Non-Hormonal Methods. Contraception Part 2: Non Hormonal Methods and Emergency Contraception. Objectives

Transcription

1 Objectives Contraception Part 2: Non Hormonal Methods and Emergency Contraception By the end of this lecture, participants will be able to: Discuss appropriate candidates for the various types of nonhormonal contraception Reinforce patient education on the appropriate use of nonhormonal contraceptive agents Explain the various forms of emergency contraception Describe the nurse s role in caring for women seeking contraception 09/12/12 2 Non-Hormonal Methods Non-Hormonal Methods of Contraception ParaGard IUD Condoms Diaphragm Cervical Cap Spermicide/Sponge 3 4

2 Non-Hormonal Intrauterine Contraception: ParaGard Copper T 380A IUD 380 coils of copper Efficacy of 99.4% Effective up to 10 years Inserted in office setting Inhibits sperm motility, fertilization and implantation Side effects Increased bleeding/pain with menses Vaginal discharge Obtained through Prosthetics Duramed Pharmaceuticals, Inc. a subsidiary of Barr Pharmaceuticals, Inc. ParaGard Advantages Long term method requiring no maintenance Overall, the most cost effective method Reversible sterilization Useful for women who can t take estrogen or don t want to use hormones Can be inserted at any time during menstrual cycle Disadvantages Not suitable for women with copper allergy Doesn t protect against HIV/STDs 5 6 ParaGard Visit Male Condom Rule out pregnancy Obtain ParaGard from prosthetics Pre insertion med: mg of ibuprofen one hour prior Equipment needed for insertion: Betadine or hibiclens, poured into pack of 4x4 gauze Sterile gloves Sterile equipment on sterile tray Uterine sound, vaginal speculum, ring forceps, suture scissors (long), single tooth tenaculum, sterile IUD package Patient received written info? Signed consent form? Questions? Remove IUD on or before expiration date with ring forceps Used especially by teens, year olds, childless women, never married women Typical use failure of 15% Advantages: Non prescription, inexpensive, easily obtained STD protection (except lambskin condoms pores allow viruses and cells to pass through) Disadvantages Break, slip Latex allergy (use polyurethane condoms instead) Tied to intercourse Check with your facility for procurement 7 8

3 Female Condom Polyurethane sheath with inner and outer ring Typical use failure of 21% Used by some sex workers Advantages Under the woman s control Greater STD protection (partly covers the labia) Disadvantages Tied to intercourse Noisy Expensive ($2.50 to $5.00) High displacement rate Diaphragm Latex or silicone dome filled with spermicide Typical use failure of 16% Advantages Under the woman s control Disadvantages Tied to intercourse Spermicide only effective for 2 hours Fitting is necessary Allergy/UTI risk Doesn t protect against HIV/STDs 9 10 Patient Education for Diaphragms How to insert Insert only up to 2 hours before sex; spermicide effective only 2 hours If inserted more than 2 hours before intercourse, leave diaphragm in place and add more spermicide directly into vagina with applicator. For further intercourse, add more spermicide. Leave diaphragm in place for 6 8 hours after intercourse. Do not leave diaphragm in vagina for more than 24 hours can increase risk of toxic shock syndrome Must also use condoms for STD protection. Irritation from spermicide may increase risk of acquiring HIV. 11 Cervical Cap Courtesy of Typical use failure of 20% FemCap Spermicide inserted into a silicone cup placed on cervix Disadvantages Tied to intercourse Wear 6 hours before and after sex (48 hours max) 3 sizes, fitting is necessary (refit after childbirth, abortion, miscarriage, or gaining 15 pounds) Can be dislodged during sex Increased risk of cervical inflammation No STD protection. Spermicide irritation may increase risk of acquiring HIV. FemCap available in US; mostly marketed in 3 rd World countries Costs $60 $75 and lasts 2 years 12

