SOAP. – Contraception – SỔ TAY LÂM SÀNG

Contraception

Erin Shankel

Definition

A.Contraception is the intentional prevention of pregnancy by either or both sexual partners. Contraception can be mechanical, chemical, or surgical and is either reversible or nonreversible. Considerations in counseling regarding contraceptive choices include cost, efficacy, safety, and personal considerations such as personal belief systems and ability to use selected method.

B.The Centers for Disease Control and Prevention’s (CDC) U.S. Medical Eligibility Criteria for Contraceptive Use is a document to assist healthcare providers in counseling women and men and assists healthcare providers to determine safe and effective contraceptive methods individualized to patient preferences and individual health issues. The CDC summary can be especially valuable for the busy clinician. Find the link to the summary charts at www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

Incidence

A.Women frequently visit primary care providers to request contraception and family planning education. Over 10 million women in the United States use oral contraceptive pills. Ninety-nine percent of women aged 15 to 44 have used at least one contraceptive method. Unfortunately, approximately 45% of all pregnancies in the United States are unintended. Consistent use of a reliable and effective contraceptive method can greatly reduce the unintended pregnancy rate. Easy access and education regarding contraceptive use is a keystone in the prevention of unintended pregnancy.

Subjective Data

A.Review complete menstrual history, including age of onset, duration, frequency, regularity, and dysmenorrhea. Review date of last menstrual period (LMP).

B.Review the patient’s pregnancy history.

C.Review the patient’s contraception and sexual history.

D.Note other medications the patient is taking, including over-the-counter (OTC) medications and supplements.

E.Ask the patient if she has had a major medical disease, including hypertension, cardiovascular incident, thromboembolic disease, diabetes, migraine headaches, gallbladder disease, or liver disease.

F.Review substance abuse/use history.

G.Review childhood illness and immunization record.

H.Note allergies.

I.Review pertinent family medical history.

Physical Examination

A.Check height, weight, blood pressure (BP), pulse, and body mass index (BMI).

B.Inspect:

1.Note overall appearance. Look at the neck (thyroid). Inspect the breast/genitalia for Tanner staging. Tanner’s Sexual Maturity Stages descriptions are located at childgrowthfoundation.org/wp-content/uploads/2018/05/Puberty-and-the-Tanner-Stages.pdf.

2.Skin assessment: Check for central hair growth, which is androgen responsive. Areas to inspect for coarse hair include the upper lip, chin, sideburns, neck, chest, lower abdomen, and perineum.

C.Palpate:

1.Palpate the neck for thyroid enlargement.

2.Palpate the abdomen for enlarged organs or uterine enlargement compatible with pregnancy.

D.Auscultate:

1.Auscultate the heart and lungs.

2.If pregnancy is suspected, consider auscultating for fetal heart tones.

E.Breast examination:

1.Palpate for masses.

2.Assess for nipple discharge.

F.Pelvic examination:

1.Inspect external genitalia. Note pubic hair pattern for Tanner staging. Note any lesions, masses, or discharge.

2.Speculum examination: Inspect vagina and cervix. Note any vaginal discharge. Obtain Pap smear and cervical/vaginal cultures according to Pap smear guidelines.

3.Bimanual examination: Palpate the cervix and check for cervical motion tenderness (CMT). Palpate the size of the uterus and assess for adnexal masses.

4.Consider rectal examination as indicated.

Diagnostic Tests

A.Urine: Pregnancy test as indicated/urinalysis as indicated.

B.Serum: Complete blood count (CBC) if indicated by history.

C.Pap smear according to American Society for Clinical Pathology (ASCP) guidelines.

D.Vaginal/cervical cultures testing for sexually transmitted infections (STIs) as indicated.

Plan

A.General interventions:

1.Review all methods of contraception available with the patient and partner, if available.

2.Consider all aspects of the client’s history and make recommendations as appropriate.

B.Patient teaching:

1.Review anatomy and physiology of the menstrual cycle and reproduction with all patients.

2.Review the risks, benefits, costs, use, and efficacy of contraceptive methods. Review perfect use versus typical use of method selected.

3.Review STI prevention and limitations of STI prevention as related to each method.

4.Assist the patient in selecting the most appropriate method of contraception with regard to cost, efficacy, health status of the patient, ability to use correctly and consistently, and the patient’s personal values.

5.Warning signs and information on when to call the care provider should be provided to all patients.

6.See Section III: Patient Teaching Guide Contraception: How to Take Birth Control Pills (for a 28-Day Cycle).

7.Provide all patients information on the prevention of STIs.

Methods of Contraception

A.Abstinence: Refraining from sexual intercourse:

1.Advantages: Easily accessible and inexpensive. Perfect use offers protection against STIs and pregnancy.

2.Disadvantages: User dependent.

