– 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?
- Menstrual Hx:
- 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
- Diseases:
- 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% |