4 Spermicides Typical use failure of 29% Available in cream, foam, gel, film, suppository No STD protection Possible increased risk of HIV transmission when Nonoxyl 9 is used alone Can irritate vagina and rectum, thus potentially increasing risk of getting HIV from infected partner 13 Sponge Barrier + spermicide method (1,000 mg of nonoxynol 9) Typical use failure of 29% Side effects: Spermicide allergy Increased risk of yeast infections, UTIs Patient education points Run under water until thoroughly wet. Insert against cervix. Can be inserted up to 24 hours before intercourse Must be left in place for at least 6 hours afterward Do not wear for more than 30 hours in a row may result in toxic shock syndrome if left in too long No HIV/STD protection. Irritation from spermicide may increase risk of acquiring HIV. 14 Today Sponge. Used with permission from Mayer Labs. Natural Family Planning / Withdrawal Other Methods of Contraception Natural Family Planning Effective in select cases for: Motivated, educated patients Women with regular cycles Some sources quote 95% efficacy but typical use failure is likely higher No contraindications, risks, side effects other than failure Withdrawal Not recommended failure rate of 27% 15 16

5 Natural Family Planning: Various Methods Cervical mucous or ovulation method Sympto thermal method Based on cervical mucous and basal body temperature Timed abstinence or Rhythm/Calendar Method Not recommended high failure rate 25% Lactational amenorrhea Time between feedings must be no longer than 4 hours during the day and 6 hours at night Most effective during first 6 months of exclusive breastfeeding Works better for older women who are less fertile Sterilization Males: vasectomy Females: tubal ligation and Essure Counseling Points >99% effective, but failures can occur Should be considered IRREVERSIBLE In U.S., spouse or partner is not required to give consent Female Sterilization Contraindications Severe medical problems not allowing anesthesia Side effects Heavier menses, more dysmenorrhea Risks Surgical risks Regret/questionable reversibility Ectopic pregnancy: Among 10,685 women, risk of ectopic pregnancy within 10 years of sterilization was about 7/1,000 Does not protect against HIV/STDs 19 Tubal Ligation Done postpartum or as an interval procedure Two small cuts made in abdomen, usually around navel. Instruments to tie tubes sent thru laparoscope. Tubes are either cauterized or shut off with small clip. Patient usually returns home in a few hours. Failure rate of 0.8 2% Counseling Points Avoid strenuous exercise for several days Return to work within a few days Sexual intercourse usually within a week Rates of regret: 20% in women under 30! Does not protect against HIV/STDs 20

6 Essure Hysteroscopic placement of soft, flexible micro inserts Growth of scar tissue results in blocked fallopian tubes Advantages: no incisions, minimal anesthesia, failure rate <1% Disadvantages: 3 month wait for confirmatory testing with hysterosalpingography (HSG) Not for women with nickel allergy No protection against HIV/STDs Courtesy of Conceptus, Inc Emergency Contraception Emergency Contraception (EC) Plan B/Next Choice (Levonorgestrel) Ella (Ulipristal) Offer in advance because Increases the likelihood that EC is used Decreases the time interval to use Does not decrease contraception use Counseling Points for Plan B Not the same as RU 486 Non prescription costs: Pharmacy: Plan B One Step $50 (generic $45) Planned Parenthood $37 Use within 5 days of unprotected intercourse Taking within 72 hours decreases chance of getting pregnant by 89% (from 8% without Plan B to 1% with Plan B) Even more effective if taken within 24 hours Effectiveness decreases with time Common side effects: nausea (23%), abdominal pain (18%), fatigue (17%), headache (17%), and menstrual changes 23 24

7 Ella Ulipristal single dose (30mg). Not on VA formulary. Take within 5 days Efficacy similar to Plan B Mechanism Delays ovulation Inhibits implantation Similar side effect profile to levonorgestrel Advanced provision required; not available without prescription Counseling points similar to Plan B 25 Other Methods of Emergency Contraception Yuzpe regimen High doses of levonorgestrel OCP woman already has on hand More nausea/vomiting, less effective ParaGard IUD Place within 5 days of unprotected intercourse Failure rate of % Can be removed after next period, or left in for long term birth control More effective for overweight and obese women Consider antibiotic prophylaxis while awaiting cultures Screen as always for STD Not FDA approved for this purpose (counsel appropriately) 26 Case 1 Grace, a 26 year old woman, calls your office: Case Studies I just started birth control and I m bleeding

