Contraception female NOS

Contraceptive management encompasses the selection, initiation, monitoring, and adaptation of birth control methods to prevent unwanted pregnancies. This requires considering individual health status, reproductive plans, convenience, side effects, and efficacy. Here’s a detailed overview:

Types of Contraception:

  1. Barrier Methods:
    1. Condoms: Male and female condoms protect against STIs and pregnancy.
    2. Diaphragm (Cervical Cap): Used with spermicide, it’s inserted into the vagina to cover the cervix.
  2. Hormonal Methods:
    1. Oral Contraceptives
      • Combined estrogen-progestin pills (COCP)
        • Ethinyloestradiol/Levonorgestrel oral OD 20/100ug (low dose) 30/150ug (standard dose)
        • Ethinyloestradiol/Drospirenone oral OD  20/3000ug (low dose – Yaz) 30/3000ug (standard dose – Yasmin)
      • Progestin-only pills.
        • Levonorgestrel 30ug oral OD
          • must be taken within 3/24 of same time or 2/7 condoms
        • Drospirenone 4mg oral OD
    2. Vaginal Ring: A flexible ring placed in the vagina releasing hormones.
    3. Injectable Contraceptives: Depot medroxyprogesterone acetate (DMPA) 150mg IM every 12 weeks.
    4. Implanon: Etonogestrel implant placed under the skin of the arm and effective for 3 years.
  3. Intrauterine Devices (IUDs):
    1. Copper IUD: Non-hormonal, can remain in place for up to 10 years.
    2. Hormonal IUD (Kyleena): Release progestin and last for 5 years.
    3. Hormonal IUD (Mirena): Release progestin and last for 8 years.
      • Update July 2024 – Mirena is now approved for 8 years.
  4. Emergency Contraception:
    1. Tablets
      1. Ulipristal acetate (Ellaone) 30mg oral stat (prescription)
        • 5 day limit
        • RU486 like SPRM (Selective progesterone receptor modulator) that is more effective than levonorgestral
      2. Levonorgestral 1.5mg oral stat
        • 3 day limit
      3. Repeat dose if vomit < 3 hours
    2. Copper IUD: Can be inserted up to five days after unprotected sex.
  5. 5. Permanent Methods:
    1. Tubal Ligation: Surgical procedure to block a woman’s fallopian tubes.
    2. Vasectomy: Surgical procedure to block the vas deferens in men.

Contraceptive Management:

  1. Initial Assessment:
    1. Medical History: To identify contraindications (e.g., history of blood clots with estrogen-containing methods).
    2. Reproductive Goals: Understanding the patient’s plans for future pregnancy.
    3. Lifestyle and Preferences: Compliance, convenience, and preference for menstrual regulation or suppression.
    4. Education: Discussing how each method works, effectiveness, side effects, and risks.
  2. Follow-Up and Monitoring:
    1. Regular Follow-Up: Especially important after initiating hormonal methods to assess side effects and compliance.
    2. Blood Pressure Monitoring: For users of hormonal methods, especially combined oral contraceptives.
    3. Weight Checks: As some methods like DMPA may be associated with weight gain.
    4. Assessment of Side Effects: Managing common side effects or complications (e.g., breakthrough bleeding).
    5. Continuation and Satisfaction: Evaluating ongoing satisfaction and potential need for switching methods.
  3. Method Switching:
    1. Reasons for switching include side effects, convenience, health changes, and desire for more (or less) effective contraception.
    2. Counseling about the correct way to switch methods to avoid gaps in protection.
  4. Non-contraceptive Benefits:
    1. Some hormonal contraceptives have non-contraceptive benefits, such as reduced menstrual bleeding, less acne, and a lower risk of certain cancers.
  5. Counseling on Correct Use:
    1. Ensuring the patient understands how to use the chosen method correctly to maximize effectiveness.
    2. Discussing the importance of condom use for STI protection, especially if using methods that do not protect against STIs.
  6. Managing Side Effects:
    1. Providing strategies for managing minor side effects.
    2. Recognizing serious complications (e.g., signs of a blood clot or hormonal IUD expulsion) and advising when to seek immediate medical care.
  7. Accessibility and Cost:
    1. Discussing the cost as this may influence the choice of contraception.
    2. Providing information on where to obtain the chosen contraceptive method.
  8. Contraception After Childbirth:
    1. Counseling about when to resume contraception after giving birth, considering breastfeeding and individual recovery.
    2. POP (Progesterone Only Pills)
      1. Do not impact milk supply and can be started day 1 post partum regardess of breast feeding status
    3. COCP (Combined Oral Contraceptive Pills)
      1. Oestrogen carries risks of thrombosis and can adversly impact milk production
      2. Non-breast feeding can start 21 days post partum
      3. Breast feeding mothes can start 6 weeks post partum once lactation is well established 
  9. Contraception in Perimenopause:
    1. Managing contraceptive needs as women approach menopause, which may also include addressing symptoms of hormonal changes.

Each method has unique considerations, and the choice of contraception should be an informed decision made by the patient.

