CHAPTER 13: REPRODUCTIVE HEALTH (BOOK) 1

CONTRACEPTION OVERVIEW CONTRACEPTIVE EFFECTIVENESS

- OCP – 16% - Typical use effectiveness – pregnancy rate given actual use, including occasional
- Sterilization – 15.5% inconsistent or incorrect use
- Condoms – 9.4% - Perfect use effectiveness – pregnancy rate given correct and consistent use
- Long-active reversible contraception (LARCS) – 7.2% - Coitus-related Xmethods & user-dependent methods < “forgettable methods”
- IUDs and implant - Two methods or dual method use – added protection

TIER ONE
General Types MOA Indication/Application Adverse Effects Contraindication Benefits
LARC Eliminates user- Single-rod
error once etonogestrel
placement occurred subdermal implant
(Nexplanon), Copper
Offered as first-line T380A IUD,
contraception to levornogestrel
most intrauterine systems
(LNG-IUS)

IUD Most commonly Copper T380A IUD All: Induce local Inserted in: *Majority – heavy or *pregnant *dec risk of
used reversible inflammatory *any day of cycle & non- prolonged menses/ *acute PID endometrial or
method of LNG-IUS – 20ug of reaction pregnant intermenstrual bleeding *postpartum cervical CA
contraception levonorgestrel is Copper: *postabortion (d/t inc prostaglandin) endometritis or
worldwide released each day *inc inflammatory *postpartum Copper: inc 50% MBL infected abortin
reaction  affects LNG-IUS: dec 60% MBL *uterine or cervical
Pregnancy rates – fxn and viability of Copper: emergency (can treat IDA) malignancy
related to skill of gametes  contraception up to 5d *Perforation – usually at *genital bleeding of
clinician inserting prevents fundus (prevention: unknown origin
the device (correct fertilization Paracervical block + straighten uterine axis *previous IUD has
high-fundal *impedes sperm dilation – if narrow cervix tenaculum & mx uterine not been removed
insertion) transport and prevents passage of cavity w/ uterine sound)
viability uterine sound *Extrauterine preg more
LNG-IUS: likely – if intrauterine,
*thicken cervical remove device
mucus *Infection – risk 6x higher
*dec tubal motility in first 3 weeks (px has 2
*thin, inactive of 3: purulent vag
endometrium discharge, adnexal
*inhibits ovulation tenderness, cervical
motion tenderness)  if
antibiotic tx does not
improve, remove device

RAT
CHAPTER 13: REPRODUCTIVE HEALTH (BOOK) 2
Subdermal Effectiveness equal Rods containing *Main – ovulation Any day of the cycle in *Bleeding irregularities –
implants or superior to progestin hormone; inhibition (30 mos) non-pregnant most common reason for
sterilization and MC is Nexplanon (68 *Thickening of discontinuation
IUDs mg of etonogestrel) cervical mucus *Local anesthesia on skin
 implant inserted using
trocar  closed w/
adhesive (5 minutes)
*Removed w/ 2mm
incision

