NR508 Week 2
WHO contraceptive contraindications of combined contraception with 35 mcg EE
or less category 2- contraceptive benefits usually outweigh risks; may require
more frequent monitoring
- ANS -1. Age > 40
2. smoker < 35yr
3. BMI > 30 due to increased VTE risk
4. Hx HTN during pregnancy, BP now normal
5. Known hyperlipidemia
6. first-degree relative with DVT/PE
7. Major surgery without prolonged immobilization
8. superficial thrombophlebitis
9. SLE on immunosuppressive therapy or with severe throbocytopenia
10. RA
11. sickle cell disease
12. valvular heart disease, uncomplicated
13. migraine without neurological aura, age <35yr
14. Unexplained vaginal bleeding, suspicious for serious underlying conditions
15. cervical intraepithelial neoplasia
16. cervical cancer, awaiting treatment
17. undiagnosed breast mass
18. DM without vascular disease
19. Asymptomatic gallbladder disease or postCHOLE
20. benign focal nodular hyperplasia of the liver
21. hx of cholestasis in pregnancy
22. ulcerative colitis or Crohn's disease
23. postpartum & breastfeeding, 4-6wks PP with normal risk of DVT and >6wk PP
24. postpartum and not breastfeeding, 3-6wks PP with normal risk of DVT
WHO contraceptive contraindications of combined contraception with 35 mcg EE
or less category 3- risks usually outweigh the benefits
- ANS -1. Postpartum & breastfeeding , 3 to 4 weeks and 4 to 6 weeks with
increased risk of DVT
2. postpartum & not breastfeeding, 3-4 wks with increased risk of DVT
3. Age > 35 yr and smoker <15 cigarettes/ day
,4. several drug interaction: protease inhibitors; anticonvulsants, lamotrigine;
rifampin
5. Multiple risk factors for CAD (based on age, smoking, DM, HTN)
6. HTN, adequately controlled and monitored (SBP 140-159 & DBP 90-99)
7. Migraine without neurological aura, age >35 yr
8. hx breast CA, no disease >5yr
9. DM with nephropathy, neuropathy, retinopathy, vascular disease, >20yr
10. symptomatic gallbladder disease
11. past COC-related cholestasis
WHO contraceptive contraindications of combined contraception with 35 mcg EE
or less category 4- Unacceptable risk
- ANS -1. postpartum < 3wks
2. age >35yr and smoker >15 cigarettes/day
3. HTN, not controlled or with vascular disease (SBP >=160 DBP >=)
4. current or hx of DVT/PE
5. major surgery with prolonged immobilization
6. Known thrombogenic mutations
7. current or hx of ischemic heart disease or stroke
8. valvular heart diseae, complicated
9. Migraine with nerological aura
10. SLE with positive or unknown antiphospholipid antibodies
11. current breast CA
12. Active viral hepatitis
13. cirrhosis, sever/decompensated
14. benign hepatocellular adenoma or malignant liver tumor.
Drug variables with COC
- ANS -1. OC undergoes first-pass metabolism in the liver
2. drugs that induce liver enzymes will decrease their contraceptive efficacy (TB
drugs, barbiturates, anticonvulsants, St. John's wort) irregular bleeding and
decreased contraceptive effectiveness may occur
3. PNC and tetracycline are know to alter steroid metabolism in the gut becuase
of changes in intestinal flora, may reduce their absorption and effectiveness. May
need back up method of contraception if accompanied by vomiting and diarrhea
,4. Lipid levels may be affected by OCs, need a based line lipid profile on women
who have a significant family history or other risk factors for cardiovascular
disease
Adverse effects of contraceptive methods
- ANS --COC- VTE (the safest option for risk of venous thrombosis is an po
contraceptive containing levonorgestrel combined with a low dose estrogen)
-increased risk of cardiovascular events with the use of drospirenone
-other rare adverse affects: cholestatic jaundice, benign hepatic neoplasms,
myocardial infarction, stroke, and neurological migraines.
patient education for starting combined oral contraceptives
- ANS -1. First-day start- first pill is taken on the first day of cycle. Suppresses
ovulation with the first cycle (no backup plan needed).
2. Sunday Start- the first pill is taken on Sunday following the start of menses; a
backup method is recommended for the first 7 days. May offer the convenience
of having menses occur only during the week.
3. Quick start- first pill is taken on the day of the office visit, backup method is
recommended for the first 7 days. Can be used if the clinician is reasonably sure
that the user s not currently pregnant
- help patient choose a time to take the pill when she is most likely going to be
near the pill pack and helping her to associate pill taking with another daily
activity
What to do if miss a day with oral contraception
- ANS --missed 1 active pill- take pill as soon as you remember, taking two pills in 1
day if missed pill was day prior. Use backup plan for 7 days.
