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ADDITIONALTHERAPIES

Other nonpharmacologic therapies include biofeedback, a first-line recommendation for patients with refractory constipation due to functional conditions involving dyssynergic defecation or inadequate propulsive force.

Behavior therapy

SURGERY/OTHER PROCEDURES

Surgery rarely indicated; sometimes required for anatomic findings (rectocele or enterocoele)

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Toxic megacolon

Manual disimpaction occasionally required in chronic refractory cases

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Encourage exercise and physical activity.

Patient Monitoring

If functional constipation persists, revisit secondary causes.

DIET

Increase soluble fiber (bloating and gas can be problematic with insoluble fiber):

Gradually increase intake to 25 g/day over a 6-week period.

Oat bran (hard outer layer of cereal grains)

Peas; onions; lentils; beans; seeds; nuts; and fruits including bananas, apples, and strawberries

Encourage liberal intake of fluids.

PATIENT EDUCATION

Occasional mild constipation is normal.

Bowel training: The best time to move bowels is in the morning, after eating breakfast, when the normal bowel transit and defecation reflexes are functioning.

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PROGNOSIS

Occasional constipation responds well to simple measures.

Habitual constipation can be a lifelong nuisance.

Patients with neurologic compromise can suffer from obstipation, impaction, and toxic megacolon.

No evidence for laxative dependence or harm from stimulant use; melanosis coli may develop but is a benign condition.

COMPLICATIONS

Volvulus

Toxic megacolon

Acquired megacolon in severe, long-standing cases

Fluid and electrolyte depletion: laxative abuse

Rectal ulceration (stercoral ulcer) related to recurrent fecal impaction

Anal fissures

REFERENCES

1.Ori Y, Rozen-Zvi B, Chagnac A, et al. Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: a single center’s experience. Arch Intern Med. 2012;172(3):263–265.

2.Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920–924.

3.Bharucha AE, Pemberton JH, Locke GR III. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013;144(1):218–238.

4.Lee-Robichaud H, Thomas K, Morgan J, et al. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev. 2010; (7):CD007570.

ADDITIONALREADING

Basilisco G, Coletta M. Chronic constipation: a critical review. Dig Liver Dis. 2013;45(11):886–893.

Bove A, Pucciani F, Bellini M, et al. Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 2012;18(14):1555–1564.

Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology

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monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol. 2014;109(Suppl 1):S2–S26. Shah BJ, Rughwani N, Rose S. In the clinic. Constipation. Ann Intern Med. 2015;162(7):ITC1.

CODES

ICD10

K59.00 Constipation, unspecified

K59.01 Slow transit constipation

K59.09 Other constipation

CLINICALPEARLS

Constipation (especially with normal transit time) is common. Reversible risk factors include inadequate hydration, sedentary lifestyle, poor dietary habits, and medication side effects.

Red flags: onset >50 years, hematochezia/melena, unintentional weight loss, anemia, neurologic defects

Osmotic agents (PEG) are most clinically effective.

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CONTRACEPTION

Kim M. Stein, MD Melissa J. Fullerton, MD

BASICS

DESCRIPTION

Medications or procedures that control timing of pregnancies and prevent unintended pregnancies

Contraception options are divided into two major categories: hormonal and nonhormonal.

The most effective methods of contraception are vasectomy, female sterilization, and the long-acting reversible contraceptives (LARCs).

EPIDEMIOLOGY

Incidence

The estimated prevalence of contraception use among women age 15 to 44 years is 61% in the United States (1).

49% of all pregnancies in the United States are unintended, and half of these occur in women using a form of reversible contraception.

43% of all unintended pregnancies in the United States result in termination.

The most frequently used forms of contraception in the United States (in order of prevalence) are oral contraceptive pills (OCPs), female sterilization, male condom, male sterilization, and depot injectables.

Although LARCs are one of the most effective forms of contraception, they are among the least used methods in the United States.