Vasectomy 13-20 ejaculations *prohibits sperm 20 min OPD procedure

before sterile from passing into *Ligation or fulguration of
ejaculate vas

Tubal ligation Most prevalent *Interval sterilization Blocks fertilization Transabdominal Risk factors for failure: Reduced risk of
method of using laparoscopy or by cutting or Approach *age – younger women ovarian cancer
contraception by US hysteroscopy occluding fallopian *through infraumbilical *mehod of sterilization
women >30 yo *Post-partum tubes and minilaparotomy while (Hulka clips)
sterilization preventing uterus is enlarged
*Infraumbilical fertilization (postpartum)
minilaparotomy *modified Pomeroy
incision method is common
Laparoscopic Approach
*General anesthesia
*Bipolar cautery, Filshie
clip, Silastic band
Transcervical approach
*Local/ General
anesthesia, IV sedation
*Essure device 
Introduction of device
transcervically thru
hysteroscope  tissue
ingrowth
TIER TWO
Injectable *MPA – inc *inhibition of Every 3 months: *Bleeding patterns – *reduces risk of
suspension progesteronic ovulation by *150mg IM – gluteal or Major side effect – endometrial
(Depo-Provera/ potency; longer suppressing FSH deltoid muscle change in mens cycle  cancer
DMPA) acting and LH & *104mg SC – anterior amenorrhea *reduces
*DMPA – crystalline eliminating LH thigh or abdominal wall *Weight changes - ¼ gain incidence of
suspension of MPA surge weight in 1st 6 mos b/n dysmenor-rhea,
*thickened cervical Resumption of Fertility: 6 1.5-4kg symptoms of
mucus months to 1 yr (9-10 mos) *Headache – most endomet-riosis,
*altering frequent medical event ovulation pain,
endometrium  reported and ovarian cysts
atrophy *Mood changes *reduces seizure
*Bone loss – resemble frequency
menopause; reversible
RAT
CHAPTER 13: REPRODUCTIVE HEALTH (BOOK) 3
Oral *most widely used Major types: *Mainly prevent by *Most regimens are *Rates of unscheduled Absolute: *Reduces acne
contraceptives method of *Progestin-only pills interfering w/ packaged in 28-day (4 bleeding highest in early *History of vascular *improves
reversible (POPs) or minipills GnRH week) cycle: cycles dse menorrhagia and
contraception *Fixed-dose *Progestin – inhibit - 21 days – active pills *Women >35 yo dysmenor-rhea
(monophasic) ovulation (major), - 7 day – hormone-free *Estrogen – nausea who also smoke (risk
*Accidental combination pills thickens cervical interval (HFI)  uterine (12%), breast tenderness of MI) w/ Reduces:
pregnancies – d/t *Multiphasic mucus and thins bleeding 1-3d after last (9%), headache (18%) uncontrolled *Endometrial
delay of new cycle combination pills endometrium pill (lasts 3-4d) [reduce EE dose below hypertension cancer
*Estrogen – 50ug] *w/ endometrial or *Ovarian cancer –
*Withdrawal *Combination pills maintains *Some have 24/84 active breast cancer 20% every 5 yrs
bleeding -bleeding are most widely used endometrium, pills *Weight gain *Pregnancy (continues for 30y
on HFI *Some provide inhibits *Thrombosis – related to *women w/ active after end)
ethinyl estradiol (EE) unscheduled *POP – everyday w/o HFI estrogen, dose- liver dse *Colon and rectal
*Breakthrough during 7-day HFI bleeding, inhibits  doses below ovulation dependent *elevated TAG cancer
bleeding – bleeding follicular devl’t inhibition dose *Dec breast milk(EE)
during active pills *35ug doses – rarely (inhibits FSH and Relative: *BMI>40
time used bc of LH surge), Begin: Cancers: (inc risk of VTE)
cardiovascular risks enhances effects of *Adolescents who *Breast cancer – inc by *Heavy cigarette
and estrogenic side progestin demonstrate maturity of 25% smoking <35yo
effects *Ovulation H-P-ovarian axis w/ *Cervical cancer *migraine – inc risk
inhibition dose – ovulatory menses *Benign hepatocellular of stroke
lowest amt of *Delivery after 28w and adenoma *undiagnosed cause
progestin needed not nursing – no sooner of amenorrhea or
to suppress LH than 6w postpartum genital bleeding
(POPs can be initiated *Galactorrhea – to
immediately) identify
prolactinoma

Contracep-tive Ortho Evra: *75ug EE *inhibition of *One patch is aplied each *Efficacy lower in women
patch *6mg orelgestromin gonadotropin week for 3weeks w/ body weight >90kg
release *Applied to: butt, upper
*Prevention of outer arms, lower
ovulation abdomen, or upper torso
(except breast)

Contracep-tive Steroids pass Comes in only one *Inhibition of Placed in the vagina for 21 Irregular bleeding – less
vaginal ring directly through size gonadotropins days, then removed for up than w/ OCs
vaginal epithelium *Prevention of to 7 days
directly into ovulation (for 6
circulation weeks)

TIER THREE
BARRIER METHODS
Diaphragm Thin, dome-shaped *Needs fitting *Mechanical Reduce risk of
membrane barrier b/ vagina cervical dysplasia
and cervix and cancer

RAT
CHAPTER 13: REPRODUCTIVE HEALTH (BOOK) 4
Cervical cap Cup-shaped silicone *Needs fitting *Mechanical *Should be applied w/ Reduce risk of
or rubber device barrier spermicide cervical dysplasia
that fits around the *Left in place for at least and cancer
cervix 8h after last coital act

