Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3055_Библиотеки_им_академика_М_И_Перельмана.pdf
436
American women: results of a random digit dialing survey.
J Womens Health. 1998;7:1167–74.
20. Van Der Pol B, Williams JA, Orr DP, et al. Prevalence, incidence,
natural history, and response to treatment of Trichomonas
vaginalis infection among adolescent women. J Infect Dis.
2005;192(12):2039–44.
21. Wilson JF. In the clinic: vaginitis and cervicitis. Ann Intern Med.
2009;151(5):ITC3-1-15.
22. Silver BJ, Guy RJ, Kaldor JM, Jamil MS, Rumbold
AR. Trichomonas vaginalis as a cause of perinatal morbid-
ity: a systematic review and meta-analysis. Sex Transm Dis.
2014;41(6):369.
23. Nappi RE, Kokot-Kierepa M. Women’s voices in the meno-
pause: results from an international survey on vaginal atrophy.
Maturitas. 2010;67(3):233.
24. Bachmann GA, Nevadunsky NS. Diagnosis and treatment of
atrophic vaginitis. Am Fam Physician. 2000;61(10):3090.
25. Stika CS. Atrophic vaginitis. Dermatol Ther. 2010;23:514–22.
26. Gutman RE, Peipert JF, Weitzen S, Blume J. Evaluation of clini-
cal methods for diagnosing bacterial vaginosis. Obstet Gynecol.
2005;105(3):551–6.
A.S. Lopez
437© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_27
Introduction
About 42 million sexually active women in the USA are at
risk for an unwanted pregnancy without adequate contracep-
tion use [1, 2]. Certain medical conditions also render preg-
nancy high risk, such that birth control can prevent significant
health complications [3]. The gamut of contraceptive options
developed makes effective, low-risk, and low-hassle choices
easily available, but requires appropriate counseling for opti-
mal choice. This chapter reviews key decision-making points,
history and physical examination elements needed to guide
contraception management, and current contraceptive
options available for sexually active patients, including com-
mon side effects and contraindications.
Chapter 27
Contraception
Athina Vassilakis
A. Vassilakis, MD, MPH (*)
Department of Medicine, Columbia University Medical Center,
5141 Broadway 2nd Floor, Room 095, New York, NY 10034, USA
e-mail: av2060@cumc.columbia.edu
438
Decision-Making
Contraception visits should start with establishing absence of
pregnancy. When appropriate, emergency contraception
options or prenatal management become the focus of the
visit. All evaluations should include key medical history and
examination to identify any contraindications or precautions
for particular modes of contraception due to medical condi-
tions (see Fig. 27.1).
Contraception discussions are a key opportunity for coun-
seling. Patient ability to refuse sexual encounters or choose
contraceptive use, as well as awareness and prevention of
sexually transmitted diseases, can allow clinicians to address
important behavioral or safety issues.
Additional elements to aid decision-making include
obstetric history, reproductive life plans, efficacy level of con-
traceptive methods, and patient preferences. Patient prefer-
ence exploration should include non-contraceptive health
benefits, interval for thinking about contraception, bleeding
patterns, side effects, comfort, practicality of use, and hor-
monal vs. non-hormonal methods [4]. For adolescents, issues
of cognitive development and reliability, high-risk behavior,
and confidentiality (including use of parent insurance) need
to be considered [5].
Key History and Physical Exam
To establish reasonable certainty that a woman is not pregnant,
ensure there are no current signs and symptoms of pregnancy,
and establish ONE of the following: last menstrual period
(LMP) within 7 days, no sexual intercourse since LMP, cor-
rect and consistent use of a reliable contraception, spontane-
ous or induced abortion within 7 days, 4 weeks or less
postpartum, or at least nearly fully breastfeeding [6, 7].
Alternatively, a pregnancy test can be obtained.
