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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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310 CASE FILES: FAMILY MEDICINE
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Table 28–1 • CONTRACEPTION AGENTS COMPARED, INCLUDING
BEST-SUITED PATIENTS
Disadvantages/
Category/Agents Mechanism Best Suited for
Barrier
• Diaphragm
• Cervical caps
• Condoms (male and
female)
Combined hormonal
(estrogen and
progestin)
• Combined oral
contraceptives
• Contraceptive patch
• Vaginal ring
Progestin-only oral
• Micronor and others
Mechanical obstruction to sperm
Inhibit ovulation
Thicken cervical
mucus to inhibit
sperm penetration
Alters tubal transport
Thins endometrium
Thickens cervical
mucus to inhibit
sperm penetration
Alters tubal transport
Thins endometrium
Avoidance of
hormones
Decrease risk of STI
(condoms)
Iron-deficiency
anemia
Dysmenorrhea
Ovarian cysts
Endometriosis
OCP—take pill
each day
Patch—less to
remember but may
cause more nausea
Ring—less to remember but may cause
vaginal irritation and
discharge
Breastfeeding Patient needs to
Contraindications
Pelvic organ prolapse
Patient discomfort
with placing devices
on genitals
Lack of spontaneity
Allergies to material
Diaphragm may be
associated with more
UTIs
Known thrombogenic
mutations
Active or history of
thromboembolic
disease
Cerebrovascular
or coronary artery
disease (current or
remote)
Cigarette smoking
(especially over
age 35)
Uncontrolled
hypertension
Diabetic retinopathy
or nephropathy
Peripheral vascular
disease
Breast or endometrial
cancer
Unexplained uterine
bleeding
Migraines with aura
Liver tumors (benign
or malignant), active
liver disease
Known or suspected
pregnancy
Application site
reaction (for patches)
remember to take
pill at the same time
each day
(Continued)
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Table 28–1 • CONTRACEPTION AGENTS COMPARED, INCLUDING
BEST-SUITED PATIENTS
Category/Agents Mechanism Best Suited for
Injectables
• Depomedroxyprogesterone
acetate (DepoProvera and others)
Implants (subdermal
in arm)
• Etonogestrel
(Implanon,
Nexplanon)
IUD
• Levonorgestrel
secreting (Mirena and
others)
(continued)
Inhibits ovulation
Thins endometrium
Alters cervical mucus
to inhibit sperm
penetration
Inhibits ovulation
Thins endometrium
Thickens cervical
mucus to inhibit
sperm penetration
Thickens cervical
mucus
Thins endometrium
Breastfeeding
Desire for long-term
contraception
Iron-deficiency
anemia
Sickle cell disease
Epilepsy
Dysmenorrhea
Ovarian cysts
Endometriosis
Breastfeeding
Desires long-term,
reversible contraception (3 years)
Iron-deficiency
anemia
Dysmenorrhea
Ovarian cysts
Endometriosis
Desires long-term,
reversible contraception (3 or 5 years)
Stable, mutually
monogamous
relationship
Menorrhagia
Dysmenorrhea (Note:
decreased bleeding)
Disadvantages/
Contraindications
Depression
Osteopenia/
osteoporosis—
partially reversible
with cessation
Appetite stimulation
leading to weight gain
Unexplained uterine
bleeding
Breast cancer
Active or history of
thromboembolic
disease
Cerebrovascular disease
Liver tumors (benign
or malignant), active
liver disease
Known or suspected
pregnancy
Active or history of
thromboembolic
disease (relative
contraindication)
Liver tumors (benign
or malignant), active
liver disease
Unexplained uterine
bleeding
Breast cancer
Hypersensitivity to any
of the components of
Etonogestrel implant
May lead to irregular
vaginal bleeding
Current STI or
recent PID
Unexplained uterine
bleeding
Untreated cervical or
endometrial cancer
Breast cancer
Anatomic abnormalities or uterine fibroids
distorting the uterine
cavity
(Continued)
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Table 28–1 • CONTRACEPTION AGENTS COMPARED, INCLUDING
BEST-SUITED PATIENTS
Category/Agents Mechanism Best Suited for
• Copper-T (Paragard) Inhibits sperm migra-
Permanent sterilization
• Bilateral tubal ligation
Vasectomy
(continued)
tion and viability