B.Barrier methods:

1.Male condom:

a.Advantages: Male condoms are easily accessible (over-the-counter [OTC] with no prescription needed) and relatively inexpensive. Condoms do not require daily intervention and offer some protections against STIs.

b.Disadvantages: Male condoms are technique dependent for efficacy. Breakage and spillage can occur. Some condoms are made from latex, and those with latex allergies need to be aware and carefully check the label for latex content. Nonlatex condoms are available. Male condoms are intended for onetime use only.

c.Efficacy with perfect use of male condoms: Approximately two in 100 women will become pregnant each year. With typical use of male condoms, approximately 15 in 100 women will become pregnant each year.

2.Female condom:

a.Advantages: Female condoms are easily accessible (OTC with no prescription needed) and relatively inexpensive. Condoms do not require daily intervention and offer some protections against STIs.

b.Disadvantages: Female condoms are technique dependent for efficacy. Slippage and spillage can occur. The female condom is intended for one-time use only and may be inserted up to 8 hours prior to intercourse.

c.Efficacy with perfect use of the female condom: Approximately five in 100 women will become pregnant each year. With typical use of the female condom, approximately 21 in 100 women will become pregnant each year.

3.Diaphragm:

a.Advantages: Diaphragms are nonhormonal and can be used for years with proper care. May be inserted up to 6 hours prior to intercourse.

b.Disadvantages: Diaphragms must be properly fitted by an experienced healthcare provider and are user controlled. Placement is crucial to contraceptive benefit and spermicide must be used. Must be removed within 24 hours because of risk of toxic shock syndrome (TSS). The patient must have fit checked after childbirth and weight gain or loss. Urinary tract infections (UTIs) may be more frequent in diaphragm users, and some women may experience sensitivity or allergy to spermicide. Avoid use during menses.

c.Efficacy with perfect use of the diaphragm: Six in 100 women will become pregnant each year. With typical use of the diaphragm, 16 in 100 women will become pregnant each year.

4.Cervical cap:

a.Advantages: Cervical caps are nonhormonal and can be used for years with proper care. The cervical cap may be inserted and left in place up to 48 hours.

b.Disadvantages: Cervical caps must be properly fitted by an experienced healthcare provider and are user controlled. Placement is crucial to contraceptive benefit, and spermicide must be used. It must be removed within 48 hours because of risk of TSS. The FemCap is made of latex and is not appropriate for latex-allergic patients. Some women may experience sensitivity or allergy to spermicide. Avoid use during menses.

c.Efficacy with use of the cervical cap is similar to the diaphragm.

5.Vaginal sponge:

a.Advantages: The vaginal sponge is a nonhormonal OTC polyurethane sponge that releases the spermicide nonoxynol-9. It can be used for multiple acts of intercourse over 24 hours.

b.Disadvantages: The vaginal sponge is user controlled. Some women may experience sensitivity or allergy to the spermicide. Avoid use during menses.

c.Efficacy with use perfects use of the vaginal sponge: Among parous women, 20 in 100 will become pregnant each year, and nine nulliparous women will become pregnant each year. With typical use, 32 in 100 parous women and 16 nulliparous women will become pregnant each year.

C.Surgical:

1.Male sterilization:

a.Advantages: Sterilization is a very effective form of contraception. User does not have to remember to do anything prior to intercourse, and it is not user dependent. Sterilization is permanent.

b.Disadvantages: Sterilization involves a surgical procedure. Insurance may not cover the cost of the procedure. A backup method of contraception is needed for 3 months after procedure.

c.Efficacy with perfect use of male sterilization: 0.1 in 100 women will become pregnant each year. With typical use of male sterilization 0.15 in 100 women will become pregnant each year.

2.Female sterilization is the second most often used contraceptive method in the United States:

a.Advantages: Sterilization is a very effective form of contraception. User does not have to remember to do anything prior to intercourse, and it is not user dependent. Sterilization is permanent.

b.Disadvantages: Sterilization involves a surgical procedure. If pregnancy does occur, there is a higher incidence of ectopic pregnancy. Insurance may not cover the cost of the procedure.

c.Efficacy with both perfect and typical use of female sterilization: 0.5 in 100 will become pregnant each year.

D.Intrauterine device (IUD; refer to Table 17.1):

1.Hormonal levonorgestrel (LNG)-medicated IUD:

a.Advantages: Very effective form of contraception. LNG-IUDs may be left in place for 3 to 5 years. User does not have to remember to use prior to intercourse. LNG-IUDs may reduce menstrual flow.

b.Disadvantages: Risks of any IUD include uterine perforation, increased spontaneous abortion; ectopic pregnancy; and pelvic pain and infection. Hormonal IUDs must be inserted by a qualified healthcare professional. IUD may be spontaneously expelled.

c.Efficacy with both perfect and typical use of the Mirena: Eight out of 1,000 (0.8%) become pregnant over 5 years using the IUD.