-missed 2 to 4 active pills- take two pills for 2 to 3 days; use backup contraception
for 7 days
-missed 5 or more active pills- start new pack on next start day; use backup
contraception until 7 day of active pills taken
Education for topical patch - ANS -- the patch is applied once a week for 3 weeks,
with 1 week being patch-free, during which withdrawal bleeding occurs.
-Patch use should be initiated on the first day of menses (if started on any other
day a backup method should be used for 7 days)
, - location should be rotated with each patch change and it should be placed on
skin that is clean and dry (abdomen, upper torso, outer arm, or buttock)
- possible issue with increase BMI, suggested continued or extended schedules in
obese women for increase efficacy
-same side effects as COC plus skin irritation at site
-Ortho Evra 20 mcg EE and 150 mcg norelgestromin (liver metabolism)
education for vaginal rings
- ANS --the ring is placed in the vagina and left in place for 3 weeks, then removed
for a week when withdrawal bleeding occurs.
-does not require fitting by provider, easily placed by user
-it releases steady , low dose hormone for better cycle control in the form of
decreased breakthrough bleeding compared to OC
-contraindication for women with significant pelvic prolapse
- NuvaRing 15 mcg EE and 120 mcg etonogstrel daily
education for progestin only OC
- ANS --pill needs to be taken diligently
-if a pill is taken even a few hours late a backup method is recommended for the
following 48 hours
- common SE changes in bleeding and breast tenderness
- Micronor & Nor-QD 0.35mg norethindrone
education for injectable progestin
- ANS --IM requires an office visit, SQ can be done at home
- only dose every 12 weeks
- user errors can occur if pt does not require within the prescribed time frame, it
is acceptable to give a repeat dose 1 week late without a clinical assessment to
exclude pregnancy
- Will change bleeding pattern with increased days of spotting or amenorrhea,
weight gain occurs, may have a delay of return to fertility of about 9 to 10 months
-can be started while menstruating or 2 negative pregnancy tests 2 weeks apart
only if the client has not had unprotected intercourse during that time
- decreased bone density with long term use, should not be use more than 2
years. Not for adolescent due to still developing bone
- bone loss is reversible and diminished with increased ca intake and stopping
smoking
WHO contraceptive contraindications of combined contraception with 35 mcg EE
or less category 2- contraceptive benefits usually outweigh risks; may require
more frequent monitoring
- ANS -1. Age > 40
2. smoker < 35yr
3. BMI > 30 due to increased VTE risk
4. Hx HTN during pregnancy, BP now normal
5. Known hyperlipidemia
6. first-degree relative with DVT/PE
7. Major surgery without prolonged immobilization
8. superficial thrombophlebitis
9. SLE on immunosuppressive therapy or with severe throbocytopenia
10. RA
11. sickle cell disease
12. valvular heart disease, uncomplicated
13. migraine without neurological aura, age <35yr
14. Unexplained vaginal bleeding, suspicious for serious underlying conditions
15. cervical intraepithelial neoplasia
16. cervical cancer, awaiting treatment
17. undiagnosed breast mass
18. DM without vascular disease
19. Asymptomatic gallbladder disease or postCHOLE
20. benign focal nodular hyperplasia of the liver
21. hx of cholestasis in pregnancy
22. ulcerative colitis or Crohn's disease
23. postpartum & breastfeeding, 4-6wks PP with normal risk of DVT and >6wk PP
24. postpartum and not breastfeeding, 3-6wks PP with normal risk of DVT
WHO contraceptive contraindications of combined contraception with 35 mcg EE
or less category 3- risks usually outweigh the benefits
- ANS -1. Postpartum & breastfeeding , 3 to 4 weeks and 4 to 6 weeks with
increased risk of DVT
2. postpartum & not breastfeeding, 3-4 wks with increased risk of DVT
3. Age > 35 yr and smoker <15 cigarettes/ day
,4. several drug interaction: protease inhibitors; anticonvulsants, lamotrigine;
rifampin
5. Multiple risk factors for CAD (based on age, smoking, DM, HTN)
6. HTN, adequately controlled and monitored (SBP 140-159 & DBP 90-99)
7. Migraine without neurological aura, age >35 yr
8. hx breast CA, no disease >5yr
9. DM with nephropathy, neuropathy, retinopathy, vascular disease, >20yr
10. symptomatic gallbladder disease
11. past COC-related cholestasis
WHO contraceptive contraindications of combined contraception with 35 mcg EE
or less category 4- Unacceptable risk
- ANS -1. postpartum < 3wks
2. age >35yr and smoker >15 cigarettes/day
3. HTN, not controlled or with vascular disease (SBP >=160 DBP >=)
4. current or hx of DVT/PE
5. major surgery with prolonged immobilization
6. Known thrombogenic mutations
7. current or hx of ischemic heart disease or stroke
8. valvular heart diseae, complicated
9. Migraine with nerological aura
10. SLE with positive or unknown antiphospholipid antibodies
11. current breast CA
12. Active viral hepatitis
13. cirrhosis, sever/decompensated
14. benign hepatocellular adenoma or malignant liver tumor.