Changes transport
speed of ovum
Damages ovum
Mechanical obstruction of tubes
Disruption of vas
deferens
Desires long-term,
reversible contraception (10 years)
Stable, mutually
monogamous
relationship
Contraindication
to contraceptive
hormones
Does not desire more
children
Disadvantages/
Contraindications
Current STI
Current PID or PID
within the past
2months
Unexplained uterine
bleeding
Malignant gestational
trophoblastic disease
Untreated cervical or
endometrial cancer
Breast cancer
Anatomic abnormalities or uterine fibroids
distorting the uterine
cavity
Wilson disease
May cause more
bleeding or
dysmenorrhea
Contraindications to
procedure or surgery
May want children in
the future
Abbreviations: OCP, oral contraceptive pill; PID, pelvic inflammatory disease; STI, sexually transmitted infection;
UTI, urinary tract infection.
Fertility Awareness and Other Methods
Fertility awareness (natural family planning or rhythm method) entails abstinence
during the woman’s fertile period or using a barrier method during this time period.
Fertility awareness has a failure rate of up to 25% with typical use and 3% to 5%
with perfect use. Women with irregular cycles have the highest failure rates. This
method is dependent on the ability to identify the approximately 10 days in each
menstrual cycle that a woman is fertile, which can be accomplished using calendar
calculation, basal body temperature charting, cervical mucus monitoring, or the
symptothermal method.
Calendar Calculation. The calendar calculation uses the length of past reproductive cycles to predict fertile periods. The beginning of the fertile period is calculated by subtracting 18 days from the shortest of the previous 6 to 12 cycles.
The end of the fertile period is calculated by subtracting 11 days from the longest
cycle. For a consistent 28-day cycle, the fertile period would occur from days 10
through 17.
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Basal Body Temperature. The basal body temperature method is based on the
knowledge that a woman’s basal temperature increases during the luteal phase of
the reproductive cycle. Temperature must be recorded early in the morning at the
same time each day. An increase of 0.4°F from baseline indicates that ovulation has
occurred. For this method to be most effective, a woman must either avoid intercourse or use barrier methods from the first day of menses to the third day after
the temperature increase.
Cervical Mucus Method. The cervical mucus method, also called the Billings ovulation method, depends on a woman recognizing the changes in cervical mucus
that indicate ovulation is occurring or has occurred. The symptothermal method
combines all three: calendar, basal body temperature, and cervical mucus methods.
Other Methods. Other methods include coitus interruptus, also known as the
withdrawal method; postcoital douching; and lactational amenorrhea. Coitus interruptus involves withdrawing the penis before ejaculation and has a 27% typical use
failure rate. Postcoital douching is used to flush semen out of the vagina, but sperm
have been found within cervical mucus within 90 seconds of ejaculation, so this
method is unreliable. Lactational amenorrhea occurs with suppression of ovulation
due to breastfeeding. During the first 6 months following delivery, women who are
exclusively breastfeeding have mostly anovulatory menstrual cycles, and pregnancy
rates have been found to be approximately 1%.
Barrier Methods
Barrier contraceptive methods include the male condom, female condom, diaphragm, cervical cap, sponge, and spermicides. The diaphragm, cervical cap, sponge,
and spermicides are falling out of favor due to high contraception failure rates with
typical use and limited protection against STIs. Barrier methods work by keeping
the sperm and egg apart. The main possible side effect is an allergic reaction either
to the material of the barrier or to the spermicides that should be used with them.