RISK FACTORS

Unintended pregnancy: higher rates among women ages 18 to 24 and >40 years, unmarried/cohabitating women, women with less than a college education, and minority women

DIAGNOSIS

HISTORY

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Review past medical, family, social, obstetric, and gynecologic histories including menstrual history, prior experience with contraceptives, and prior sexually transmitted diseases (STDs).

Contraindications: See CDC medical eligibility criteria (MEC) (2).

–Estrogen-progestin contraceptives

Absolute: age ≥35 years and smoking ≥15 cigarettes per day, <21 days postpartum, SBP≥160 mm Hg or DBP≥100 mm Hg, multiple CAD risk factors, current/prior venous thromboembolism (VTE), thrombophilia, long-standing/complicated diabetes, ischemic heart disease, stroke, complicated valvular disease, systemic lupus, migraine with aura, breast cancer, severe cirrhosis, solid organ transplant, hepatocellular adenoma, or malignant hepatoma

Relative: age ≥35 years and smoking <15 cigarettes per day, breastfeeding <42 days postpartum, SBP140 to 159 mm Hg or DBP90 to 99 mm Hg (or well-controlled on medications), symptomatic cholelithiasis, certain anticonvulsants, bariatric surgery, migraines without aura but ≥35 years, or breast cancer history in remission >5 years

–Progestin-only (pill/Depo/implant) Absolute: current breast cancer

Relative: bariatric surgery, ischemic heart disease, history of stroke, lupus, migraine with aura, severe cirrhosis, certain anticonvulsants, hepatocellular adenoma, or malignant hepatoma

–Levonorgestrel (LNG)-intrauterine device (IUD)

Absolute: postseptic abortion, postpartum sepsis, gestational trophoblastic disease, current breast/cervical/endometrial cancer, unexplained vaginal bleeding, distorted uterine cavity, current pelvic inflammatory disease (PID), purulent cervicitis, gonorrhea/chlamydia infection, pelvic tuberculosis (TB)

Relative: ischemic heart disease, lupus, severe cirrhosis, hepatocellular adenoma or malignant hepatoma, increased risk of STDs, solid organ transplant

–IUD–copper (“ParaGard”)

Absolute: same as LNG-IUD except use in cancer of breast, possibly cervix OK

Relative: severe thrombocytopenia, increased risk of STDs, solid organ transplant

DIAGNOSTIC TESTS & INTERPRETATION

Anegative pregnancy test (urine or serum) is advised prior to initiating

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contraception.

Consider testing for gonorrhea and chlamydia prior to IUD insertion especially if age <25 years or multiple sexual partners. Testing can be done at time of insertion if symptomatic infection is ruled out.

Perform Pap smear if otherwise indicated.

Screen for hypertension.

In family history of thrombophilia, testing can be considered before initiation of estrogen-containing contraception, especially if specific defect is known.

TREATMENT

GENERALMEASURES

Method(s) should be selected based on patient preference, effectiveness, need for STD prevention, side effects, and contraindications.

General categories included hormonal and nonhormonal methods.

–Nonhormonal methods include condoms, diaphragm, cervical cap, copper IUD, vasectomy, female sterilization, fertility awareness, sponge, spermicides, and abstinence.

–Hormonal methods include oral contraceptives, patch, ring, injectables, IUDs, and implants.

MEDICATION

Estrogen-progestin contraceptives

–Mechanism of action: work by suppression of ovulation, thickening cervical mucus, and endometrial changes that interfere with transport of sperm to egg and with implantation

–Efficacy: failure rate of about 4.8% at 1 year

–Side effects: nausea, bloating, headaches, mastalgia, depression, acne, and hirsutism

–Side effect management: Breakthrough bleeding is usually self-limiting after 3 months; if persists, change pill. Amenorrhea: Rule out pregnancy.

–Combined oral contraceptives (COCs): pill

All COCs contain the same type of estrogen (ethinyl estradiol) but differ in the amount of estrogen (range of 10 to 50 µg) and the type of progestin.

Newer progestins (such as norgestimate and desogestrel) are less androgenic but may have increased rate of VTE.