Additional history and examination should focus on
safety and self-determination, patient preferences, and pos-
A. Va s sila k i s
439
sible gynecologic pathology or dysregulation including men-
strual cycle problems (dysmenorrhea, menorrhagia,
endometriosis), uterine problems (leiomyomas, other ana-
tomic changes), pelvic inflammatory disease (bimanual and
cervical inspection as well as associated symptoms), personal
and family history of cancer, smoking, as well as comorbidi-
ties such as hypertension (blood pressure check), HIV status
and antiretroviral use, obesity, ischemic heart disease, vascu-
lopathy, pro-thrombotic states (lupus, sickle cell disease,
prior thromboses), lactation status, anticonvulsant use,
Establish reasonable certainly that patient
is not pregnant
Need for emergency contraception
Tier 1 (Table 27.1) Tier 2 (Table 27.1) Tier 3 (Table 27.1)
Contraindications to modes of contraception?
(Table 27.2)
-How would they feel if female partner became pregnant in the next
year? (link discussion to tier of efficacy of methods)
-STI Prevention; Safety and self-determination
-Patient preferance, non-contraceptive benefits
Counseling
-Implant (0.05%)
-LNG IUD (0.2%)
Hormonal
Permanent Contraception
-Male: Vasectomy
(0.15%)
-Female: tubal
occlusion or
salpingectomy (0.5%)
Hormonal
-Progestin only:
injection (6%), pill
(9%)
-Combined harmone
contraceptives:
patch, ring, pill (9%)
-Condoms: Male (18%) or
Female (21%)
-Withdrawal (22%)
-Sponge (12-24%)
-Fertility awareness (24%)
-Spermicide (28%)
Non-hormonal
-Diaphragm (12%)
Non-hormonal
-Copper IUD (0.8%)
Fig. 27.1 Contraception choice. Percentages are of women becom-
ing pregnant within one year of typical use, which can be signifi-
cantly higher than failure rates with perfect use of these methods
27 Contraception
440
gallbladder disease, migraines, inflammatory diseases (rheu-
matoid arthritis, inflammatory bowel disease), liver disease,
and history of bariatric surgery.
Treatment
The currently available contraceptive methods are summa-
rized in Table 27.1. Table 27.2 presents contraindications or
precautions based on the CDC Medical Eligibility Criteria
from 2016 [3]. Additional information for select contracep-
tive methods is presented here, as well as information for
emergency contraception. Lesnewsky et al. provide detailed
information on preventing contraception gaps when switch-
ing methods of contraception [9].
Progestin implant is the most efficacious, reversible
method of contraception available at this time [10]. A small
rod containing etonogestrel is placed subcutaneously in the
inner aspect of the woman’s nondominant arm. The rod can
be felt under the skin and is visible on X-ray imaging. It is
approved for 3 years, but may be effective for up to 5 years
from the time of placement [5, 7, 11].
Permanent contraception options for women include mini
laparotomy, laparoscopy, or hysteroscopic tubal occlusion.
Surgical options include clipping, electrocautery, and partial
or total salpingectomy. Complications of these procedures
are low at 0.9–1.6% [12]. Intraperitoneal adhesions can com-
plicate these procedures. Hysteroscopic tubal occlusion
(Essure) involves placing a nickel–titanium coil that induces
intratubal fibrosis under local anesthesia. It takes time to
occlude the tubes and requires a confirmatory salpingogram
3 months after placement [13].
Intrauterine device (IUD) use is now recommended as a
first- line method of contraception, especially for teenagers, nul-
liparous women, and women infected with HIV [14, 15].
Placement is performed in clinic and can involve significant
pain. The copper IUD is effective immediately after placement.
It should be avoided in Wilson’s disease. The levonorgestrel
A. Va s sila k i s
441
Table 27.1 Contraceptive modes available by efficacy tiers (color code)
Method
Failure
rate
c
Time to
effectiveness
Possible side effects General tips/routine follow–u p evaluation
Implant 0.05% 7 days
a
– Prolonged bleeding: NSAIDs 5–7 days OR
CHC/estrogen for 10–20 days if eligible
– Associated with bleeding changes
– Breast tenderness, weight gain, headache, nausea,
dizziness, and insertion site pain, discoloration, or
scarring
– Check for presence of implant after placement. If
not palpable, can obtain X–ray imaging, offer other
birth control method
– Approved for 3 years, effective up to 5 years in
small studies
Vasectomy 0.15% 4months
– Chronic testicular discomfort in 15% overall,
0.9% severe
– Vasovasostomy, when available, can at times
return fertility—subsequent pregnancy rates range33–
64%.
