Chapter 5

1. Chapter 5 Women’s Health: Family Planning

2. Overview of Family Planning • 62 million U.S. women are of childbearing age • 62% of these women practice contraception • 50% of all pregnancies are unplanned • Four out of 10 are terminated • 52% of these women are under 25

3. Benefits of Family Planning • Improved health of women • Lower rates of induced abortions • Fewer unwanted pregnancies and births • Improved socioeconomic status

4. Choosing a Contraceptive Method • Awareness of: • Advantages • Disadvantages • Side effects • Contraindications • Long-term effects

5. Choosing a Contraceptive Method (cont’d) • Choice is influenced by: • Cultural practices and religious beliefs • Personality • Cost and effectiveness • Availability • Misinformation • Practicality of method • Self-esteem

6. Fertility Awareness-Based Methods • Fertility awareness, combined methods: • Use of a barrier method during fertile days • Takes into account lifepan of sperm 2 to 7 days and • Lifespan of ovum 1 to 3 days • Natural family planning: • Abstinence during fertile days

7. Fertility Awareness Methods • Basal body temperature method • Ovulation method • Calendar rhythm method • Symptothermal method • Standard days method • Lactational amenorrhea

8. Spermicides • Nonoxynl-9 (N-9) available as: • Jelly, cream • Foam • Vaginal film • Suppository Works by destroying sperm by disrupting the cell membrane.

9. Barrier Methods • Male condom • Female condom • Diaphragm • Cervical cap • Vaginal sponge

10. Female condom

11. Dysmenorrhea • Painful menstruation • Occurs at the onset of menstruation • Disappears by the end of menses

12. Combined Oral Contraceptives (COC) • Contain estrogen and progestin • Methods of administration: • Day one start • Sunday start • Quick start

13. COC Contraindications • Previous history of thromboembolic disease • Acute or chronic liver disease • Presence of estrogen-dependent carcinomas • Undiagnosed uterine bleeding • Heavy smoking • Gallbladder disease

14. COC Contraindications(cont’d) • Hypertension, diabetes • Migraine with visual disturbances • Hypercoagulable disorders • Hyperlipidemia

15. Side Effects of COC Due to Estrogen • Alterations in lipid metabolism • Breast tenderness • Fluid retention, weight gain • Headache and hypertension • Nausea • Thromboembolic complications • Decreased breast milk production

16. Side Effects of COC Due to Progestin • Acne • Breast tenderness • Decreased libido • Decreased high-density lipoprotein (HDL) • Depression and fatigue • Hirsutism, weight gain, an amenorrhea

17. Noncontraceptive Benefits of COC • Relief of menstrual symptoms and premenstrual syndrome • Decreased incidence of functional ovarian cysts • Reduction in the incidence of: • Ectopic pregnancy and pelvic inflammatory disease (PID) • Ovarian, endometrial, and colorectal cancer • Iron deficiency anemia and benign breast disease

18. Other Hormonal Contraceptives • Combination estrogen-progestin: • Transdermal • Vaginal ring • NuvaRing • Progestin only: • Minipill • Long-acting injectable progestin • Depo-Provera

19. Nuvaring • Left in place for 21 days, then removed for 7 days • Inserted monthly

20. OrthoEvra Patch • Used weekly for 3 weeks on one of four sites: abd, buttocks, upper outer arm or trunk.

21. Minipill • Progestin-only pills (also called mini-pills) are taken daily at the same time. • Micronor • If you are late taking a pill or if you miss a pill, a back-up form of birth control is needed for a week or more. • Good choice for BF moms

22. Depo • An injection of progestin is given in the arm or buttocks. It works for up to three months, so four shots are needed each year. In some cases, a lower dose shot of progestin is also available. • DMPA 150 mg

23. Side Effects of Depo • Irregular menses • Amenorrhea • ? Weight gain • Screen for depression • Bone compromise

24. Implanon • The implant is a thin plastic rod that releases progestin. It works for up to three years.

25. EC • Worried about pregnancy • Contraceptive failure • Unplanned intercourse • Sexual assault

26. Emergency Contraception • Combined oral contraceptive: • May cause nausea and vomiting • 72 hours of unprotected intercourse • Progestin-only contraceptive (Plan B): • More effective than combined postcoital emergency contraception (EC) • 72 hours of unprotected intercourse • Intrauterine device (IUD): • Must be placed within five days of unprotected intercourse

27. Intrauterine Devices • Copper IUD (ParaGARD T380A): • Provides protection for 10 years • Mirena Levonorgestrel Intrauterine System (LNG-IUS): • Provides protection for 5 years

28. Advantages of IUD • High rate of effectiveness • Continuous contraceptive protection • Noncoitus-related activity • Relative inexpensiveness over time

29. Possible Adverse Reactions • Increased and intermenstrual bleeding • Increased risk of pelvic infection • Perforation of the uterus during insertion • Dysmenorrhea • Expulsion of the device

30. Post-Placental IUDs • Mirena (20mcg Levo) Approved in 12/2000 after 10 years of use in Europe • Paraguard Copper 380A Post placental: within 10 minutes of delivery of placenta Before repair. 90% of women first year postpartum want to delay Pregnancy at least 2 years

31. Post Placental IUD • Safe for HIV+ women • No effect on BFg • Expulsion first 3 mts is 12% • Late PP (48 hrs to 4 weeks) expulsion rate too high • Immediate PP 10 minutes to 48 hrs: 25-37% expulsion • At c/s before closing incision.

32. Sterilization • Operative: • Vasectomy • Tubal ligation • Nonoperative: • Essure

33. Post procedure counseling • Vasectomy: full contraceptive benefit not realized until 4-6 weeks and 6-36 ejaculations, need to clear sperm from vas deferns • BTL: PP ideal time, uterus enlarged and tubes easy to find • Essure: no incision; within 3 months microinserts create at tissue response that occludes fallopian tubes.

34. Surgical Pregnancy Termination • First trimester: • Safer than second trimester • Vacuum curettage • Second trimester: • Dilatation and evacuation • Nursing management: • Support • Education

35. Medical Pregnancy Termination • Mifepristone (RU-486)/misoprostol: • First 7 weeks of pregnancy • Mife blocks progesterone, alters enometrium and inhibits implantation. Miso causes contractions that expell fetus • Methotrexate: • First 7 weeks of pregnancy, stops cell division • Not currently approved for this use in US • Given with miso

36. Resources • International Planned Parenthood FederationThis site offers information on family planning methods and sexually transmitted diseases. Health policies affecting family planning worldwide are discussed. • Family Health InternationalThe Family Health International (FHI) site reports on research and projects in the U.S. and more than 60 developing countries related to family planning. There are links to publications and a glossary of terms related to family planning. Information is also provided in French, Spanish, Russian, and Arabic.

37. Resources • Birth Control GuideThe Epigee site provides facts about methods of contraception control, including risks and benefits. Included is a birth control quiz. • Emergency ContraceptionThis site is operated by the Office of Population Research at Princeton University and by the Association of Reproductive Health Professionals. It provides information about emergency contraception derived from the medical literature.

38. Resources • Contraception OnlineBaylor College of Medicine offers this online educational resource for healthcare providers and health educators seeking the latest information on reproductive health, family planning, and contraception. The resources can be used for self-study or to educate others about reproduction and a range of contraceptive methods. It includes downloadable issues of the Contraception Report.