Drug variables with COC
- ANS -1. OC undergoes first-pass metabolism in the liver
2. drugs that induce liver enzymes will decrease their contraceptive efficacy (TB
drugs, barbiturates, anticonvulsants, St. John's wort) irregular bleeding and
decreased contraceptive effectiveness may occur
3. PNC and tetracycline are know to alter steroid metabolism in the gut becuase
of changes in intestinal flora, may reduce their absorption and effectiveness. May
need back up method of contraception if accompanied by vomiting and diarrhea
,4. Lipid levels may be affected by OCs, need a based line lipid profile on women
who have a significant family history or other risk factors for cardiovascular
disease
Adverse effects of contraceptive methods
- ANS --COC- VTE (the safest option for risk of venous thrombosis is an po
contraceptive containing levonorgestrel combined with a low dose estrogen)
-increased risk of cardiovascular events with the use of drospirenone
-other rare adverse affects: cholestatic jaundice, benign hepatic neoplasms,
myocardial infarction, stroke, and neurological migraines.
patient education for starting combined oral contraceptives
- ANS -1. First-day start- first pill is taken on the first day of cycle. Suppresses
ovulation with the first cycle (no backup plan needed).
2. Sunday Start- the first pill is taken on Sunday following the start of menses; a
backup method is recommended for the first 7 days. May offer the convenience
of having menses occur only during the week.
3. Quick start- first pill is taken on the day of the office visit, backup method is
recommended for the first 7 days. Can be used if the clinician is reasonably sure
that the user s not currently pregnant
- help patient choose a time to take the pill when she is most likely going to be
near the pill pack and helping her to associate pill taking with another daily
activity
What to do if miss a day with oral contraception
- ANS --missed 1 active pill- take pill as soon as you remember, taking two pills in 1
day if missed pill was day prior. Use backup plan for 7 days.
-missed 2 to 4 active pills- take two pills for 2 to 3 days; use backup contraception
for 7 days
-missed 5 or more active pills- start new pack on next start day; use backup
contraception until 7 day of active pills taken
Education for topical patch - ANS -- the patch is applied once a week for 3 weeks,
with 1 week being patch-free, during which withdrawal bleeding occurs.
-Patch use should be initiated on the first day of menses (if started on any other
day a backup method should be used for 7 days)
, - location should be rotated with each patch change and it should be placed on
skin that is clean and dry (abdomen, upper torso, outer arm, or buttock)
- possible issue with increase BMI, suggested continued or extended schedules in
obese women for increase efficacy
-same side effects as COC plus skin irritation at site
-Ortho Evra 20 mcg EE and 150 mcg norelgestromin (liver metabolism)
education for vaginal rings
- ANS --the ring is placed in the vagina and left in place for 3 weeks, then removed
for a week when withdrawal bleeding occurs.
-does not require fitting by provider, easily placed by user
-it releases steady , low dose hormone for better cycle control in the form of
decreased breakthrough bleeding compared to OC
-contraindication for women with significant pelvic prolapse
- NuvaRing 15 mcg EE and 120 mcg etonogstrel daily
education for progestin only OC
- ANS --pill needs to be taken diligently
-if a pill is taken even a few hours late a backup method is recommended for the
following 48 hours
- common SE changes in bleeding and breast tenderness
- Micronor & Nor-QD 0.35mg norethindrone
education for injectable progestin
- ANS --IM requires an office visit, SQ can be done at home
- only dose every 12 weeks
- user errors can occur if pt does not require within the prescribed time frame, it
is acceptable to give a repeat dose 1 week late without a clinical assessment to
exclude pregnancy
- Will change bleeding pattern with increased days of spotting or amenorrhea,
weight gain occurs, may have a delay of return to fertility of about 9 to 10 months
-can be started while menstruating or 2 negative pregnancy tests 2 weeks apart
only if the client has not had unprotected intercourse during that time
- decreased bone density with long term use, should not be use more than 2
years. Not for adolescent due to still developing bone
- bone loss is reversible and diminished with increased ca intake and stopping
smoking