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Start with a pill that is inexpensive (generic); contains an average amount of estrogen (30 to 35 µg)

Dosing: Most pills have a 21/7 regimen (21 active days and 7 placebo); alternatively, can take active pills continuously with four yearly scheduled withdrawal bleeds

Initiation: 1st day start (begin the pill on the 1st day of menses), quick start (begin pill on day medication is obtained), or Sunday start (begin pill on first Sunday)

–Weekly hormonal patch (Ortho Evra):

Releases 20 µg/day ethinyl estradiol and 150 µg/day norelgestromin

Applied transdermally and changed weekly

Produces higher serum estrogen levels than oral 20 µg pill and may be associated with a slightly increased risk of blood clot

Patch may cause local skin irritation; not as reliable in women >90 kg

–Vaginal contraceptive ring (NuvaRing):

Flexible polymer ring with 15 µg/day of ethinyl estradiol and 120 µg/day of etonogestrel absorbed via vaginal wall

Insert into vagina for 3 weeks/cycle or use continuous cycling for 4

weeks then replace immediately with a new ring (off-label).

Although systemic exposure to estrogen is about 50% of exposure with COCs, the risk of blood clots is about the same.

Progestin-only birth control

–Mechanism of action: thickening cervical mucus and thinning endometrial lining

–Progestin-only pill (Micronor)

Efficacy: failure rate of about 0.3% with perfect use, 9% with typical use at 1 year

Can be used in women with contraindication to estrogen, including breastfeeding women after 6 weeks postpartum

Dosing: 1 pill at the same time daily, no placebo days

Side effects: irregular bleeding

–Injectable contraceptive (medroxyprogesterone) ”Depo-Provera”

Efficacy: failure rate of 0.2% with perfect use, 6% with typical use at 1 year

Dosing: 150 mg IM or Depo-SubQ Provera 104 mg SC, both are given every 3 months. Contraceptive levels of hormone persist for up to 4 months (2- to 4-week margin of safety).

Side effects include irregular bleeding, weight gain (average of 5 lb/year of use), and amenorrhea.

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LARCs: IUDs and implantable devices

–Mirena (52-mg levonorgestrel-releasing IUD):

Mechanism of action: sterile inflammatory reaction due to foreign body that is toxic to sperm and ova, thickens cervical mucus, endometrial decidualization and glandular atrophy, inhibiting sperm-egg binding, partial inhibition of ovarian follicular development, and ovulation

Efficacy: failure rate of 0.2% with both perfect and typical use at 1 year

Dosing: releases 20 µg/day (very low serum levels) initially and subsequently reduces to 10 µg/day

Approved for use up to 5 years; has been used off-label for up to 7 years

Safe in nulliparous women/teenagers

Can be inserted immediately postpartum or immediately following dilation and curettage for miscarriage or abortion, but these are associated with higher rates of expulsion compared to delayed placement (6 to 10 weeks)

Side effects: irregular menstrual spotting for the first 3 to 6 months that usually resolves after 6 months of use; may see absence of menses after 1 year

Side effect management: Consider COCs or estrogen alone for spotting and cramps.

Can reduce heavy bleeding in menorrhagia

–Liletta (52-mg levonorgestrel-releasing IUD):

Releases 18.6 µg/day initially; approved for 3 years, at which time it releases 12.6 µg/day

–Kyleena (19.5-mg levonorgestrel-releasing IUD):

Releases 17.5 µg/day for the 1st year, down to 7.5 µg/day. Approved for 5 years. Smaller insertion tube with 3.8 mm diameter offers potential for easier insertion in nulliparous women.

–Skyla (13.5-mg levonorgestrel-releasing IUD):

Releases 14 µg/day initially, down to 5 µg/day, approved for 3 years. Smaller insertion tube (3.8 mm diameter); more bleeding days than Mirena

–ParaGard (copper IUD):

Mechanism of action: In addition to sterile inflammatory reaction due to foreign body, free copper and copper salts enhance the cytotoxic inflammatory reaction–toxic to sperm and ova.

