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%

 


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