Contraception.

Contraception

Poll Question Patricia Benner (1984) developed the 5 Stages of Clinical Competence. Which stage best describes your personal nursing practice with regard to women’s health? Novice Advanced beginner Competent Proficient Expert I wanted to begin with a poll question to find out more about who is attending today. Patricia Benner developed the 5 Stages of Clinical Competence in Which stage best describes your personal nursing practice with regard to women’s health? Novice-with no experience Advanced beginner--has gained prior experience in actual situations Competent—2-3 years on the job in the same area Proficient—learns from past experiences what to expect in certain situations…knows how to modify plans Expert—has intuitive grasp of clinical situations Reference: Benner P (1984) From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, Addison-Wesley

Learning Objectives Explain major contraceptive issues for women
Answer patient questions about contraceptive methods Reinforce patient education on contraceptive use and their side effects Appropriately triage women who present with contraceptive issues Provide a focused nursing assessment for women presenting with contraceptive problems Develop nursing plans of care to manage common contraceptive concerns We have 6 objectives for this talk. By the end of the program, you should be able to: Explain major contraceptive issues for women Answer patient questions about contraceptive methods Reinforce patient education on contraceptive use and their side effects Appropriately triage women who present with contraceptive issues Provide a focused nursing assessment for women presenting with contraceptive problems Develop nursing plans of care to manage common contraceptive concerns Now let’s take a look at our poll results.

Poll Results Patricia Benner (1984) developed the 5 Stages of Clinical Competence. Which stage best describes your personal nursing practice with regard to women’s health? Novice Advanced beginner Competent Proficient Expert

64 Million U. S. Pregnancies, 2001
Birth 41% Miscarriage 10% 7% Abortion 20% 22% Intended Pregnancies (51%) Unintended Pregnancies (49%) Approximately half of US pregnancies are unintended Of these 1 in 5 will end in abortion. This slide tells us American women are not using contraception effectively for a variety of reasons and many are not satisfied with currently available choices. New contraceptive options may help to decrease the number of unwanted pregnancies. Data Source: Finer LB and Henshaw SK. Disparities in Rates of Unintended Pregnancy in the United States, 1994 and Perspectives on Sexual and Reproductive Health, 2006; 38(2):90–96.

Contraceptive Use During the Month of Unintended Pregnancy
Elective Abortions Unintended Births Many women with unintended pregnancies report that they used contraception during the month that they became pregnant. The proportion who make this claim is even higher among those who terminated pregnancy through elective abortion. (54% of those who chose to terminate were using contraception) Again these data suggest that women are not selecting a highly effective method of contraception or that highly effective methods are not being used consistently or correctly. Data source: Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24--9,46. 46% didn’t use contraception 52% didn’t use contraception

Contraceptive Use, 2006-2010 Other 50% Vasectomy 6% IUD 4%
Tubal ligation 17% Oral contraceptives Vasectomy 6% IUD 4% Withdrawal 3% DMPA 2% Ring 1% Implant/Patch 1% Nat Fam Plan 0.7% Other 0.3% Male condom 10% Contraceptive Use in the U.S. These data depict contraceptive use in the U.S. They are from the CDC. Oral contraceptives are used nearly 20% also permanent sterility in the form of tubal ligation and vasectomy account for another nearly 25% Source: CDC. National Health Statistics Report, Number 60, October 2012.

Pregnancy rate in first year of use
Contraceptive agent Ideal Use Typical Use Implant 0.05 % Vasectomy 0.10 % 0.15 % Mirena 0.2 % Tubal ligation 0.5 % ParaGard 0.6 % 0.8 % DepoProvera 6.0 % Pill, patch, ring 0.3 % 8.0 % Male condom 2.0 % % Withdrawal 4.0 % % Diaphragm % Periodic abstinence 9.0 % % Sponge % % Spermicides % No method % Pregnancy rate in first year of use This table compares failure rates for ideal vs. typical use. The red line denotes the point at which the rates diverge. Note ABOVE =Less user dependent –either permanent or involve a clinician DOING something Note BELOW =More user dependent-requires patient effectively using the option. What this slide shows is there is no such thing as perfect use. Human Nature prevails…condom in drawer at home -when away for weekend Shared decision making-How do you feel about taking a pill everyday? What do you see as getting in the way? Yes we must give options but #1 they gotta use it. To help with this we need to discuss methods that the PATIENT feels will be easy to use. Counsel on expected side effects and management strategies. The last line shows from adolescents to mid-40’s % of couples using no method will become pregnant within 1 year. Source: Trussell J, Contraceptive failure in the United States, Contraception, 2011, 83(5):397–404. Data from: Trussell, James. Contraception, May 2011.

The Contraceptive Visit
So now we move from a general overview to the actual contraceptive visit… The Contraceptive Visit

Nurse Intake: Collect Information
First day of LMP? Contraceptive use? Method? Regular use? Pregnancy status Urine test? Specific concerns? Methods of interest? Current weight and BP? What is the nurse’s role? Collect information: First day of her LMP? Currently using contraception? If so, what method? Regular use? Could she be pregnant? If so, she may need urine pregnancy test Any specific contraceptive concerns? Any specific contraceptive methods in mind? Current weight and blood pressure?