Efficacy: failure rate of 0.6% with perfect use, 0.8% with typical use at 1 year

Approved for up to 10 years

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Same insertion timing as LNG-IUD

Side effects: blood loss and cramping

–Nexplanon (etonogestrel implant):

Mechanism of action: thickening cervical mucus and thinning endometrial lining

Efficacy: failure rate of 0.05% with perfect use, 0.3% with typical use at

1 year

Dosing: 40 mm × 2 mm semirigid plastic rod containing 68 mg of etonogestrel; initially releases 60 to 70 µg/day, down to 25 to 30 µg/day at the end of the 3rd year

Effective for up to 3 years

Must be inserted only by certified providers

Side effects: menstrual irregularities (common first 6 to 12 months, often continue for full 3 years)

Emergency contraception: should be initiated as soon as possible postunprotected intercourse. Copper IUD is the most effective, followed by ulipristal, levonorgestrel, and Yuzpe method (least effective) (3)[A].

–Copper-bearing IUD (ParaGard): Insert up to 5 days after intercourse; failure rate of 0.04–0.19%

–Ulipristal acetate (Ella): 30 mg × 1 dose; selective progesterone modulator, effective up to 5 days after unprotected intercourse with minimal decline in efficacy; about 2% failure rate

–Levonorgestrel: 1.5 mg taken as two 0.75-mg tablets (Plan B) or one 1.5- mg tablet (Plan B 1-Step). Failure rate: 1.1–2.4%. Less nausea than “Yuzpe regimen.” Available over the counter; may be less expensive if prescribed. Most effective within 72 hours, efficacy declines with time. May be ineffective for women with BMI >30. Estradiol/levonorgestrel (Preven, Lo Ovral, Ogestrel): “Yuzpe regimen” 50 µg/0.25 mg, 2 tablets q12h (4 tablets total). Any OC may be used as long as the dose of estrogen component ≥100 µg/dose. Failure rate: 3.2%. Note: Antiemetic should be given 1 to 2 hours before each dose.

ADDITIONALTHERAPIES

Condoms: failure rate of 2% with perfect use, 18% with typical use at 1 year

Spermicides: All contain nonoxynol-9; may alter vaginal flora and mucosal barrier. Failure rate: 28% at 1 year with typical use.

Sponge (Today Sponge): Soft foam disk contains nonoxynol-9. Moisten with water before use; effective for 24 hours; must leave in for 6 hours after use; less effective in parous women. Failure rate: 12–24% at 1 year with typical

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use

Diaphragm: latex or silicone dome-shaped device with flexible springactivated rim, works by preventing sperm from entering cervix; used with spermicides. Failure rate: 12–16% at 1 year with typical use.

SURGERY/OTHER PROCEDURES

Permanent sterilization

Female: tubal ligation or Essure (micro-insert system placed hysteroscopically). Essure requires confirmation of tubal occlusion with hysterosalpingogram 3 months postprocedure. Failure rate: 0.5% at 1 year

Male: vasectomy. Less complicated than female. Failure rate: 0.15% at 1 year

COMPLEMENTARY& ALTERNATIVE MEDICINE

Fertility awareness methods: calendar method, cervical mucus method, temperature method. Low cost but generally not as effective as other methods. Failure rate: 24% at 1 year with typical use.

Withdrawal method: Male partner withdraws from vagina before ejaculation. Failure if not timed accurately. Failure rate: 22% at 1 year with typical use

Lactational amenorrhea method: Breastfeeding is effective contraception only if (i) the infant is <6 months old, (ii) the infant is exclusively breastfeeding, and (iii) the mother has not resumed regular menses. Failure rate: 7% at 1 year with typical use

Pediatric Considerations

AAPand ACOG recommend LARCs as the most effective in sexually active adolescents.

Contraception counseling should include anticipated adverse effects, need to use condoms for STD prevention, and indications for emergency contraception (including options and how to obtain).

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Pelvic exam, Pap smear, and STI testing per guidelines and routine follow-up

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