2.Nonhormonal (ParaGard):

a.Advantages: ParaGard is a very effective form of contraception. ParaGard may be left in place for 10 years. User does not have to remember to use prior to intercourse.

b.Disadvantages: Risks of any IUD include uterine perforation, increased spontaneous abortion, ectopic pregnancy, and pelvic pain and infection. ParaGard must be inserted by a qualified healthcare professional. IUD may be spontaneously expelled.

c.Efficacy with perfect use of the ParaGard: 0.6 in 100 women will become pregnant each year. With typical use of the ParaGard, 0.8 in 100 women will become pregnant each year.

Women who are not appropriate candidates for an IUD include those with recent pelvic infections, anatomical uterine abnormalities, and pregnancy. Caution should be exercised when considering an IUD in women who have multiple sexual partners; pelvic inflammatory disease (PID); immunosuppression; undiagnosed, irregular, or heavy menstrual bleeding; abnormal Pap smear; and difficulty obtaining follow-up care.

E.Pharmaceutical therapy:

1.Progestin only pills (POPs; also known as mini pill):

a.Advantages: The POP is a safe hormonal alternative for women who cannot take estrogen. It is preferred to combined oral contraceptives (COCs) for lactating women as it is not as likely to decrease milk supply. POPs are rapidly reversible and controlled by women.

b.Disadvantages: The POP cannot be taken if the patient has any contraindications to progestin use. POPs are less effective than COCs and must be taken daily at the same time, requiring strict adherence to regimen. May cause menstrual changes or follicular cysts. Does not consistently suppress ovulation but increases cervical mucus and thins endometrium.

c.Efficacy with perfect use of POPs: 0.3 in 100 women per year will become pregnant. With typical use, nine in 100 women per year will become pregnant.

2.Injection of Depo-Provera long-acting depot medroxyprogesterone acetate (DMPA):

a.Advantages: Easy to use. The user only has to remember the injection every 3 months. May decrease vaginal bleeding. DMPA is a safe hormonal alternative for women who cannot take estrogen.

b.Disadvantages: Women cannot use DMPA if they have any contraindications to progesterone use. May cause amenorrhea or irregular vaginal bleeding. May cause weight gain. Requires routine (3 months) visits to the provider’s office for intramuscular (IM) injections. DMPA does not provide protection against STIs. DMPA is associated with reversible decreased bone mineral density (BMD).

c.Efficacy with perfect use of DMPA: 0.2 in 100 women per year will become pregnant. With typical use, six in 100 women per year will become pregnant.

d.Depo-Provera should be administered during the first 7 days of the menstrual cycle, or postpartum prior to resumption of intercourse (preferably after lactation has been established). If this is not possible or if a woman is late for injection, administer pregnancy test and have the patient use condoms for at least 1 week after injection.

3.Contraceptive implant (Nexplanon): Long-acting reversible etonogestrel implant:

a.A single-rod subdermal radiopaque implant

b.Advantages: Progestin implant is a safe hormonal alternative for women who cannot take estrogen. This is a long-acting (3 years) reversible contraceptive.

c.Disadvantages: Women cannot use Nexplanon if they have any contraindications to progestin use. Possible insertion and removal complications exist.

d.The manufacturer strongly recommends that care providers who wish to insert and/or remove Nexplanon participate in training sessions. Only clinicians who have completed the training program are eligible to purchase the product. The link to request this training is www.nexplanon-usa.com/en/hcp/services-and-support/request-training/index.asp.

e.Absolute contraindications to progestogen therapy:

i.Active thrombophlebitis or thromboembolic disorders.

ii.Acute liver disease, liver tumors (benign or malignant).

iii.Known or suspected cancer of the breast, history of breast cancer, or other progestin-sensitive cancer.

iv.Pregnancy.

v.Undiagnosed, abnormal vaginal bleeding.

4.Combined estrogen/progesterone contraceptives: Combined estrogen/progesterone contraceptives come in three delivery methods: oral pills, a transdermal patch, and a vaginal ring. Advantages and disadvantages and efficacy are similar regarding hormones, but there are some differences in delivery method.

a.Advantages: Combined contraceptives are easy to use, convenient, rapidly reversible, and controlled by women. The transdermal patch is only changed weekly, and the vaginal ring is left in place for 3 weeks. In addition to predictable menses, combined contraceptives decrease menstrual flow and length of menses.

b.Disadvantages: Dependent on user, and oral pills must be taken daily. Exposure to hormones may not be suitable for certain women based on health status and risk. See absolute and relative contraindications that are not appropriate for some women in a prescriber’s reference guide. Smoking in conjunction with use of combined contraceptive use increases cardiovascular risk and should be considered. Does not protect against STIs. Other medications, such as anticonvulsants and antibiotics, may interfere with the effectiveness of combined hormonal contraceptives and should be considered in prescribing.