Giving and Gathering Information
Informed decision should be based on: Prior methods used Safety Efficacy Ease of use / Privacy of use / Initiation of use Side effects Hormonal vs. natural method Reversibility Avoid influencing her decision Giving and Gathering Information Allow her to make an informed decision Avoid influencing her decision with your personal bias Proper techniques when giving and gathering information is important. Allow the patient to make an informed decision based on: Prior methods used Safety Efficacy Ease of use/Privacy of use/Initiation of use Side effects Hormonal versus natural method Reversibility Avoid influencing the patient’s decision with your personal bias

Patient Education for Contraceptives
Additional questions about method? Printed information Provider’s contact information Follow-up plan/return visits Patient education for contraceptive agents includes… Any additional questions regarding her chosen method? Printed information regarding the chosen method in her hand as she leaves the office How to contact the provider with questions Clear understanding of when she is to return

Multiple Contraceptive Methods
Hormonal Combined estrogen + progestin Pills, Patch, Ring Progestin-only Pill, Injection, Implant, Mirena IUD Non-Hormonal ParaGard IUD Condoms, Diaphragm Cervical cap Sterilization Spermicide, Sponge Natural family planning Contraceptive methods can be grouped into 2 main types: hormonal (which includes combined hormonal -- estrogen plus progestin or progestin-only – and non-hormonal. Hormonal Combined hormonal Oral contraceptives Ortho Evra Patch NuvaRing Progestin-only methods Depo-Provera injection Implanon / Nexplanon Mirena IUD Non-hormonal ParaGard IUD Diaphragm Cervical cap Condoms Sterilization Natural Family Planning

Follicular Phase Estrogen rises, endometrium thickens Ovulation occurs 14 days BEFORE onset of menses Luteal Phase Corpus luteum formed, progesterone created, endometrium stabilized Before discussing the different methods of contraception, let’s review the menstrual cycle. Although we normally see the cycle displayed as a 28 day cycle, 28 days is only an average. A normal cycle can range from 21 – 35 days in length and 3-8 days in duration. The 1st phase is the follicular phase. The pituitary gland emits Follicle Stimulating Hormone (FSH) which wakes up the ovaries. Estrogen begins to rise, which acts on the endometrium to thicken it. Then ovulation occurs. The 2nd phase is the Luteal Phase. The Leutenizing hormone surges, and progesterone “kicks in”. It is progesterone’s job to be the glue for the endometrial lining. Progesterone normally lives for 14 days, getting the endometrium ready for a fertilized egg to implant. If an egg is not fertilized, estrogen/progesterone drops and menses occurs. This cycles repeats itself. Combined hormonal contraceptives provide a steady state of ethinyl estradiol and a progestin to prevent this normal turn of events. Note that during the normal menstrual cycle, ovulation occurs 14 days BEFORE onset of menses. Menstrual Cycle

Combined Hormonal Contraceptives
Combined Oral Pill NuvaRing© Ortho Evra© Patch Typical efficacy 93% Estrogen Progestin Combined Hormonal Contraceptives These use both estrogen and progestin to prevent pregnancy Combined oral contraceptives NuvaRing© Ortho Evra© Patch Using Brand Names because there are no generics available at this time. Typical efficacy of about 93% for all methods

Side Effects of Combined Hormonal Contraception
Breakthrough bleeding Nausea Headaches Breast tenderness Decreased libido Vaginal discharge, irritation Side effects of combined hormonal contraception include: Breakthrough bleeding Nausea Headaches Breast tenderness Decreased libido Vaginal discharge, irritation, infections These are mostly annoying, but it’s very important that we discuss them with our patients. Many of these side effects can be managed by working through them for a few months.

Patient Education for Oral Contraceptives
Quick Start to initiate use Habit formation Side effects (previous slide) Non-hormonal backup x 7 days Missed pill protocol Impact effectiveness: St. John’s wort, medications (e.g., antibiotics), vomiting/diarrhea No HIV/STI protection Several strategies can be employed to increase daily pill adherence: Quick Start method to initiate use Take the first pill on the day of prescription receipt Habit formation Try to take a pill at the same time each day Use a cell phone alarm as a reminder Adopt a daily routine…wash your face/brush your teeth/take your pill Employ Motivational Interviewing . Ask her: “What is the most routine part of your day?” Common side effects Mention effects listed on previous slide Address weight gain concern… multiple systematic reviews conclude that the current evidence is insufficient to determine the effect of oral contraceptives on weight, but no large effect is evident Additional patient education includes: Non-hormonal backup birth control for the first 7 days What to do if one or more pills are missed (1 missed pill = take it) (2nd day take 2) (>2 use backup birth control for 7 days and start a new pill pack) Common things that affect contraceptive effectiveness: Medications such as antibiotics Herbal remedies such as St. John’s Wort Vomiting and diarrhea Pill doesn’t protect against HIV or other STIs

NuvaRing© 2-inch vaginal ring Worn 3 weeks out of 4
No fitting necessary Kept in place by vaginal muscles Appropriate for women who experience nausea with oral pill The contraceptive vaginal ring is 2 inches in diameter and 4 mm thick. Worn for three weeks out of four Replaced every four weeks No need for fitting or special placement Kept in place by muscles in the vaginal wall If a woman experiences nausea with an OCP, the NuvaRing© may be for her.

