women using the 20mcg LNG-IUD report oligomenorrhea or amenorrhea after 2 years of use? (AFP)
- 70%
How effective are the Mirena IUD and Nova T IUD for contraception?
- Mirena = 99.9%
- Nova T = 99.3%
What is the difference between a NovaT IUD, Jaydess IUD and Mirena IUD? (DFCM Open)
- NovaT = Copper
- Mirena = Levonorgestrel 20 mcg/day
- Jaydess = Levonorgestrel 6 mcg/day
Compare and contrast the Mirena IUD and Nova T IUD by contraceptive effects, non-contraceptive benefits and adverse effects.
Nova T (99.3%)
Mirena IUD (99.9%)
Contraceptive Effects
- Inflammatory response in uterus
- Cu is spermotoxic
- Thins endometrium
- Thickens cervical cap
- Alters tubal transport
Non-contraceptive Benefits
- Lower Endometrial Ca
- Decreased Menorrhagia
- 30% Amenorrhea
- Decreased Dysmenorrhea
- Decreased endometrial hyperplasia if on tamoxifen
Side Effects
- Increased flow
- Increased dysmenorrhea
- Irregular bleeding
What are 4 potential risks associated with IUDs?
- Uterine Perforation – 1 in 1,000
- Unclear risk of PID
- Expulsion 5% over 5 years (6.7% copper > 5.8% progestin)
- Ectopic pregnancy
What should be done to the IUD in the case of an ectopic pregnancy?
- Remove IUD – lowers risk of septic abortion
- If cannot remove then get ultrasound to evaluate for perforation
When should an IUD be inserted during the menstrual cycle and when is it easiest?
- Any point in the menstrual cycle
- After pregnancy is excluded
- Easiest if during menses
- Copper = Any time in the menstrual cycle
- Levonorgestrel = First 7 days of menses
Following removal of an IUD, when does fertility return?
- 3-6 months
What are 3 possible causes for a lost IUD string and what should be done?
- Causes: Expulsion (5%), Perforation, String in Cervical Canal
- Exclude Pregnancy
- Get ultrasound
- If present, can leave it
- If not, get AXR to evaluate for perforation
How should an STI be managed in a patient with an IUD?
- If LOWER symptoms – treat STI
- If suggestive of PID – remove IUD
Is the use of misoprostol recommended before IUD insertion to allow for easier insertion? (AFP)
- No – no benefit and increased AEs
- ACOG makes NO recommendation regarding its use
Are prophylactic antibiotics recommended before IUD insertion? (AFP)
- No
How long after treatment for an STI should women with an IUD be screened? (AFP)
- 3 to 6 months after treatment
How long after resolution of an STI should an IUD be inserted? (AFP)
- 3 months
What are the risks of tubal ligation?
- Bleeding
- Infection
- Failure
- Low chance at reversing
- Risk of damage to bladder/bowel, general anesthetic
What is the annual failure rate for surgical sterilization techniques? (AFP)
- Abdominal tubal ligation (1 in 100 to 200)
- Laparoscopic tubal ligation (1 in 100 to 200)
- Male vasectomy = 1 in 100 overall (1 in 2,000 with confirmed azoospermia)
For patients starting long-term contraception what should you always counsel them about?
- Emergency Contraception
What should be done for a patient that misses a period?
- Pregnancy test and REPEAT in 2 weeks
What are the contraindications for emergency contraceptives?
- None
When should you follow-up with a patient after taking an emergency contraceptive?
- 3-4 weeks
- Repeat pregnancy test vs Spontaneous menses
- Contraception counseling
What are 3 options for emergency contraceptive use?
- Yuzpe
- Plan B
- IUD
How should the Yuzpe regimen be used for emergency contraception and how effective is it?
- Yuzpe
- 2 tablets, then repeat in 12h
- 100mcg Ethinyl estradiol and 500mcg Levonorgestrel q12h x2
- Best within 24h (98% effective), can use up to 72h (30% effective)
- AE: nausea and spotting
How should Plan B be used for emergency contraception and how effective is it?
- Plan B
- Progesterone only (Levonorgestrel 750mcg q12h x2), PO within 3 days
- Alters endometrial lining to prevent implantation
- Best within 24h (98% effective), can use within 72h (70% effective)
- AE: less N/V, still spotting
How should an IUD be used for emergency contraception and how effective is it?
- IUD – ONLY with COPPER – up to 99.9% effective
- Use within 5 days
What should be done if there is no menstrual bleeding within 21 days of treatment with emergency contraception? (Toronto Notes)
- Pregnancy test