FPN – Contraception

Oct 28, 2019 admin PHỤ KHOA 0

Contraception

Aka: Contraception, Birth Control, Provision of Contraception, Family Planning, Contraceptive Services

II. Efficacy: First year failure rates of Contraception

  1. Most effective methods: Permanent (<1 pregnancy per year in 100 women)
    1. Vasectomy: 0.15% failure rate
    2. Tubal Ligation: 0.5% failure rate
    3. Hysteroscopic Sterilization: 0.5% failure rate
  2. Most effective methods: Reversible (<1 pregnancy per year in 100 women)
    1. Implantable Contraception (e.g. Nexplanon): 0.05% failure rate
    2. Levonorgestrel IUD (e.g. Mirena): 0.2% failure rate
    3. Copper-T IUD: 0.8% failure rate
  3. Effective methods (6-12 pregnancies per year in 100 women)
    1. Depo Provera Injection: 6% failure rate
    2. Oral Contraceptives: 9% failure rate
    3. Contraceptive Patch (e.g. Ortho Evra): 9% failure rate
    4. Vaginal Contraceptive Ring (NuvaRing): 9% failure rate
    5. Contraceptive Diaphragm: 12% failure rate
  4. Least effective methods (>18 pregnancies per year in 100 women)
    1. Male Condom: 18%
    2. Female Condom: 21%
    3. Withdrawal Method: 22%
    4. Contraceptive Sponge: 12% (nullip) to 24% (parous) failure rate
    5. Natural Family Planning: 24% failure rate
    6. Vaginal Spermicide: 28% failure rate
  5. References
    1. (2013) MMWR Recomm Rep 62(RR-05):1-60 +PMID:23784109 [PubMed]
      1. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm

III. Preparations: Non-Hormonal Options

  1. Male Condom
  2. Female Condom
  3. Contraceptive Diaphragm
  4. Contraceptive Sponge (no longer available in U.S.)
  5. Cervical Cap
  6. Vaginal Spermicide
  7. Natural Family Planning and Fertility awareness
  8. Contraceptive Sponge (returns to U.S. market in 2005)

IV. Preparations: Hormonal Contraception

  1. Oral Contraceptive
  2. Depo Provera Injectable (repeated every 3 months)
  3. Intrauterine Device
    1. Copper T-380A (Paragard) IUD: 10 years
    2. Mirena (5 year device)
    3. Skyla (3 year device)
    4. Older devices included the one year Progestasert IUD (discontinued)
  4. Vaginal Contraceptive Ring (NuvaRing)
  5. Contraceptive Patch (Ortho Evra)
  6. Implantable Progesterone Rods
    1. Nexplanon (single rod system approved for 3 years of Contraception)
    2. Older devices included Implanon (lasted 2 years) and Norplant (lasted 5 years)

V. History

  1. Confirmation of Non-Pregnant State
    1. Menstrual history
      1. Last Menstrual Period
      2. Menstrual period regularity
    2. Pregnancy history
    3. Lactation history
    4. Most recent intercourse
  2. Chronic medical problems (directs contraceptive selection as in management below)
    1. Diabetes Mellitus
    2. Cardiovascular Disease
    3. Seizure Disorders
    4. Bariatric Surgery
    5. Venous Thromboembolism or Thrombophilia
    6. Migraine Headache with aura
    7. Hypertension
    8. Tobacco abuse
    9. Chronic Corticosteroid use
    10. Systemic Lupus Erythematosus
    11. Antiphospholipid Antibody Syndrome
  3. Sexual history (and risks for STI)
    1. Current and recent sexual partners
    2. Condom use
    3. Prior Sexually Transmitted Infection (STI)
  4. Other history related to contraceptive selection
    1. Contraceptive use in the past and preferences
    2. Intention for future pregnancy

VI. Exam

  1. Blood Pressure
    1. Avoid combination Oral Contraceptives in Uncontrolled Hypertension
  2. Body weight and BMI
    1. Consider avoiding Depo Provera in low BMI patients (increased Osteoporosis risk)
    2. Monitor weight for methods that may be associated with significant weight gain (e.g. Depo Provera)
  3. Pelvic Examination
    1. Not required for extra-pelvic forms of Contraception (e.g. OCP, Depo Provera, Nexplanon, Contraceptive Patch)
    2. Indicated when placing Intrauterine Device, Cervical Cap, Contraceptive Diaphragm
    3. STD Testing may be performed at time of IUD Placement in asymptomatic patients (to avoid delays)
    4. Avoid requiring Pap Smear or well woman physical exam prior to starting Contraception

VII. Labs

  1. Pregnancy Test
    1. Confirmation of Non-Pregnant State by history may also suffice

VIII. Management: General

  1. Initiation: Avoid barriers and delays
    1. Start Contraception at time of visit (unless not able to reliably confirm Non-Pregnant State)
    2. Bridge to longterm method if unable to confirm Non-Pregnant State
      1. Use non-intrauterine Contraception until repeat Pregnancy Test in 2-4 weeks
  2. Compliance
    1. Prescribe one year supply of Contraception
    2. Help facilitate compliance (reminder systems, longterm Contraception)
    3. Reassess Contraception compliance and method satisfaction at routine visits
    4. Discuss permanent methods (e.g. Vasectomy, Tubal Ligation) if completed intended child bearing
  3. Sexually Transmitted Infection prevention
    1. Make Condoms readily available as part of dual protection for those at risk of STI
  4. Specific cohorts
    1. Postpartum counseling on Contraception after delivery
    2. Perimenopause continuation of Contraception until Menopause or age 50 to 55 years old
    3. Adolescent Health counseling on Contraception and Sexually Transmitted Infection prevention
      1. Consider Long-Acting Reversible Contraception are preferred (e.g. IUD, dermal implants)
      2. Diedrich (2015) Am J Obstet Gynecol 213(5): 662 [PubMed]
      3. Schmidt (2015) J Adolesc Health 57(4): 381-6 [PubMed]

IX. Management: Contraceptive Selection in comorbid conditions

  1. See Contraceptive Selection in Diabetes Mellitus
  2. See Contraceptive Selection in Underlying Cardiovascular Disease
  3. See Contraceptive Selection in Seizure Disorder
  4. History of Bariatric Surgery (only roux-en-Y affected due to malabsorption)
    1. Avoid Oral Contraceptives
  5. History of Venous Thromboembolism
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  6. Migraine Headache with aura
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  7. Poorly controlled Hypertension
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  8. Corticosteroids chronically
    1. Avoid Depo Provera (risk of Osteoporosis)
  9. Tobacco abuse over age 35 years
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  10. Cerebrovascular Accident
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  11. Systemic Lupus Erythematosus, Antiphospholipid Antibodies
    1. Avoid all Estrogen products (Oral Contraceptives, NuvaRing, Ortho Evra)
  12. References
    1. (2006) Obstet Gynecol 107(6): 1453-72 [PubMed]

X. References

  1. Klein (2015) Am Fam Physician 91(9): 625-33 [PubMed]

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