Patient Education for the NuvaRing©
Insertion process and 4-week schedule Non-hormonal backup x 7 days at initiation and if out for >3 hours Store for up to 4 months at 59-86° Ok if broken. If falls out, rinse with cold water, reinsert. Same side effects as other combined hormonal methods plus discharge. Avoid douching. Ok to use tampons, spermicides, vaginal yeast products No HIV/STI protection Patient Education for the NuvaRing©: Insertion (similar to placing a tampon (intravaginal) Four-week schedule Non-hormonal backup birth control for the first 7 days Other use issues Ok to use if it’s broken Rinse with cool water and reinsert if it falls out If out for >3 hours, use backup non-hormonal birth control for 7 days Store for up to 4 months at 59-86° Ok to use tampons, spermicides, vaginal yeast products Same side effects as other combined hormonal methods. In addition, expect vaginal discharge; avoid douching. Doesn’t protect against HIV or other STIs

Ortho Evra© Patch Transdermal delivery Worn 3 weeks out of 4
Changed weekly Can get wet Affected by weight The Ortho Evra ©Patch is a transdermal delivery system. Worn 3 weeks out of four Changed once per week Adheres through bathing, swimming, exercising Efficacy is affected by body weight ≥198 lbs. Due to weekly change, a little more difficult to use.

Potentially increases risk for VTE and stroke
Ortho Evra© Patch has same risks as other combined hormonal contraceptives EXCEPT… Causes higher blood levels of estrogen than equivalent oral contraceptives Potentially increases risk for VTE and stroke Ortho Evra© Patch Risks Same risks as other combined hormonal contraceptives EXCEPT… Ortho Evra use results in higher blood levels of estrogen than equivalent oral contraceptives Potentially increasing the risk for blood clot and stroke We say “potentially increases the risk of VTE” because results of the studies to date are mixed. It’s important to remember that the risk of VTE with the patch is much lower than the risk of VTE with pregnancy. References: Jick et al, 2010: no increased risk of VTE Cole et al, 2008: increased risk for VTE

Patient Education for Ortho Evra© Patch
4-week schedule Placement sites What to do it patch comes off Skin irritation No HIV/STI protection Side effects similar to other combined methods plus potential skin irritation Patient Education for Ortho Evra© Patch Use: Four-week schedule Wear on upper-outer arm, upper torso, abdomen, buttock. Don’t put on breast, irritated skin, same place as last Patch. Do not cut in half or alter in any way If Patch is off or partially off… ≤1 day, try to reapply or put on new Patch immediately . Do not use tape to keep the patch on. >1 day, apply new Patch and start a new 4-week cycle. Use backup birth control for 7 days. --Doesn’t protect against HIV/other STIs --Side effects similar to other combined hormonal methods plus potential skin irritation at application site

Poll Question Which of the following is not a side effect of oral contraception? Headache and nausea Spotting Breast tenderness Decreased libido Weight changes I have a question about oral contraception… Which one of the following is not a side effect of oral contraception? Headache and nausea Spotting Breast tenderness Decreased libido Mood and weight changes

Extended Cycle Jolessa on VA formulary
Eliminates/delays placebo week to reduce menses frequency Thins uterine lining over time Safe, effective Jolessa is on the VA formulary. Extended cycle use: Eliminates or delays placebo week to reduce frequency or manipulate timing of menses Thins uterine lining over time (reassure women that nothing is “backing up” inside of them) Safe and equally (or possibly more) effective than regular oral contraception

Patient Education for Extended Cycle
Begin first Sunday after start of menses. One active tablet x 84 days, one inert tablet x 7 days. Habit formation Same side effects as other combined hormonal contraceptives plus vaginal spotting Non-hormonal backup x 7 days Missed pill protocol Impact effectiveness: St. John’s wort, some meds, vomiting/diarrhea No HIV/STI protection Ok to take continuously until breakthrough bleeding, then stop for a week Patient Education for Extended Cycle Use Start on first Sunday after start of menstruation. Take one active tablet daily for 84 days, then 7 days of inert tablets. Habit formation Try to take at same time each day Set cell phone alarm as reminder Side effects similar to other combined hormonal contraceptives plus vaginal spotting… 26 days of unscheduled bleeding per 13 week cycle compared to 13 days in traditional cyclic use Is reduced to 1.5 days per month by 4th 13-week cycle Non-hormonal backup birth control for first 7 days What to do if one or more pills are missed Common things that affect contraceptive effectiveness Medications such as antibiotics Herbal remedies such as St. John’s Wort Vomiting and diarrhea Doesn’t protect against HIV/other STIs --Some Women take continuous until they experience an increase in breakthrough bleeding —listen to body and then stop for a week. This is considered reasonable.

Poll Results Which one of the following is not a side effect of oral contraception? Headache and nausea Spotting Breast tenderness Decreased libido Mood and weight changes Several systematic reviews conclude that current evidence is insufficient to determine the effect of oral contraceptives on weight, but no large effect is evident.