c.Efficacy with perfect use of combined hormonal contraceptive: 0.3 in 100 women per year will become pregnant. With typical use, nine in 100 women per year will become pregnant.

d.Prescribing considerations: Oral contraceptives come in combination extended cycle, combination monophasic, combination biphasic, combination triphasic, and progestin-only formulations. Side effects can be managed in consideration of pill composition (see prescribing reference guides such as the Monthly Prescribing Reference at www.empr.com). General considerations for pill selection include age, health history/status, and the patient’s preference. Because POPs are highly sensitive to consistency in timing, reserve prescriptions of them for women who have contraindications to estrogen. Alternatives for COCs should be considered in women older than 35 who smoke due to increased risks of thrombolytic events. In asymptomatic adolescents, it is acceptable to prescribe COCs without an initial pelvic exam. For adolescents or anyone who may have difficulty remembering to take a daily pill, consideration should be given to prescription of the vaginal ring, patch, or other methods. See the office’s prescriber’s reference for complete information on safety side effects and contraindications.

e.Absolute contraindications to estrogen therapy (ET):

i.Acute liver disease.

ii.Cerebral vascular or coronary artery disease, myocardial infarction (MI), or stroke.

iii.History of or active thrombophlebitis or thromboembolic disorders.

iv.History of uterine or ovarian cancer.

v.Known or suspected cancer of the breast.

vi.Known or suspected estrogen-dependent neoplasm.

vii.Pregnancy.

viii.Undiagnosed, abnormal vaginal bleeding.

f.Relative contraindications to ET:

i.Active gallbladder disease.

ii.Familial hyperlipidemia.

iii.Smoker older than 35.

iv.Use with caution in patients with migraine with aura because of increased risk for ischemic stroke.

5.Spermicide (foam, film, gel, tablets, and suppositories):

a.Advantages: Spermicide is a nonhormonal OTC preparation and contains nonoxynol-9. It is inexpensive and easily accessible.

b.Disadvantages: Spermicide is user controlled and if not used consistently will lead to contraception failure. Some may experience sensitivity or allergy to spermicide. Spermicide has a high failure rate.

c.Efficacy with perfect use of spermicide: 18 in 100 women will become pregnant each year. With typical use of spermicide, 28 of 100 women will become pregnant each year.

F.Natural family planning (NFP):

1.Advantages: NFP is nonhormonal. It is inexpensive and easily accessible.

2.Disadvantages: NFP is user controlled and depends on regularity of cycle and avoidance of

intercourse. Can be complex for user and has a high failure rate. Does not protect against STIs.

3.Efficacy with use: With typical use of the fertility awareness method, 24 in 100 women will become pregnant each year.

Additional information, training, and patient teaching may be found at the following websites: Association of Reproductive Health Professionals: www.arhp.org Institute for Reproductive Health: www.irh.org; Planned Parenthood: www.plannedparenthood.org

G.Withdrawal:

1.Advantages: Withdrawal is nonhormonal. It is inexpensive and easily accessible.

2.Disadvantages: Withdrawal is user controlled. Withdrawal has a high failure rate and does not protect against STIs.

3.Efficacy with use: With typical use of withdrawal method, 22 in 100 women will become pregnant each year.

Follow-Up

A.The patient should return in 3 months of initiation of oral contraceptives, ring, and patch to assess BP, use, side effects, and satisfaction. Then yearly visits are recommended for health maintenance.

B.Patients on Depo-Provera injections should return every 3 months for follow-up injection and weight evaluation and then yearly for health maintenance.

C.Patients with a diaphragm should return for refitting with change in weight or postpartum and for routine health maintenance.

Consultation/Referral

A.If the contraceptive method selected is one the practitioner is not experienced in providing (diaphragm, implant, IUD, surgical sterilization), refer to an experienced appropriate provider.

Individual Considerations

A.The risk of pregnancy is decreased but still needs to be considered for women over 40 years of age. Midlife women who do become pregnant have increased risks including venous thromboembolism (VTE) and hypertensive disorders:

1.Intrauterine contraception is one of the most effective and is safe to use in midlife women with few exceptions.

2.Progestin-only contraception is also a safe option because it is not associated with an increased risk of cardiovascular complications.

3.Combined (estrogen-progesterone) contraception can be safely used by midlife women who do not have cardiovascular risk factors (smokers, hypertension, and diabetes).

4.The U.S. Selected Practice Recommendation (U.S. SPR) guideline for contraceptive use state that contraception can be used by midlife women without medical contraindications until the age of menopause, at which time they may consider transition to systemic hormone therapy (HT).