Abdominal/
laparoscopic
0.5% Immediate
– Surgery complication, blood transfusion,
infection, ectopic pregnancy, anesthesia complications
– Only postoperative follow–up
Hysteroscopy 0.5% 3 months
– Nickel sensitivity, chronic pain from malposition
or expulsion: remove or reposition device
– Bowel injury or obstruction
– Requires confirmatory salpingogram in 3 months
then no follow–up
Copper IUD
(Cu)
0.8% Immediate
– Prolonged bleeding: NSAIDS for 5–7 days
– Pelvic pain: expulsion, perforation, infection,
ectopic pregnancy. Remove device or treat specific
etiology
– LNG IUD associated with amenorrhea or
oligomenorrhea, breast tenderness, acne, headaches, and
mood swings
– Bimanual and cervical inspection prior to
placement
– LNG approved for 3 or 5 years(different
devices)
– Cu approved for 10 years, can be efficacious for 12
– Can treat pelvic inflammatory disease without
removal of device
LNG IUD 0.2% 7 days
b
Injectable
progesterone
(DMPA)
6% 7 days
b
– Bleeding: NSAIDs 5–7 days. For heavy or
prolonged bleeding CHC or estrogen for 10–20 days (if
eligible)
– Breast tenderness, weight gain, amenorrhea: if
eligible, consider CHC
– Headache, nausea, dizziness
– Check weight
– IM injection every 3 months. If delayed for more
than 2 weeks, check pregnancy test. If negative, inject
and advise backup contraception for 7 days
Progesterone
pill
5– 9% 2 days
a
– Hirsutism, acne, bleeding: if eligible, consider
CHC
Excellent for lactating women
Combined
hormonal
contraceptive
pill, patch, ring
5– 9% 7 days
a
– Headache: if during scheduled bleed, consider
extended cycle use
– Unscheduled bleeding: consider triphasic
formulation
– Decreased libido: use higher estrogen dose pills
– Breast tenderness, mood swings, thrombosis
– Blood pressure check every visit
– Patch is changed weekly, ring removed at
3 weeks, pills taken daily
– Extended hormone use can decrease side effects
– Do not cause weight gain
Diaphragm 12% Immediate – Va ginal irritation from spermicide
– Use spermicide with each new encounter while
in place and keep for 6 h after last intercourse
Condom 14– Immediate – Latex allergies – Prevents sexual transmitted diseases
21% – Female condoms usually not latex
Withdrawal 22% Immediate – Requires partner complianceand body awareness
Sponge
12–
24%
Immediate – Vaginal irritation from spermicide
– Effective for 24 h. Keep 6 h post intercourse
– Much less effective in parous women
Fertility
awareness
25%
Immediate
after period
– Various methods available
Spermicide 28% Immediate –Vaginal irritation, allergies – Best used with other methods
a
If > 5 days since LMP
b
If > 7 days since last LMP
c
Typical use failure rates, which can be significantly different from perfect use failure rates. Created
using all references in this chapter
Table 27.2 Category 3 (risks usually outweigh the advantages) or 4
conditions (unacceptable health risk) by type of contraceptive method
Contraceptive
method
Contraindications or precautions (method
contraindicated or risks likely outweigh the benefits)
Progestin-
only implant
or pill
Ischemic heart disease*, liver disease,
a
history
of stroke*, SLE with antiphospholipid antibody,
anticonvulsant use, rifampin/rifabutin use,
history of breast cancer, bariatric surgery causing
malabsorption (pill only), unexplained vaginal
bleeding (implant only). *Pill or implant can be
initiated for short-term acute benefits, but should
not be continued for prolonged periods of time.