Progestin-Only Contraceptives
Depo-Provera Oral Pill Nexplanon Mirena Progestin Estrogen Now, we’ll discuss progestin-only contraceptives…

Depo-Provera (DMPA) IM shot every 12-14 weeks
Rule out pregnancy first and if >14 wks between injections Efficacy >97% Ok for post-partum use In first 5 days if not breastfeeding During 6th postpartum week if fully breastfeeding Depo-Provera (DMPA) Single injection every weeks. If >14 weeks elapse between injections, determine pregnancy status. 150 mg medroxyprogesterone acetate IM Q 3 months SubQ also available but not on VA formulary Rule out pregnancy before initiation Efficacy of >97% Ok for postpartum use Within first 5-days postpartum if not breastfeeding During sixth postpartum week if fully breastfeeding (no infant food or formula)

Depo Advantages Depo Disadvantages Dosing schedule Effects on cycle
May reduce GYN cancers or PID Depo Disadvantages Injection Weight gain, hair loss, mood changes, headache Irregular bleeding 1st 6-9 mos May worsen uncontrolled depression Delayed return to fertility of up to 1 year Reduced BMD that reverses Potential thrombotic events Women must weigh the pros and cons of Depo-Provera: Advantages Dosing schedule Effects on cycle May decrease risk of gynecologic cancer or pelvic inflammatory disease Disadvantages Injection Weight gain, hair loss, mood changes, headache Irregular bleeding first 6-9 mos May worsen uncontrolled depression Delayed return of fertility (may take up to one year for menses to return) Reduces bone density; reverses upon discontinuation Has been associated with thrombotic events

Patient Education for Depo-Provera
Shot every 3 months Initial spotting, amenorrhea over time Weight gain average 15 lbs over 5 years Delayed fertility Temporarily affects BMD Exercise + calcium Return visit reminder No HIV/STI prevention Patient Education for Depo-Provera Shot every 3 months Side effects Initial bleeding or spotting; amenorrhea over time Weight gain (avg 15 lbs over 5 years) Delayed return to fertility after discontinuation Reduction in bone mineral density reverses upon discontinuation Routine use of calcium and weight-bearing exercise are important to discuss. Reminder for return visit Doesn’t protect against HIV/other STIs

Oral Progestin Typical efficacy 93% Inexpensive
Strict adherence to schedule Ok for breast-feeding mothers Start 6 wks postpartum if fully breastfeeding; 3 wks postpartum if partially breastfeeding Oral Progestin Typical efficacy of 93% Advantages Can stop medication immediately if there are problems Inexpensive compared to injectable/implant methods Disadvantages User-controlled so pills may be missed Strict adherence to schedule is required—timing is important. Complete compliance so good for Type A personalities Ok for breast-feeding mothers If fully breastfeeding (no food/formula), start 6 weeks after delivery If partially breast-feeding, start 3 weeks after delivery

Patient Education for Oral Progestin
Strict adherence to schedule If missed by >3 hrs, use non- hormonal backup x 5 days No placebo week Missed pill protocol Spotting, irregular bleeding until cycle 12 Potential amenorrhea No HIV/STI protection Patient education for oral progestin includes: Requires strict adherence to schedule If a pill is missed by more than 3 hours, use non-hormonal backup birth control for 5 days No placebo week with progestin-only pills What to do if a pill is missed Side effects include spotting or breakthrough bleeding, amenorrhea, or shortened cycles. Irregular bleeding decreases in many users by cycle 12 Doesn’t protect against HIV or other STIs

Nexplanon® (formerly IMPLANON®)
Nexplanon is radio opaque and can be detected by x- ray. New applicator simplifies insertion. Subdermal implant is inserted in groove between biceps and triceps on non-dominant arm Efficacy >99% x 3 years Ok for immediate postpartum contraception Less effective for women >130% of ideal body weight Irregular menses do not improve with time Insertion training through manufacturer Nexplanon (formerly Implanon) is a subdermal implant (the size of a matchstick). Inserted in groove between biceps and triceps on non-dominant arm Stops ovulation and thickens cervical mucus Efficacy of >99%, effective for 3 years Safe for immediate postpartum contraception May be less effective for women >130% of ideal body weight Does not affect bone mineral density Side effect: irregular menses that doesn’t get better with time Some may ask why is Nexplanon replacing Implanon? Nexplanon is radio opaque and can be detected by X-ray. Also the new applicator makes insertion easier and insertion failure less likely. Training is offered through the manufacturer.