Condoms. Condoms on the market are made of latex rubber, polyurethane, or
sheep intestine. Of these types, only latex and polyurethane condoms are effective in
preventing STIs by providing a good barrier to viruses and bacteria. Polyurethane
condoms have a higher rate of breaking or slipping than latex, and thus higher
failure rates, but they can be used by patients with a latex allergy. Each condom can
only be used once. Condoms have a typical use failure rate of approximately 15%,
with most of the failures the result of improper use. Perfect use failure rate is about
2%. For maximal efficacy, a condom must be used with every coital act, it should
be in place before contact of the penis with the vagina, withdrawal must occur
with the penis still erect, the base of the condom must be held during withdrawal,
and an intravaginal spermicide or a condom lubricated with spermicide should be
employed. Only water-based lubricants should be used with latex condoms, as oilbased lubricants reduce efficacy.
The female condom consists of a lubricated polyurethane sheath with a flexible polyurethane ring on each end. One ring is inserted into the vagina while the
other remains outside, partially covering the labia. The female condom may offer
some protection against STIs but is not as effective as the male latex condom due
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to increased user error. The estimated typical use failure rate is estimated at 21%
and perfect use at 5%.
Oral Contraception
Oral contraception is a form of hormonal contraception that temporarily impacts
fertility and has the potential for rare but serious side effects. When starting an oral
contraceptive pill (OCP), ideally a patient should take the first pill on the first day
of the start of menses. Women may choose to start on the Sunday after the start
of their menses for convenience. A quick-start method has also been proposed, in
which patients start taking the pills as soon as they obtain the prescription (ifpregnancy is unlikely), which improves compliance. Both Sunday-start and quick-start
methods require an additional backup method to be used for the first week. Per
the Centers for Disease Control and Prevention, estrogen-containing OCPs should
not be started until 3 weeks following delivery and 6 weeks if at increased risk for
thromboembolism. Progestin-only pills (POPs) can be started immediately postpartum. Estrogen-containing OCPs should be avoided in breastfeeding mothers
until 6 months postpartum. OCPs can be started the day after an induced or spontaneous abortion.
Efficacy. When properly used, hormonal methods are extremely effective.
OCPs include both combination pills, which contain both estrogen and a progestin (a natural or synthetic progesterone), and POPs (commonly known as the
“minipill”). When taken as directed, the failure rate for the POP is 1% to 3%;
the failure rate of the combination pill is 1% to 2%. Typical use of OCPs has a
failure rate of 8% to 10%. The effectiveness of OCPs may be reduced by a few
other medications, including some antibiotics, barbiturates, antiepileptics, and
antifungal medications.
Combination Pills. Combination pills are the most commonly used contraceptive method. The combination pill suppresses ovulation through inhibition of
the hypothalamic-pituitary-ovarian axis, alteration of the cervical mucus, retarding sperm entry, and discouraging ovum implantation by creating an unfavorable
endometrium. Combination OCPs offer significant protection against ovarian cancer,
endometrial cancer, iron-deficiency anemia from menstrual blood loss, pelvic inflammatory disease (PID), and fibrocystic breast disease. Women who take combination
pills have a lower risk of functional ovarian cysts.
Progestin-Only Pills. The POP reduces cervical mucus and causes it to thicken.
The mucus thickening prevents the sperm from reaching the egg and keeps the
uterine lining from thickening, which prevents a fertilized egg from implanting in
the uterus. The POP is ideal for breastfeeding mothers because it does not interfere
with milk production, which combined OCPs can do.
Contraindications. Women over the age of 35 who smoke cigarettes and women
with certain medical conditions should not take the combined OCP. Table 28–2
lists the absolute and relative contraindications to taking the combined OCPs.
Minor side effects, which usually subside after a few months of usage, include nausea, headaches, breast swelling, fluid retention, weight gain, irregular bleeding, and
depression.