(continued)
27 Contraception
442
Contraceptive
method
Contraindications or precautions (method
contraindicated or risks likely outweigh the benefits)
IUD Pelvic, uterine, or cervical distortion, cancer, or
acute infection,
a
unexplained vaginal bleeding with
suspicion for serious condition before evaluation,
gestational trophoblastic disease with suspicion/
evidence of intrauterine disease, complicated solid
organ transplantation. For LNG-IUD only: current
or recent history of breast cancer, liver tumor or
decompensated cirrhosis,
a
ischemic heart disease,
SLE with antiphospholipid antibody. For Cu-IUD
only: SLE with severe thrombocytopenia or
Wilson’s disease.
Progestin
injection
Current or history of breast cancer, liver
disease,
a
diabetes with complications,
b
uncontrolled hypertension, vascular disease,
ischemic heart disease or high risk for coronary
artery disease, rheumatoid arthritis on
immunosuppressive therapy, history of stroke,
lupus with antiphospholipid antibody or severe
thrombocytopenia, unexplained vaginal bleeding
with suspected serious condition, breast cancer.
Combined
hormone
contraception
(pill, ring,
patch)
Hypertension (even controlled), high risk for or
current acute thrombosis,
a
ischemic heart disease,
liver disease,
a
high risk for coronary artery disease,
peripartum cardiomyopathy, smoking and age > 34,
history of stroke, diabetes with complications,
b
vascular disease, complicated valvular heart
disease, complicated solid organ transplantation,
inflammatory bowel disease (need higher doses of
estrogen), antiretroviral therapy or anticonvulsant
therapy, rifampin/rifabutin use, breast cancer,
symptomatic gallbladder disease, migraines with
aura, bariatric surgery causing malabsorption
(for pills only), history of cholestasis while on
combined oral contraceptives.
Adapted and summarized from CDC’s Medical Eligibility Criteria
for Contraceptive Use, 2016
a
See original for specific conditions included in this category
b
Vasculopathy, nephropathy, retinopathy, neuropathy
Table
27.2 (continued)
A. Va s sila k i s
443
IUD (LNG-IUD) is available in devices for 3 and 5 years of use.
It can take up to 7 days to become effective [5, 7, 15].
Progestin-only pills (POPs) are a good option for postpar-
tum and lactating women and work as well as estrogen-con-
taining products without safety issues. They are taken daily
and become effective within 2 days of use [7].
Combined hormonal contraceptives (CHC) are often used
for their non-contraceptive benefits including improvement in
acne, menstrual disorders, and menstrual migraines. They are
known to increase risk for venous thromboembolism up to
ninefold, a risk that is still lower than that of pregnancy and
the postpartum period [16, 17]. Typical use involves hormone
treatment followed by a hormone-free period during which
scheduled bleeding occurs. Extended CHC use involves skip-
ping the hormone-free period for months at a time. It gener-
ally induces amenorrhea without any additional health risks.
The pill is taken daily. The ring is placed intravaginally and
removed at 3 weeks for 3–7 days. If needed, it may be removed
for no more than 3 h in any 24-h period. The transdermal
patch is changed weekly [5, 7, 18]. For management of missed
doses of CHC, readers are referred to the CDC recommenda-
tions at http://www.cdc.gov/reproductivehealth/contraception/
pdf/recommended-actions-late-missed_508tagged.pdf [7].
Notes on hormonal contraceptives: Data for up to seven
years of oral contraceptive use shows no difference in fertility
and no concerns for pregnancy outcomes [19]. Oral contra-
ceptives affect a small increase in cervical cancer risk over
time (higher risk with longer use) and a significant decrease
in endometrial and colorectal cancer risks. High estrogen
dose CHC increase breast cancer risk slightly. Studies assess-
ing risk of low estrogen dose CHC in women with BRCA
mutations show no significant increase in breast cancer inci-
dence from their baseline, but a decreased risk of ovarian
cancer [20].
Condoms are the only option to reduce sexually transmit-
ted infections in sexually active people and should be encour-
aged in addition to all other methods for this purpose.