Nexplanon® Insertion/Removal
Obtain from Prosthetics Trained provider Rule out pregnancy Informed consent, written info in packaging Insertion supplies Record replacement date Can replace through same incision Nexplanon Insertion/Removal Visits Obtain implant from prosthetics Ensure a trained provider is available Rule out pregnancy Get user card and consent form from implant packaging Ensure patient has received written info. Any questions? New implant can be inserted through the same incision

Nexplanon® Insertion/Removal
Exam table to lie on Sterile surgical drapes, sterile gloves, antiseptic solution, sterile marker (optional) Local anesthetic spray (or 2 mL injection of 1% lidocaine), needles, and syringe Skin closure, sterile gauze, adhesive bandage, pressure bandage Removal Exam table to lie on Sterile surgical drapes, sterile gloves, antiseptic solution, sterile marker (optional) Local anesthetic (i.e., 0.5 to 1 mL 1% lidocaine), needles, and syringe Sterile scalpel, forceps (straight and curved mosquito) Skin closure, sterile gauze, adhesive bandage, pressure bandage Nexplanon Insertion/Removal Visits Obtain implant from prosthetics Ensure a trained provider is available Rule out pregnancy Get user card and consent form from implant packaging Ensure patient has received written info. Any questions? Equipment needed for insertion: Exam table for woman to lie on Sterile surgical drapes, sterile gloves, antiseptic solution, sterile marker (optional) Local anesthetic spray (or 2 mL injection of 1% lidocaine), needles, and syringe Skin closure, sterile gauze, adhesive bandage, pressure bandage Equipment needed for removal: Local anesthetic (i.e., 0.5 to 1 mL 1% lidocaine), needles, and syringe Sterile scalpel, forceps (straight and curved mosquito) Skin closure, sterile gauze, adhesive bandage, pressure bandages New implant can be inserted through the same incision

Patient Education for Nexplanon®
Use non-hormonal contraception x 7 days Irregular menses Wound care Pressure bandage minimizes bruising. Remove in 24 hours. Remove small bandage over site in 3 to 5 days. Must be removed no later than end of the third year. Record expiration date. No HIV/STI protection Patient Education for Nexplanon Use barrier contraception for 7 days after insertion Expect irregular menses Care of insertion /removal site: - Pressure bandage minimizes bruising. Remove in 24 hours. Remove small bandage over site in 3 to 5 days. Implant must be removed no later than end of the third year - Complete implant user card from packaging. Give to patient as record of location of implant and when it should be removed/replaced. Doesn’t protect against HIV/other STIs

Poll Question In your facility, if a woman wants an IUD, where does she go? Primary Care Women’s Specialty Clinic Fee-basis provider Before we begin talking about IUD’s, I’d like to know how your facility approaches dispensing IUD’s for women. In your facility, if a woman wants an IUD, where does she go? Primary Care Women’s Specialty Clinic Fee-basis provider

Mirena© IUD Levonorgestrel 20 mcg Efficacy 99.9% x 5 years
Inserted in office Irregular bleeding, spotting 20% amenorrhea by 1 year Obtain from Prosthetics Mirena is a small, flexible intrauterine device. Levonorgestrel 20 mcg/day Inhibits sperm motility by thickening the cervical mucus. Suppresses growth of the uterine lining which inhibits ovulation in some cycles. Sperm is only happy with high levels of estrogen (thinking back to the menstrual cycle--no ovulation means no higher levels of estrogen) Efficacy of 99.9% Effective up to 5 years Inserted in office setting Side effects Irregular bleeding/spotting –a few % will have light unpredictable bleeding—minimal but worth mentioning. 20% amenorrhea at 1 year Obtained through Prosthetics

Mirena© Advantages Long-term method, no maintenance Cost-effective
“Reversible sterilization” Insert any time during cycle New strings not amenable to bacteria Mirena Advantages Long-term method requiring no maintenance Very cost-effective method “Reversible sterilization” May be place at any time during cycle This is not your mother/grandmothers IUD. The strings are different; they are not amenable to bacteria.

Poll Results In your facility, if a woman wants an IUD, where does she go? Primary Care Women’s Specialty Clinic Fee-basis provider

Mirena Insertion Rule out pregnancy Obtain from Prosthetics
Trained provider Pre-medicate with mg of ibuprofen one hour before procedure Informed consent, written information Record removal date Mirena Insertion Mirena Insertion/Removal Visit Rule out pregnancy (document in the medical record) Obtain Mirena© from prosthetics Trained provider Pre-insertion med: mg of ibuprofen one hour prior to procedure Provide written information to patient Signed consent form? Questions?

Insertion/Removal Supplies
Exam table with footrests Betadine or hibiclens, poured into a pack of 4x4 gauze Sterile gloves Sterile equipment on sterile tray: Uterine sound, vaginal speculum, ring forceps, suture scissors (long), single tooth tenaculum, sterile IUD package Removal: Remove on or before expiration date Ring forceps Mirena Insertion/Removal Suppplies Equipment needed for insertion: Betadine or hibiclens, poured into pack of 4x4 gauze Sterile gloves Sterile equipment on sterile tray: Uterine sound, vaginal speculum, ring forceps, suture scissors (long), single tooth tenaculum, sterile IUD package Remove IUD on or before expiration date with ring forceps