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Table 28–2 • CONTRAINDICATIONS TO COMBINED HORMONAL
CONTRACEPTION
Absolute Contraindications Relative Contraindications
Previous thromboembolic event Severe vascular headache (classic migraine, cluster)
Cerebral vascular disease Severe hypertension (if younger than 35-40 years and in
good medical control, can elect OCP)
Coronary occlusion Diabetes mellitus (prevention of pregnancy outweighs
the risk of complicating vascular disease in a diabetic
who is younger than 35-40 years)
Impaired liver function Gallbladder disease (may exacerbate emergence of
symptoms when gallstones are present)
Known or suspected breast cancer Obstructive jaundice in pregnancy
Smokers (> 15 cigarettes/day) older
than 35 years
Congenital hyperlipidemia Morbid obesity
Epilepsy (antiepileptic drugs may decrease
effectiveness of OCPs)
Other Hormonal Contraception Methods
Transdermal Contraceptive. A transdermal contraceptive patch (Ortho Evra
and others) is a combined hormone patch containing norelgestromin and ethinyl estradiol. The treatment regimen for each cycle is three consecutive 7-day
patches followed by one patch-free week, so that withdrawal bleeding can occur.
It can be started in a similar fashion to combined OCPs. If the Sunday-start or
quick-start methods are used, a backup method of contraception is needed for
7 days. The patch may be placed on the buttocks, lower abdomen, upper outer
arm, and upper torso, except for the breasts. If a patch becomes detached, it
should be replaced as soon as possible. If the patch is detached for more than
24 hours, it should be replaced and a backup method of contraception used for
the next 7 days. The patch’s efficacy and side effects are comparable to that of
combined OCPs, although there may be an increased risk of vascular thrombosis
with use of the patch. Women who weigh more than 90 kg may be at increased
risk of pregnancy with patch use.
Intravaginal Ring Contraceptive. The etonogestrel/ethinyl estradiol vaginal ring
(Amneal, NuvaRing) is a flexible, transparent ring about 5 cm in diameter that
delivers etonogestrel and ethinyl estradiol. A woman inserts the etonogestrel/ethinyl
estradiol vaginal ring herself, wears it for 3 weeks, then removes and discards the
device. After one ring-free week, during which withdrawal bleeding occurs, a new
ring is inserted. It does not need to be fitted by a health professional and does not
need to be removed during intercourse. If a patient or her partner experiences
problems with the ring during intercourse, it may be removed, but it should be
replaced within 3 hours. If it is out for more than 3 hours, ovulation may occur. The
manufacturer recommends using backup birth control for the first 7 days after placement if not switching from another hormonal contraceptive. Rarely, the etonogestrel/
ethinyl estradiol vaginal ring can slip out of the vagina, and it is recommended to
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check the position of the ring before and after intercourse. The efficacy and side
effects of etonogestrel/ethinyl estradiol vaginal ring are similar to those of combined OCPs, although vaginitis, discomfort, and foreign body sensation are also
commonly reported.
Medroxyprogesterone Injection. Medroxyprogesterone acetate (Depo-Provera,
depo-subQ provera 104) is an injectable form of a progestin. Medroxyprogesterone acetate has a failure rate of only 0.3% with perfect use and 3% with typical
use. Each injection provides contraceptive protection for 13 weeks, but it can last for
up to 4 months. It is injected every 3 months (90 days) into the gluteus or deltoid
muscle. The first dose should be given within 5 days of the onset of menses, so that
no backup contraception is needed. Its side effects include irregular menses, weight
gain, acne, reversible bone loss, and injection site reactions. Irregular bleeding and
spotting are more significant during the first few months and then are followed by
periods of amenorrhea. About half of women develop amenorrhea after a year of
medroxyprogesterone acetate use. There may be a prolonged period of time prior to
the return of fertility after discontinuing medroxyprogesterone acetate injections, up
to 18 months in a small proportion of women.