Detailed Aspects of Contraceptive Management:

  1. Selection Process:
    • The selection of a contraceptive method is a complex decision that involves a thorough understanding of the patient’s medical history, reproductive health, lifestyle factors, personal preferences, and potential risks.
    • Medical History: Clinicians should assess any pre-existing health conditions that might contraindicate certain contraceptive methods. For instance, combined hormonal contraceptives are not recommended for women with a history of thromboembolic disorders or certain types of cancers.
    • Counseling: Detailed counseling sessions should be provided to help patients understand their options, how they work, their effectiveness, side effects, and how to use them.
  2. Initiation Protocols:
    • Check the patient is not pregnant
    • All COCPs will work immediately if an active pill is taken in the first 5 days of the menstrual cycle.
    • If not started in the first 5 days then 7 days of barrier contraception should be used
  3. Monitoring and Adherence:
    1. Ongoing monitoring is key to ensuring the effectiveness of the contraceptive method and managing any side effects.
    2. Side Effects: Common side effects should be discussed in advance. For instance, spotting is common with new hormonal contraceptive use but often resolves within a few months.
    3. Adherence: Strategies to improve adherence, particularly with daily methods like the pill, include setting reminders or linking pill-taking with a daily routine.
  4. Addressing Side Effects:
    • Management of side effects is crucial to encourage continued use of contraception.
    • Nausea: Taking the pill at night or with food may help.
    • Headaches: Monitoring for headaches is essential, especially with estrogen-containing methods, as this could signal more serious complications.
    • Breakthrough Bleeding: Can often be managed by reassurance, as it typically decreases over time, or by adjusting the hormone doses.
  5. Method-Specific Considerations:
    • Each contraceptive method comes with specific considerations:
    • COCPs: Discussing the late/missed pill protocol
      • A late pill is defined as being taken <24 hours late.
        • Take the late hormone pill as soon as possible, then continue taking the pills as usual
        • Two pills can be taken on the same day.
        • No additional contraceptive required.
      • A missed pill is defined as being taken >24 hours late.
        • The most recent pill should be taken and previously missed pills discarded
        • Continue taking the pills as usual (two pills can be taken on the same day).
        • Additional contraceptive methods (eg condoms) or abstinence are required until 7 consecutive active pills are taken
    • POPs: A POP is considered missed if it’s taken more than 3 hours late (or 12 hours if using a desogestrel-containing pill).
      • If < 3 Hours late (12 Hours for Desogestrel):
        • Take the missed pill as soon as possible.
        • The next pill should be taken at the usual time.
        • No additional contraceptive protection is needed.
      • If > 3 Hours Late (12 Hours for Desogestrel):
        • Take the missed pill as soon as remembered, even if it means taking two pills at the same time.
        • Continue taking the remaining pills at the usual time.
        • Use additional contraception (like condoms) or avoid sex for the next 2 days.
      • If Multiple Pills Missed:
        • If more than one pill is missed, the same advice applies – take the most recent missed pill, then continue as normal, with additional contraceptive precautions for the next 2 days.
    • IUDs: Ensuring the patient understands the possibility of expulsion, especially in the first year, and how to check for IUD strings periodically.
    • Implants: Discussing the potential for scar tissue at the insertion site and irregular bleeding patterns.
    • Depot Injections: Addressing potential bone density loss with long-term use and discussing the delay in return to fertility after stopping.
  6. Long-Term Management:
    • Long-term management of contraception may include annual visits to renew prescriptions, assess blood pressure for patients on hormonal methods, and ensure that there are no contraindications for continued use.
    • Weight Gain: While data is mixed, some patients may experience weight gain on certain contraceptives like depo shots; discussing healthy lifestyle choices is important.
    • Bone Health: For users of depot injections, considering bone health is important, and dietary calcium and vitamin D are often recommended.
  7. Transition and Discontinuation:
    1. Patients may decide to switch methods or discontinue contraception due to various reasons like side effects, desire for pregnancy, or reaching menopause.
    2. Switching Methods: Discussing the correct process to switch methods to avoid an unintentional gap in contraceptive coverage.
    3. Preconception Counseling: For those discontinuing contraception to become pregnant, preconception health optimization is important.
  8. Special Populations:
    1. Contraceptive management must be tailored to special populations such as adolescents, perimenopausal women, and those with comorbidities like diabetes or hypertension.
    2. Adolescents: May need additional counseling about STIs and may prefer long-acting reversible contraceptives (LARCs) for convenience and efficacy.
    3. Perimenopausal Women: May still need contraception and could benefit from hormonal methods that can also manage menopausal symptoms.
  9. Regulatory and Ethical Considerations:
    • Providers should be aware of any legal or ethical considerations regarding contraception provision, particularly for minors or in settings with specific regulations.
    • Confidentiality: It’s crucial to maintain patient confidentiality, especially for young or vulnerable populations seeking contraceptive services.
    • Cultural Sensitivity: Being sensitive to and respectful of diverse beliefs and practices regarding family planning is important in delivering care.
  10. Health Promotion and Education:
    1. Educating patients about reproductive health and the importance of STI prevention is an integral part of contraceptive management.
    2. STI Prevention: Emphasizing the importance of condoms, even when using other contraceptive methods, for STI prevention.
    3. Healthy Relationships: Providing information on consent and healthy relationship dynamics, particularly for younger patients.

Contraceptive management is a multifaceted aspect of healthcare that involves ongoing communication, education, and personalized care.