Patient Education for Mirena©
Irregular bleeding, cramping for first few weeks Cannot be felt during sex String check after every menses (every 2 months if no menses) Keep expiration date in safe place No HIV/STI protection Call if strings missing/seem longer, or plastic felt at cervix or vagina Contact provider immediately if… Severe pelvic pain with vaginal bleeding, extreme dizziness or fainting, symptoms of heart attack or stroke, signs of pregnancy, unusually heavy vaginal bleeding, pain during sex, unexplained fever, unusual or foul-smelling vaginal discharge, lesions or sores, very severe headaches or migraines, yellowing of skin or eyes, STI exposure Patient education for Mirena: Expect irregular bleeding and/or cramping during first weeks after insertion Can’t be felt during sex (unless string is cut too short, then partner may notice it) After every period (or every 2 months if no menses), check that IUD strings are protruding from the cervix. Don't pull! Record Mirena expiration date and keep in a safe place Mirena does not protect against HIV or STIs Contact provider if… IUD strings are missing, strings seem longer, hard plastic can be felt at cervix or in vagina Normal periods return Contact provider immediately if… Severe abdominal/pelvic pain with vaginal bleeding Extreme lightheadedness or fainting Signs or symptoms of heart attack or stroke Signs of pregnancy Unusually heavy vaginal bleeding Abdominal pain or pain during sex Unexplained fever Unusual or foul-smelling vaginal discharge, lesions or sores Very severe headaches or migraines Yellowing of the skin or eyes Exposed to a sexually transmitted infection Counseling on side effects is important —20% of women will have amenorrhea by one year. Expect light spotting monthly. A fair percent of women will have light unpredictable bleeding. As effective as sterilization

Non-Hormonal Contraceptive Methods
ParaGard IUD Condoms, Diaphragm, Cervical Cap Spermicides, Sponge Sterilization Natural Family Planning Estrogen Progestin Now, we’ll discuss non-hormonal contraceptive methods…

ParaGard – Copper T 380A IUD
380 copper coils Efficacy of 99.4% for 10 years Vaginal discharge, pain/ bleeding with menses Get from Prosthetics Avoid for women with copper allergy The ParaGard - Copper T 380A is an intrauterine device. Effective up to 10 years Inserted in office setting Inhibits sperm motility, fertilization and implantation--Copper is not a happy place for sperm—creates a toxic environment. Remember in <90 seconds sperm can travel to the uterine cavity. Side effects Increased bleeding/pain with menses Vaginal discharge Obtained through Prosthetics Not suitable for women with a copper allergy

ParaGard© Advantages Long-term, requires no maintenance
Most cost effective method Considered “reversible sterilization” Useful for women who can’t take estrogen or won’t take hormones Insert any time during cycle ParaGard Advantages Long-term method requiring no maintenance Overall, the most cost-effective method “Reversible sterilization” Useful for women who can’t take estrogen or don’t want to use hormones Can be inserted at any time during menstrual cycle

ParaGard©Insertion Rule out pregnancy Obtain from Prosthetics
Trained provider Pre-medicate with mg of ibuprofen one hour prior to procedure Informed consent, written info Record removal date ParaGard Insertion/Removal Visit: Rule out pregnancy (document in the medical record) Obtain ParaGard© from prosthetics Ensure trained provider available Pre-insertion medication: mg of ibuprofen one hour prior to procedure Provide written information to patient Signed consent form? Questions?

Insertion/Removal Supplies
Exam table with footrests Betadine or hibiclens, poured into a pack of 4x4 gauze Sterile gloves Sterile equipment on sterile tray: Uterine sound, vaginal speculum, ring forceps, suture scissors (long), single tooth tenaculum, sterile IUD package Removal: Remove on or before expiration date Ring forceps ParaGard insertion and removal supplies are similar to those used for Mirena IUDs. Equipment needed for insertion: Betadine or hibiclens, poured into a pack of 4x4 gauze Sterile gloves Sterile equipment on a sterile tray Uterine sound, vaginal speculum, ring forceps, suture scissors (long), single tooth tenaculum, sterile IUD package Remove IUD on or before expiration date with ring forceps

Patient Education for ParaGard©
Irregular bleeding, cramping for first few weeks Cannot be felt during sex String check after every menses (every 2 months if no menses) Keep expiration date in safe place No HIV/STI protection Call if strings missing/seem longer, or plastic felt at cervix or vagina Contact provider immediately if… Severe pelvic pain with vaginal bleeding, signs of pregnancy, severe or prolonged vaginal bleeding, pain during sex, unexplained fever, unusual or foul-smelling vaginal discharge, vaginal lesions or sores, STI exposure Patient Education for ParaGard Expect irregular bleeding and/or cramping during first weeks after insertion Can’t be felt during sex (unless the string is cut too short, then it will poke partner) After every period (or every 2 months if no menses), check that IUD strings are protruding from cervix. Don't pull! Record expiration date and keep in a safe place Does not protect against HIV or STIs Contact provider if… IUD strings are missing, strings suddenly seem longer, or device can be felt at the cervix or in vagina Normal periods return Contact provider immediately if… Signs of pregnancy Pain during sex Unusual or foul-smelling vaginal discharge, lesions or sores Severe abdominal/pelvic pain with vaginal bleeding Unexplained fever Exposed to a sexually transmitted infection Become HIV positive or your partner becomes HIV positive Severe of prolonged vaginal bleeding Miss a menstrual period