Contraceptive Subdermal Implant. The contraceptive etonorgestrel subdermal
implant (Nexplanon) is inserted subdermally in an in-office minor surgical procedure and may be removed with another minor procedure. Placement should
be timed during the menstrual cycle or during the hormone-free week if using a
combined hormonal contraceptive method. The implant contains the progestin
etonorgestrel and is effective for 3 years. At the end of 3 years, when the device is
removed, a new device may be placed in the same site. The failure rate is less than
1% for women who weigh less than 70 kg. The potential side effects of the implant
include irregular menstrual bleeding, which is the most common reason for discontinuation; headaches; depression; acne; breast tenderness; abdominal pain; and
weight gain.
Intrauterine Devices
The IUDs are small, plastic, flexible devices that are inserted into the uterus
through the cervix by a trained clinician. Several IUDs are presently marketed in
the United States:
Cooper T IUD (ParaGard T380A) is a T-shaped plastic device partially cov-
ered by copper that is effective for 10 years.
Levonorgestrel IUD (Mirena) is also a T-shaped plastic device, but it contains
levonorgestrel (a progestin) released over a 5-year period. Smaller levonorgestrel IUDs (Skyla and Kyleen) are designed for the nulliparous uterus and
release slightly less levonorgestrel. They last for 3 and 5 years, respectively.
Efficacy. All IUDs are very effective: The copper-T IUD has a 0.6% to 0.8% fail-
ure rate, and the levonorgestrel IUDs have failure rates of 0.2% to 0.9%. An IUD
alters the uterine and tubal fluids, particularly in the case of copper-bearing IUDs,
inhibiting the transport of sperm through the cervical mucus and uterus. Progesterone-containing IUDs also thin the uterine lining. Timing of placement should
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occur during the menstrual cycle due to ease of insertion and greater certainty that
the patient is not pregnant.
Contraindications. Manufacturer contraindications for IUDs include current or suspected pregnancy; current or recent acute PID or mucopurulent
cervicitis; postpartum endometritis or infected abortion in the past 3 months;
anatomically distorted uterine cavity; known or suspected uterine or cervical
malignancy; or unexplained uterine bleeding. The copper IUD is contraindicated in Wilson disease. Levonorgestrel IUDs are contraindicated in acute liver
disease or with liver tumors, breast cancer, and prior ectopic pregnancy. A history of STIs is not a contraindication to IUD placement, but if a woman has
a known STI, it is recommended to delay insertion for 3 months following
resolution of the infection.
Side Effects. Side effects of IUDs include irregular bleeding patterns during the
first few months of use, headache, nausea, hair loss, acne, depression, decreased
libido, ovarian cysts, and mastalgia. Many patients will become amenorrheic or
oligomenorrheic with a levonorgestrel IUD in place, so it can be used to treat
patients with menorrhagia. The copper IUD may actually cause heavy, irregular bleeding. Women may also experience some short-term side effects, such as
cramping and dizziness (due to stimulation of the vagal nerve) at the time of
insertion; bleeding, cramps, and backache may continue for a few days after the
insertion.
Complications. Complications include expulsion, perforation of the uterus, and
ectopic pregnancy. Approximately 5% of women expel their IUD within the first
year. The patient should check that the strings are palpable once a month, and if
she cannot find the strings, she should see a health care provider. The absolute rate
of ectopic pregnancy is reduced with the IUD because of its high contraceptive
efficacy. However, when accidental pregnancy does occur, there is increased likelihood of ectopic pregnancy.
Surgical Sterilization
Tubal ligation seals a woman’s fallopian tubes so that an egg cannot travel to
the uterus. Vasectomy involves closing off a man’s vas deferens so that sperm
will not be carried to the penis. Vasectomy is a minor surgical procedure, most
often performed in a doctor’s office under local anesthesia. Tubal ligation is an
operating room procedure performed under general anesthesia. Major complications, which are rare in female sterilization, include infection, hemorrhage, and
problems associated with the use of general anesthesia. The failure rate is less
than 1%. Although there has been some success in reopening the fallopian tubes
or the vas deferens, the success rate is low, and sterilization should be considered
irreversible.
Emergency Contraception
All female patients of reproductive age should be made aware of postcoital contraception, some types of which are available over the counter. It is well documented
that knowledge of emergency contraception does not increase the likelihood of
high-risk sexual behavior.
