Contraception Counseling

– History –

• Contraception Hx:
  • Previous contraception? If yes; type? Complications\SE?
  • Current breastfeeding? If yes; frequency? Duration?

• Obstetric Hx:
  • Gravida? Para? Abortions? Living?
  • If prev: mode of delivery? Fetal\maternal complications?

• Gynecological Hx:
  • Menstrual Hx:
    • FMP + LMP?
    • Regular? Duration? Amount?
    • Intermenstrual bleeding? Pain?
  • Gynecological procedures, IVF\induction of ovulation?
  • Last pap smear, mammogram?

• PMHx:
  • Diseases:
    • Chronic ds (HTN, DM\GDM, DLP)
    • VTE (DVT, stroke, MI)
    • Liver ds
    • Migraine w\ aura
    • Malignancy (breast ca)
    • Gyn (STDs, PID, endometriosis, fibroids)
  • Medications
  • Surgery, hospitalization, trauma
  • Allergies

• FMHx:
  • Malignancy (breast ca)

• Social Hx:
  • Occupation, marital status, children?
  • Smoking, alcohol, recreational drugs?
  • Travel Hx
  • Diet, exercise

 

---

– Counseling –

• What do you want to know from this consultation?
• Any preferences?
• Are you forgetful?

 

» Methods of contraception available?

• Abstinent, withdrawal, spermicides, barrier methods (condoms, diaphragm), lactational amenorrhea, combined hormonal methods (pills, patches, rings, injectable), implants, IUCD, sterilization

 

» Advantages and disadvantage of Combined Oral Contraception?

Advantages	Disadvantages
–   Reliable, less pain –   Good cycle control –   Less acne and hirsutism –   Protects against ovarian + endometrial ca	–    CVS, esp if > 40, smoker (DVT, stroke) –    Liver adenoma\toxicity –    Fluid retention\weight gain –    Mood (anxiety\depression) –    Migraines, nausea –    HTN\DM –    Stops milk production –    Breakthrough bleeding

• If breast feeding -> don’t use COC, use POP instead
• In non-lactating women -> give COC 3 wks postpartum (to allow the hypercoagulable state to reverse)
• If missed one dose? Take it as soon as possible, and the next one on the usual time
• If missed > 1 in a row? Take the most recently missed pill and the rest of the pack as normal, BUT use barrier contraception for the next 7 days
• Needs regular BP measurement every 6 mo

 

» Difference btw Combined Oral Contraception ‘COC’ and Progesterone Only Pills ‘POP’?

COC	POP “mini-pill”
–   Start on the first day of bleeding. –   Daily for 21-24 w\ free interval 7 days (where you get your period) –   Inhibit ovulation –   Less breakthrough bleeding –   Monthly withdrawal cycle –   Stops milk production –   Not for > 40, DM\HTN\obese, epileptic –   No effect on libido –   Excessive vaginal discharge	–    One pill daily, continuously, taken at the exact time –    Tube motility and thick Cs plug –    More breakthrough bleeding –    Irregular cycles \ amenorrhea –    For breastfeeding and when estrogen to be avoided –    Decreases libido –    Vaginal dryness, dysparunia

• If missed one dose? Take it ASAP. But if > 3 hrs -> use back up condom for 1 wk

 

» Breakthrough bleeding while on pills?

• R\o pregnancy -> B-hCG
• Missed pill?
• Hx of diarrhea\vomiting, medications (Abx, anti-epileptics, enzyme inducing meds like anti-TB)
• Examine for vaginal or cervical pathology (infection, polyps, cervitis)
• Pap smear, endometrial sample, chlamydia swab
• Check:
  • Estrogen dose (20-50 ug) -> go higher
  • Progestin type -> change to another

 

» Advantage of injectable hormones (medroxyprogestrone acetate ‘MDA’ = depo-provera)?

Advantages	Disadvantages
–   Very effective, reliable –   Convenient -> IM every 4 mo –   For > 40, fibroids, migraines, anemia, sickle cell, non-compliant pts –   Protects from STDs (thick Cx) –   Protects from endometrial ca	–   Irregular bleeding \ amenorrhea –   Fluid retention –   Mood\cognition –   Loss of libido –   Osteoporosis (give Ca supplements) –   Thrombogenic?

 

» Breakthrough bleeding while on MDA\depot-provera?

• First, pre-warn the pt so that she expects and accepts it
• R\o pregnancy -> B-hCG
• Examine for vaginal or cervical pathology (infection, polyps, cervitis)
• Pap smear, endometrial sample, chlamydia swab
• Give:
• NSAIDs (mefanemic acid) 500 mg daily for 1 wk
• Estrogen (Premarin) 1.25 mg for 7 d (unless CI)
• Shorten interval between injections (8-10 wk)

 

» Difference between Intra-Uterine Contraception Devices?

Copper	Hormonal
–     Several sizes and shapes –     Lasts for 5-7 yrs –     Regular periods, but heavier + more painful –     Rapid return to fertility –     Risk of ectopic, PID –     For <40 yo	–    Levenorgestril 20 ug\d –    Lasts for 3-5 yrs –    Irregular bleeding \ amenorrhea –    Slow return to fertility –    Less risk of ectopic, PID –    Protects endometrium –    For fibroids, HRT, DUB, anemia

 

» Breakthrough bleeding while on IUCD?

• R\o pregnancy -> B-hCG
• Do US to check if IUCD is misplaced
• Give:
  • NSAIDs -> 50% reduction
  • A 7-10 d course of Abx (doxycycline\augmentin)
  • One course of COC (unless CI)
• Reassure
• Remove IUCD after 6 if no change

 

» Advantages and disadvantages of hormonal implants?

Advantages	Disadvantages
–   Effectiveness ~ 100% –   For long-term use –   Every 5 yrs –   Less bleeding \ amenorrhea –   For prisoner females, in mental institutes, military personnel	–  Surgical insertion under LA –  Difficult to remove –  Spotting for the first year –  Risk of osteoporosis? –  Progesterone S\E: mood, wt gain, VTE

 

» Vaginal rings = Nuva rings?

• Inserted for 3 weeks then removed
• 15 ug ethinylestrdiol + 120 ug etonogestrel
• Advantages: half the dose of systemic hormones -> less side effects, good cycle control, rapid return to fertility
• Disadvantages: excessive vaginal discharge, ulceration

 

» Barrier methods?

Female condoms	Cervical cap	Spermicidal
§ Protects against some STDs § Compared to male condoms: less likely to cause an allergic reaction, break, or tear § No prescription § Use on demand, self-control	§ 90-92% effective w\ spermicide § Protects against some STDs (not AIDS) § Doesn’t interfere w\ intercourse § Compared to diaphragms: smaller, more comfortable, requires less spermicides § Inexpensive, reusable	§ Jellies, creams, foams, suppositories, films § Nonoxynol, octoxynol § Disadvantages: ineffective alone, skin irritation, allergic reactions

 

» Natural methods?

• Types: lactational amenorrhea method, withdrawal, outer-course, safe period (d14±3)
• Disadvantages: 20-30% failure rate, anxiety, not for irregular periods

 

» Emergency contraception?

	Levonorgestrel	E + P	Mifepristone (anti-progesterone)	Copper IUD
Used w\in	72 hrs	72 hrs	1 wk	5 d
Dose	0.75 mg twice, 12 hrs apart	100 ug ethinyl estradiol + 0.5 mg levonorgestrel, each given twice, 12 hrs apart	Single dose of 600 mg	Insert it 🙂
% of pregnancies prevented	89%	75-80%	100%	>90%

 

---

Download the PDF version: here