Contraception 1 Recognize the impact of unintended pregnancies on the healthcare system and discuss the role of the Affordable Care Act regarding contraception 50 of pregos are unintended ACA cannot be charged more than men for health insurance premiums or denied coverage for pre existing conditions Able to maintain coverage under parent s health insurance until age 26 Private health insurances to provide preventative services at no cost ex mammograms cervical cancer screenings prenatal care flu and pneumonia shots and regular well baby and well child visits breastfeeding support contraceptive services and other Medicaid expansion provide comprehensive coverage for lower income women who were previously only eligible for coverage while prego private health insurance plans to provide birth control w o co pays and deductible Not ALL free August 1st 2013 health plans established or maintained by religious employers are exempt from the requirement to cover contraceptive services 2 Recommend and appropriately counsel patients on non hormonal contraceptive options Barrier Hormonal Other Condoms male female Cervical cap Diaphragm Sponge Spermicide Intrauterine device IUD Progestin only pills mini pills Vaginal ring Transdermal patch Injectable Combination oral contraceptives COCs Sterilization Abstinence Withdrawal Sponge made of foam inserted into vagina to prevent prego Use only once 2 ways blocks sperm from entering uterus release spermicide that stops sperm from moving Diaphragm silicone cup inserted into vagina Reusable up to 2 years 2 ways blocks opening to uterus spermicide stops sperm from moving Rx only must see a HC provider to determine which size appropriate Cervical cap silicone cup into vagina reusable up to 2 years Same at diaphragm Condoms latex only use with water based lubricant b c oil based Vaseline breaks down latex Non latex polyurethane good for latex allergies thinner but less flexible risk of breakage use with water or oil based lube Lamskin sheepskin oldest type intestinal membrane of lamb natural feel ineffective in preventing against STI transmission but protect against prego Male condoms Pros Cons Inexpensive Variety sizes textures colors tastes Greater widespread availability Smaller easier to conceal Greater responsibility on male partner Latex condoms may cause allergic reactions Use may be an interruption in intimacy Female condoms Pros Cons More expensive about 4 5x more Outer ring cumbersome Higher failure rate 21 with typical use More noisy popping crackling sounds may be disruptive More difficult to insert Less likely to cause an allergic reaction Able to insert beforehand Male erection not needed to keep in place Gives female control to prevent pregnancy STIs Less likely to break spermicides increase risk of STI No prescription needed except cervical caps diaphragm 3 Explain the pathophysiology of the female menstrual cycle Gonodotropin Releasing Hormone GnRH stimulates release of FSH and LH Follicle stimulating Hormone FSH secreted by the anterior pituitary gland stimulates growth and maturation of follicle before ovulation thins the endometrium Luteinizing Hormone LH also secreted by the anterior pituitary gland stimulates final maturation of follicle surge of LH about 14 days before next menstrual period causes ovulation stimulates the transformation of the growing follicle into corpus luteum as well as thickens the endometrium Hormonal contraceptives raise estrogen progestin levels preventing the release of FSH LH through negative feedback If there are no fluctuations in the FSH LH levels ovulation does not occur 4 Recommend appropriate contraceptive methods given patient specific information including when to start side effects management of late or missed doses switching between products and management of common patient complaints IUD T shaped device wrapped in copper or levonorgestrel inserted into uterus Levonorgestrel Mirena duration up to 5 years skyla up to 3 years Copper Paragard 10 years must be inserted by HC provider f u in 1 3 months Side effects common abd pain fatigue HA dizziness breast tenderness Rare expulsion of IUD perforation of cervix or uterus infections esp first month of insertion Affect on menses copper longer and heavier menses more cramping LNG spotting 1st month then amenorrhea no period INSERTION w i 7 days of menses LNG no back up needed After 7 day window back up 7 days Switching to another IUD Lng to copper no back up needed copper Lng back up 7 days Switching to another form of contraception if remove iud during first 7 days of menses and begin new therapy no back up needed Similarities very effective dosing once requires office visit for insertion and removal fertility returns immediately after removal cost lack of estrogen componenet good for pt who can t take estrogen smokers 35y o post partum breastfeeding mothers Diff copper iud effective right away duration of effectiveness affect on menses active ingredient MOA copper create toxic environment for sperm lng inhibit sperm motility and function by thickening cervical mucus and may also black release of egg from ovum Good candidates effective method compliance issues long term treatment decreet method desire for immediate return of fertilization Poor candidates current recent pelvic inflammatory disease current recent STI past 12 month distorted uterine cavity uterine cervical cancer unexplained vaginal bleeding current PMH of breast cancer lng IUD only increased risk of infection HIV AIDs IVDU Implant active ingredient etonogestrel progestin only Nexplanon MOA prevent ovulation and sperm from meeting egg Last 3 years INSERTION if not on contraceptive between day 1 day 5 of menses If switch from OCO nuvaring or path insert on last day of active If switch from progestin only insert plant and stop progestin pill same day No back up needed if recommendation done right SE irregular bleeding mood changes weight pain good candidates effective method compliance issue long term treatment discreet desire immediate fertility return bad current or PMH of breast cancer unexplained vaginal bleeding liver disease VTE PE Heart attack stroke Injectable DepoProvera active ingredient medroxyprogesterone progesterone Dosing 150mg IM q 3 months RX only shot at doc office SE irregular bleeding weight gain 10 lbs at 24 months bone mineral density loss BLACK Box good candidates effective compliance issues cannot take estrogen desire fewer menses 4 year not interested in immediate