27 Contraception
444
Emergency contraception (EC) can prevent unwanted
pregnancy after sexual intercourse. It should not be used for
routine contraception because it is not as effective as regular
contraceptive methods. No significant health risks have been
associated with its recurrent use. There are three effective
options for EC: the copper IUD, ulipristal acetate (UPA), and
levonorgestrel. Patients should be counseled not to take
higher doses than recommended or mix hormonal methods,
as this can decrease efficacy as well as worsen side effects.
The copper IUD is the most effective up to 5 days after an
encounter, with a failure rate of 0.1%. UPA is a one-time,
30 mg progesterone receptor binder pill which inhibits or
delays ovulation. It has a failure rate of 0.9–2.1%, which does
not decrease over time for up to 5 days. Women should not
restart hormonal contraception for at least 5 days after UPA
use and should be counseled about decreased efficacy of
progestin-only contraception for up to 2 weeks. Levonorgestrel
(plan B) is taken as a one-time dose of 1.5 mg and is available
over the counter and by prescription. Its failure rate is 0.6%
in the first 12 h, but increases to nearly 4% by 72 h [7, 21].
Combination oral contraceptives can also be used, but they
are less efficacious. Specific dosing options can be found at
http://ec.princeton.edu/questions/dose.html. Side effects of
hormonal EC are usually minor and no more frequent than
side effects experienced with placebos. They can include
headache, abdominal pain, dizziness, fatigue, nausea, dysmen-
orrhea, and breast tenderness.
Hormonal EC is less efficacious in women with BMI over
30 (ulipristol 2.6% failure, levonorgestrel 5.6% failure) [22].
It can also have decreased efficacy due to drug interactions,
especially with rifampin, griseofulvin, anticonvulsants, St
John’s wort, and antiretrovirals. Dose doubling has been sug-
gested, however efficacy of this practice has not yet been
demonstrated [21].
Clinical Pearls
• IUDs and implants are recommended as first-line, revers-
ible modes of contraception for most women.
A. Va s sila k i s
445
• Start by asking women how they would feel if they became
pregnant in the next year.
• Use tiers of effectiveness to present contraceptive
methods.
Don’t Miss This!
• Opportunities to promote discussions about contraception
in the clinic—flyers, pamphlets.
• Teenager confidentiality—know state laws, decide whether
to use parent insurance.
• Contraception gaps when initiating or switching methods
of contraception.
• Offer contraception to women with serious medical prob-
lems to prevent complications.
References
1. Daniels K, Daugherty J, Jones J. Current contraceptive status
among women aged 15–44: United States, 2011–2013. NCHS
Data Brief [Internet]. 2014 Dec [cited 2017 Feb 11];(173):1–8.
http://www.ncbi.nlm.nih.gov/pubmed/25500343.
2. Daniels K, Daugherty J, Jones J, Mosher W. Current contracep-
tive use and variation by selected characteristics among women
aged 15–44: United States, 2011–2013. Natl Health Stat Report
[Internet]. 2015 Nov 10 [cited 2017 Feb 11];(86):1–14. http://
www.ncbi.nlm.nih.gov/pubmed/26556545.
3. Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG,
Zapata LB, et al. U.S. medical eligibility criteria for contracep-
tive use, 2016. MMWR Recomm Reports [Internet]. 2016 Jul
29 [cited 2017 Feb 11];65(3):1–103. http://www.cdc.gov/mmwr/
volumes/65/rr/rr6503a1.htm.
4. Wyatt KD, Anderson RT, Creedon D, Montori VM, Bachman J,
Erwin P, et al. Women’s values in contraceptive choice: a system-
atic review of relevant attributes included in decision aids. BMC
Womens Health. 2014;14(1):28.
5. Raidoo S, Kaneshiro B. providing contraception to adolescents.
Obstet Gynecol Clin North Am [Internet]. 2015/11/26. 2015 Dec
[cited 2017 Feb 11];42(4):631–45. http://www.ncbi.nlm.nih.gov/
pubmed/26598305.
27 Contraception