Male Condom *Mechanical *Applied to erect penis Prevent

barrier before any contact pregnancy and
*Tip should extend transmission of
beyond penis by half an STDs
inch

Female condom Loose-fitting *Mechanical *One ring – insertion *Protects

urethrane sheath barrier mechanism and internal introitus and the
w/ 2 flexible ring anchor base of penis
*Outer ring – external *Protects against
edge outside the vagina STDs

Others
Lactational *Prolactin inhibits Night nursing is
amenorrhea gonadotropin highly protective
method (LAM) pulsatility 
amenorrhea

Periodic abstinence
Calendar rhythm By calculating Fertile period: 3 assumptions: *Irregular cycles
method length of individual Subtract 18d from (1) ovum – fertilized for *Over age 35
woman’s previous her previous shortest only 24h after ovulation *Immediately
menstrual cycle cycle and 11d from (2) sperm can fertilize for following pregnancy
her previous longest up to 3-5d after coitus
cycle (3) ovulation occurs 12-
16d before onset of
menses

Daily basal body *Increasing Abstain from intercourse

temp progesterone after from cessation of menses
ovulation causes until 3rd consecutive day
rise in temp of elevated body temp

Cervical mucus Recognize and *Increasing Intercourse can occur

method interpret presence estradiol increases after menses end until 1st
and consistency of production of day that copious, slippery
mucus cervical mucus mucus is observed & 4d
after last day mucus was
present

RAT
CHAPTER 13: REPRODUCTIVE HEALTH (BOOK) 5
COITUS-BASED METHODS
Spermicides *Carrier – gel, foam, Placed into vagina before
cream, tablet, film, each coital act
suppository
*Active agent –
surfactant that kills
sperm on contact
Coitus *Removal of penis Fail – sperm in pre-
Interruptus from vagina prior to ejaculate, or not
ejaculation performed in timely
fashion

EMERGENCY CONTRACEPTION - Serial hCG or repeat ultrasound in 1wk – ensure termination

- Prevent pregnancy after an act of unprotected intercourse After first trimester
- Morning-after-pill – used up to 120h after intercourse - Dilation and evacuation
o Effectiveness is greater the closer it is taken to time of intercourse - Dilators – Laminaria japonica
Yuzpe method o Otheers: misoprostol, prostaglandin, E1 analogue
- One dose of one to six OC tablets Medical Abortion
- Second dose 12h later First Trimester Medication Abortion
- Most dedicated contain progestin levonorgestrel - Mifeprisotone or Mifreprex – affinity for progesterone receptors
Plan B One Step o w/ prostaglandin up to 72h later – 95% terminate
- Most well known and most commonly used o alone – 2 out of 3 pregnancies
- 1.5mg levonorgestrel single dose or - Mifepristone 600mg followed 48h later by 400ug oral misoprostol – 49d or less
- Two 0.75mg pills 12h apart - Mifepristone 200mg oral, followed 24-72h by 800mg misoprostol intravaginally or
- Given w/in 72h buccally -63d
- Works by delaying or inhibiting ovulation - Bleeding after – 7-14d
Ulipristal acetate (Ella) Second-Trimester Abortion
- 30mg single dose of selective progesterone receptor modulator - Induction of uterine contraction – mostly
- Ovulation is delayed for 5 days o Prostaglandins – 400mg intravaginally every 6h
- For use up to 120h Ancillary Techniques
Copper IUD - Ultrasound – AOG and to confirm that pregnancy s intrauterine
- Up to 5d after - If gestational sac not identified, B-hCG is helpful
Complications
INDUCED ABORTION - Two important determinants
- Most common gynecologic operation o Gestational age
- Illegal abortion – one of the leading causes of maternal death o Method of abortion
- 90% - performed w/in 12w of pregnancy - Beyond 10w – abortion complication rates increase
- Mifepristone – abortion drug; alternative to surgical abortion - Induced abortion – safer
- Suction curettage – safest surgical abortion
METHODS OF ABORTION - Infection – most common complication of surgical abortion
Curettage o Antibiotic prophylaxis
- By vacuum aspiration – perdominant method - Rare complications: hemorrhage, anesthetic hazards
First trimester
- Manual vacuum aspiration – up to 10w AOG
- Electric vacuum aspiration (EVA) – after 10w
o Less disruption of small gestational sacs – may facilitate identification
- Sonogram: identify retained tissues
RAT