Male Condom Especially used by teens, yo people, childless/never-married women Failure rate 15% Advantages: Cheap, easily obtained STI protection (except lambskin) Disadvantages: Break/slip, allergies Check how to procure at your facility Male condoms are used especially by teens, 20–24 year-old people, childless women, and never-married women. Typical use failure is 15% Advantages: Non-prescription, inexpensive, easily obtained STI protection (except lambskin condoms – the pores allow viruses and cells to pass through) Disadvantages Break, slip Latex allergy (use polyurethane condoms instead) Tied to intercourse Check with your VA facility for procurement (can be ordered for males/females)

Female Condom Polyurethane sheath with inner and outer ring
Failure rate 21% Advantages: woman–controlled, more STI protection Disadvantages: expensive, noisy, easily displaced Female condoms are used by some sex workers. Polyurethane sheath with inner and outer ring Typical use failure is 21% Advantages Under the woman’s control Greater STI protection (partly covers the labia) Disadvantages Tied to intercourse Noisy Expensive ($2.50 to $5.00 each) High displacement rate

Diaphragm Latex or silicone dome
Fill with spermicide (effective for 2 hr) Failure rate 16% Must be fitted Allergy/UTI risk No HIV/STI protection The diaphragm is a latex or silicone dome. Fill with spermicide Typical use failure of 16% Advantages Under the woman’s control Disadvantages Tied to intercourse Spermicide is only effective for 2 hours Fitting is necessary Allergy/UTI risks Doesn’t protect against HIV or STIs Not a barrier method; designed to keep spermicide in place up against the cervix.

Patient Education for Diaphragms
How to insert Insert <2 hr before sex If >2 hr or further intercourse, add more spermicide Leave in place for 6-8 hr after sex; max 24 hr No HIV/STI protection Irritation from spermicide may increase risk of acquiring HIV Patient education for the diaphragm: How to insert Insert only up to 2 hours before sex; spermicide is effective for only 2 hours If inserted more than 2 hours before intercourse, leave diaphragm in place and add more spermicide directly into vagina with applicator. For further intercourse, add more spermicide. Leave diaphragm in place for 6-8 hours after intercourse. Do not leave diaphragm in vagina for more than 24 hours - can increase risk of toxic shock syndrome Must also use condoms for STI protection. Irritation from spermicide may increase risk of acquiring HIV.

Cervical Cap FemCap available in U.S. Cost $60-$75, lasts 2 yrs
Failure rate 20% Silicone cup; add spermicide and place against cervix Wear 6 hr before and 6 hr after sex; 48 hr max 3 sizes; fitting and refitting necessary after childbirth, abortion, miscarriage, or gaining 15 pounds Increased risk of cervical inflammation, can dislodge during sex, no HIV/STI protection, irritation from spermicide may increase risk of acquiring HIV The cervical cap is a silicone cup. FemCap is available in U.S.; cap is mostly marketed in 3rd World countries Costs $60–$75 and lasts 2 years Typical use failure rate of 20% Cap is a silicone cup. Spermicide is inserted into cup and placed on cervix. Disadvantages Must wear 6 hours before and after sex (48 hours max) 3 sizes, fitting is necessary (refit after childbirth, abortion, miscarriage, or gaining 15 pounds) Increased risk of cervical inflammation Tied to intercourse Can be dislodged during sex No HIV/STI protection. Spermicide irritation may increase risk of acquiring HIV. Photo is courtesy of FemCap.

Spermicides Cream, foam, gel, film, suppository Failure rate 29%
No HIV/STI protection Possible increased HIV risk when Nonoxyl-9 is used alone Spermicides are available as a cream, foam, gel, film, or suppository. Typical use failure of 29% No HIV/STI protection Possible increased risk of HIV transmission when Nonoxyl-9 is used alone (can irritate the vagina and rectum, thus potentially increasing risk of getting HIV from infected partner)

Sponge Both barrier and spermicide Failure rate 29%
Side effects: allergy, risk of yeast infections/UTIs Patient education Thoroughly wet with water Insert against cervix ≤ 24 hr prior to intercourse Leave in ≥ 6 hr, max 30 hr No STI protection; spermicide may increase risk of acquiring HIV The sponge is both a barrier and a spermicide method. It keeps sperm from entering the cervix and also absorbs sperm to decrease the chance of pregnancy. Contains 1,000 mg of nonoxynol-9 Typical use failure rate of 29% $9-$15/3-pack Side effects: Spermicide allergy Increased risk of yeast infections, UTIs Patient education points Run under water until thoroughly wet. Insert against cervix. Can be inserted up to 24 hours before intercourse Must be left in place for at least 6 hours afterward Do not wear for more than 30 hours in a row - may result in toxic shock syndrome if left in too long. At one time, the sponge was taken off the market due to TSS. No HIV or STI protection. Irritation from spermicide may increase risk of acquiring HIV. Photo of the Today Sponge is courtesy of Mayer Labs.