8 Clarifying Questions Could you be pregnant? What form of birth control are you using? When did you start it? How are you using it? When did you start bleeding? How long have you been bleeding? How much blood is there? What was the first day of your last menstrual period? Are you experiencing pain with the bleeding? Have there been any prior episodes of bleeding? Have you undergone any recent gynecologic procedures? Is the bleeding related to sex? Have you experienced any trauma? Have you recently had any vaginal discharge? Do you have chills or fever too? 29 Triage: Differentiate urgent from emergent situation 1. Is she hemodynamically stable? 2. Could she be pregnant? 3. Is she experiencing a high risk complication from her contraceptive? If she could be pregnant Which test is available (urine vs. 2 types of serum) and how to order? Contraceptive high risk complications Recent IUD insertion: fever, lower abdominal pain Hormonal contraceptive: Deep vein thrombosis (skin pain/swelling/discoloration especially in an extremity, low back pain) Pulmonary embolism (chest pain when taking a deep breath, shortness of breath, coughing up blood, heart racing or pounding, lightheadedness or fainting) When to contact a provider? Based on Available protocol or team dynamics Your comfort level and your provider s comfort level 30 Determine Appropriate Disposition of Patient Case 2 1. When to send to ER 2. When to discuss/refer to a provider 3. Patient education (what to tell her, how to tell her, what she needs to tell us) Janine, a 22 year old veteran, calls your clinic. The condom broke. What if I m pregnant? I don t know the guy all that well. 4. How test results will be communicated 31 32

9 Clarifying Questions Assess Janine s Risk Factors for an STI In addition to the possibility of pregnancy, do you have any other concerns? When did the condom break? Are you on another form of birth control? Was the sex consensual? Have you had any other episodes of unprotected sex recently? Unprotected sex Young age Unmarried Multiple sexual partners History of a prior STD Illicit drug use Contact with sex workers New sex partner in past 60 days No HPV vaccination You need to address. Potential pregnancy Know which test is available (urine vs. 2 types of serum); how to order Possible STD exposure Know her STD risk factors, screening tests available, how to offer them to her, how to order tests, her HPV vaccine status Emergency contraception options Plan B: Know VHA policy, availability, and how it works. Educate her on efficacy, side effects, and use. ParaGard: Know how it works and its availability. Educate her on insertion, efficacy, and side effects. Yuzpe method: Know how it works and if she has oral contraceptives at home. Educate her on efficacy, side effects, and how to do it. Educate her on pregnancy symptoms, potential teratogenic medications 35 Determine Appropriate Disposition of Patient 1. When to send to ER 2. When to discuss/refer to a provider 3. Patient education (what to tell her, how to tell her, what she needs to tell us) 4. How test results will be communicated 36

10 For more information: 1. Association of Reproductive Health Professionals. Patient Resources CDC. United States Medical Eligibility Criteria (USMEC) for Contraceptive Use Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. 2005;71(1): Weissmiller, D. Emergency contraception. Am Fam Physician. 2004; 70(4):707 14, McKinley Health Center, University of Illinois at Urbana Champaign. Thinking about birth control. [excellent summary for nurses and patients] 37 Primary author: Contributors: Sherry Nordstrom, MD Jesse Brown VA, Chicago, IL Linda Baier Manwell, MS University of Wisconsin Madison Rose Birkmeier, DNP, FNP Aleda E. Lutz VA Medical Center, Saginaw, MI Amanda Johnson, MD, FACOG Cheyenne VA Medical Center, Cheyenne, WY WH Nurse Reviewers: Barbara Robinson, RN Katrina Goldby, RN, BSN, JD Susan Johnson Molina, RN, BSN, MAOM Connie LaRosa, RN, MSA, CPHQ Barbara Polak, RN, MSN Mary Ann Reale, MS, RN Lisa Roybal, MSN, WHNP