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Hormonal methods of emergency contraception prevent release of oocytes
but do not affect eggs that have already been fertilized or that are already
released into the tube. The Yuzpe method consists of taking high-dose combined OCPs for emergency contraception and can decrease the risk of pregnancy by about 75%. This method can be used up to 5 days after unprotected
intercourse but is most effective when used within 72 hours. Consider prescribing an antiemetic to be used 1hour before each dose, as nausea and vomiting
are common side effects.
Progestin-only emergency contraception is available without a prescription.
One or two oral doses of levonorgestrel (Plan B) 0.75 mg, with 12 hours between
doses, are more effective than the Yuzpe method, are better tolerated, and work
best within 72 hours of intercourse. Preven, a convenient emergency contraception
kit, includes two doses of medication and a pregnancy test.
A single dose of mifepristone (RU-486), a progesterone antagonist, is the most
effective emergency contraceptive and has few side effects. A selective progesterone
receptor modulator, known as ullipristal acetate (Ella), is taken in a single dose up
to 5 days after unprotected intercourse. Placing a copper-containing IUD within
5days after unprotected sex is the most effective form of emergency contraception
and also provides another 10 years of birth control. In the setting of emergency
contraception, the copper IUD likely works by preventing implantation. Copper
IUDs should be avoided in those at significant risk for STIs or ectopic pregnancy
or if long-term contraception is not desired.
CASE CORRELATION
See also Case 16 (Male Genitourinary Conditions), Case 22 (Vaginitis
and Other Vaginal Infections), and Case 26 (Postpartum Care).
COMPREHENSION QUESTIONS
28.1 While working in the clinic of the county jail you see a gravida 5, para 2032
(G5P2032) for a well-woman examination. She openly tells you that she was
arrested for a history of prostitution. On arrest, she was found to be HIV
positive. She is to be released next week and would like contraception. Which
of the following agents is most appropriate for this patient?
A. Oral contraceptive agent
B. Depot medroxyprogesterone
C. Intrauterine contraceptive device
D. Condoms
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28.2 An 18-year-old woman reported having intercourse with her boyfriend
20hours ago. She was concerned because the condom broke. She used no
other form of contraception. The patient reported a history since age 14 of
regular periods of heavy flow that usually last for longer than 7 days. Her
body mass index (BMI) is 25 kg/m2. She plays as a forward on her high
school basketball team and is worried about becoming pregnant. Which of
the following is the most appropriate method of “emergency contraception”?
A. Yuzpe method
B. Plan B method
C. Insertion of a copper IUD
D. Intramuscular methotrexate
28.3 A 16-year-old young woman presents to your clinic for a wellness check. She
has been having regular periods for over 2 years, does not drink or smoke,
gets straight. As on her report cards, and is in the 75th percentile for height
and weight. She is Tanner stage 5 for both breast and pubic hair development.
During your interview, she reveals that she is sexually active and not using
contraception. If she continues to have unprotected intercourse, what is the
likelihood that she will become pregnant over the course of the next year?
A. 20%
B. 40%
C. 80%
D. 100%
28.4 A 36-year-old woman is seeking contraception. She delivered her baby
8weeks ago and is breastfeeding. She undergoes a history and physical examination and is counseled regarding the various options. She is healthy, drinks
an occasional glass of wine per month, does not smoke, and plans to have
another child in a year or two. Her blood pressure is 114/70 mm Hg. The
patient would like to initiate birth control at this visit. Which method is the
most appropriate in her case?
A. Laparoscopic sterilization
B. Natural family planning
C. The minipill
D. Combination oral contraception pills
E. Coitus interruptus
28.5 Which one of the following is an absolute contraindication to combined oral
contraceptives in a 40-year-old woman?
A. Obesity (BMI 32 kg/m2)
B. Smoking 1 pack of cigarettes/day
C. Sickle cell disease
D. A family history of ovarian cancer
E. Varicose veins
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