Tubal ligation or Essure
Sterilization Males Vasectomy Females Tubal ligation or Essure 99% effective, but failures occur Consider irreversible Risks: surgery; ectopic pregnancy Regret in 20% in women <30 No partner consent needed Sterilization is also a non-hormonal contraceptive option. Males: Vasectomy Females: Tubal ligation and Essure 99% effective, but failures do occur Should be considered IRREVERSIBLE Contraindications Severe medical problems not allowing anesthesia Risks Surgical risks Ectopic pregnancy: Among 10,685 women, the risk of ectopic pregnancy within 10 years of sterilization was about 7/1,000 The rate of regret is 20% in women under 30! In the U.S., a spouse or partner is not required to give consent

Essure© Micro-inserts cause scar tissue in fallopian tubes
No incisions, minimal anesthesia Failure rate < 1% 3-mo wait for confirmatory testing (hysterosalpingography) Not for women with nickel allergy No HIV/STI protection May interfere with IVF success Essure uses soft, flexible micro-inserts. Hysteroscopic placement of inserts causes growth of scar tissue and blocked fallopian tubes Advantages: no incisions, minimal anesthesia, failure rate <1% Disadvantages: 3-month wait for confirmatory testing with hysterosalpingography (HSG). This is an x-ray with dye injected thru the uterus to the tubes. In most facilities, this is fee-based. Check the policy at your facility. Not for women with nickel allergy No protection against HIV/STIs A portion of the coil protrudes into the uterine cavity; may interfere with IVF success if a woman later decides she wants to have a baby Photos are courtesy of Conceptus.

Tubal Ligation Done postpartum or as “interval” procedure
Failure rate % Patient education No strenuous exercise for several days Return to work in a few days Sex within a week Heavier menses and more dysmenorhea No HIV/STI protection Tubal Ligation Tubal Ligation can be done as a postpartum or as an “interval” procedure Two small cuts are made in abdomen, usually around navel. Instruments to tie tubes are sent thru laparoscope. Tubes are either cauterized or shut off with a small clip. Patient usually returns home in a few hours. Failure rate of % Counseling Points Avoid strenuous exercise for several days Return to work within a few days Sexual intercourse usually within a week Side effects include heavier menses, more dysmenorrhea Does not protect against HIV or STIs

Natural Family Planning / Withdrawal
Effective in select cases for: Motivated, educated patients Women with regular cycles Some sources quote 95% efficacy but typical use failure is likely higher No contraindications, risks, side effects other than failure Withdrawal Not recommended - failure rate of 27% Natural family planning For motivated, educated women with regular cycles Failure rate 25% Withdrawal Failure rate 27% Not recommended

Natural Family Planning Methods
Cervical mucous or ovulation method Sympto-thermal method (mucous + body temperature) “Timed abstinence” or rhythm/calendar method (25% failure) Lactational amenorrhea Time between breastfeedings no longer than 4 hr during day and 6 hr at night Most effective during first 6 mo of exclusive breastfeeding Works better for older women who are less fertile Recommend that patients check with Natural Family Planning clinics in their community Natural family planning encompasses several methods: Cervical mucous or ovulation method Sympto-thermal method Based on cervical mucous and basal body temperature “Timed abstinence” or Rhythm/Calendar Method Not recommended - high failure rate 25% Lactational amenorrhea Time between feedings must be no longer than 4 hours during the day and 6 hours at night Most effective during first 6 months of exclusive breastfeeding Works better for older women who are less fertile For patient education, recommend checking with Natural Family Planning clinics in your community if this is something you don’t do on a regular basis

Poll Question How many times per week do women call your clinic with questions related to contraception? 1-5 times per week 6-10 times per week 11-20 times per week More than 20 times per week week Over the next hour, I’ll answer your questions after we discuss a couple of case studies. A nurse will join me in the case discussions. Before we bring her onstage, I’d like to ask this question to get you thinking. How many times per week do women call your clinic with questions related to contraception? 1-5 times per week 6-10 times per week 11-20 times per week More than 20 times per week

Case Study Discussions
Welcome back, everyone. I’m here with a VA nurse. She’s going to help me discuss some case studies that’ll get us thinking about how to handle contraceptive issues.

Poll Results

How would you respond? What clarifying questions would you ask?
Case 1 A 26-year-old woman veteran calls your office… “I just started birth control and I’m bleeding.” Case 1 A 26-year-old woman veteran calls your office: “I just started birth control and I’m bleeding.” How would you respond? What clarifying questions would you ask? How would you respond? What clarifying questions would you ask?

Case 2 A 22-year-old woman veteran calls your clinic…
How would you respond? What clarifying questions would you ask? What issues need to be considered for someone in her situation? Case 2 A 22-year-old woman veteran calls your clinic… “The condom broke. What if I’m pregnant? I don’t know the guy all that well.” Case study 2 A 22-year-old female veteran calls your clinic... “The condom broke. What if I’m pregnant? I don’t know the guy all that well.” How would you respond? What clarifying questions would you ask? What issues need to be considered for someone in her situation?

Helpful Resources Armstrong C. ACOG recommendations on emergency contraception. Am Fam Physician. 2010; 82 (10): 1278. Association of Reproductive Health Professionals. Patient Resources. Bonnema et al. Contraception choices in women with underlying medical conditions. Am Fam Physician. 2010;82: Carusi DA, et al. Insertion and removal of an intrauterine contraceptive device. UpToDate, Jan 23, 2013. CDC. United States Medical Eligibility Criteria (USMEC) for Contraceptive Use , updated 2012. This list of helpful resources is available as a handout in case you’d like to print them off and share them with others at your facility. The handout includes the web addresses for each item cited.

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