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Test 2 - Chapter 5 - Contraception and Abortion

Terms in this set (35)

Fertility awareness methods (FAMs) of contraception depend on identifying the beginning and end of the fertile period of the menstrual cycle. When women who want to use FAMs are educated about the menstrual cycle, three phases are identified:
1. Infertile phase: Before ovulation
2. Fertile phase: About 5 to 7 days around the middle of the cycle, including several days before and during ovulation.
3. Infertile phase: After ovulation

Although ovulation can be unpredictable in many women, teaching the woman about how she can directly observe her fertility patterns is an empowering tool. In addition, knowledge about the signs and symptoms of ovulation can be very helpful when the couple desires pregnancy. There are nearly a dozen categories of FAMs. To prevent pregnancy each one uses a combination of charts, records, calculations, tools, observations, and either abstinence or barrier methods of birth control during the fertile period of the menstrual cycle. The charts and calculations associated with these methods can also be used to increase the likelihood of detecting the optimal timing of intercourse to achieve conception.

Advantages of these methods include low-to-no cost, absence of chemicals and hormones, and lack of alteration in the menstrual flow pattern. Disadvantages of FAMs include adherence needed for strict record keeping, unintentional interference from external influences that may alter the woman's core body temperature and vaginal secretions, decreased effectiveness in women with irregular cycles (particularly adolescents who have not established regular patterns of ovulation), decreased spontaneity of coitus, and the necessity of attending possibly time-consuming training sessions by qualified instructors. The typical failure rate for most FAMs is 24% during the first year use. FAMs do not protect against STIs or HIV infection.
The normal menstrual cycle is maintained through hormonal feedback mechanisms. FSH and LH are secreted in response to fluctuating levels of ovarian estrogen and progesterone. Regular ingestion of combines oral contraceptive pills (COCs) suppresses the action of the hypothalamus and anterior pituitary, leading to insufficient secretion of FSH and LH; therefore follicles do not mature, and ovulation is inhibited.

Other contraceptive effects are induced by the combined steroids. Maturation of the endometrium is altered, making the uterine lining a less favorable site for implantation. COCs also have a direct effect on the endometrium; thus from 1 to 4 days after the last COC is taken the endometrium sloughs and bleeds as a result of hormone withdrawal. The withdrawal bleeding is usually less profuse than that of normal menstruation and may last only 2 to 3 days. Some women have no bleeding at all. The cervical mucus remains thick from the effect of the progestin. Cervical mucus under the effect of progesterone does not provide as suitable an environment for sperm penetration as does the thin, watery mucus that the healthy reproductive woman produces before and during ovulation.

Monophasic pills provide fixed dosages of estrogen and progestin. They alter the amount of progestin and sometimes estrogen within each cycle. These preparations reduce the total dosage of hormones in a single cycle without sacrificing contraceptive efficacy. To maintain adequate hormone levels for contraception and enhance compliance, COCs should be taken at the same time each day. Taken exactly s directed, COCs prevent ovulation, and pregnancy cannot occur. The overall theoretic effectiveness rate of COCs is almost 100%.

Because taking the pill does not relate directly to the sexual act, COC acceptability may be increased. Improvement in sexual response may occur once the possibility of pregnancy is not an issue. For many women it is convenient to know when to expect the next menstrual flow.

Contraindications for COC use include a history of thromboembolic disorders, cerebrovascular or coronary artery disease, breast cancer, estrogen-dependent tumors, pregnancy, impaired liver function, liver tumor, lactation less than 6 weeks pospartum, smoking if older than 35 years of age, migraine with aura, surgery with prolonged immobilization or any surgery on the legs, hypertension, and diabetes mellitus with vascular disease.

The effectiveness of oral contraceptives is decreased when the following medications are taken simultaneously:
Anticonvulsants such as barbiturates, oxcarbazepine, phenytoin, phenobarbital, carbamazepine, primidone, and topiramate. Systemic antifungals such as rifampican and rifabutin. Anti-HIV protease inhibitors such as nelfinavir and amprenavir.

Nursing Considerations: Many different preparations of oral hormonal contraceptives are available. Because of these wide variations in pills, each woman must be clear about the unique dosage regimen for the preparation prescribed for her and follow directions on the package insert.
EC offers protection against pregnancy after intercourse occurs in instances such as broken condoms, sexual assault, dislodged cervical cap, disruption of use of any other method, or any other case of unprotected intercourse. Methods that are available in the United States that could provide postcoital contraception include:

Ella (Ulipristal): single 30-mg pill containing an antiprogestin
Plan B One-Step: single progestin-only pill containing 1.5 mg levonorgestrel.
Next Choice: two levonorgestrel 0,75-mg tablets taken orally 12 hours apart or both together..
Combined oral: estrogen-progestin contraceptive pills.
Copper intrauterine device (IUD) insertion within 120 hours of intercourse

Plan B One-Step and Next Choice are approved by the FDA for over-the-counter sale to women ages 17 and older with proof of age. Adolescents 16 years and under require a prescription. Ella is available only with a prescription. States vary in the ability of pharmacists to dispense EC, and some states have implemented refusal legislation.

In general, for the most effectiveness, EC should be taken by a woman as soon as possible but within 72 hours of unprotected intercourse or a birth control mishap to prevent unintended pregnancy. Research has shown a moderate amount of effectiveness between 72 and 120 hours but no data are available for effectiveness after 120 hours.

If taken before ovulation, EC prevents ovulation by inhibiting follicular development. If taken after ovulation occurs, there is little effect on ovarian hormone production of the endometrium. To minimize the side effect of nausea that occurs with high doses of estrogen and progestin, the woman can be advised to take an over-the-counter antiemetic 1 hour before each dose. Nausea is not as common with the plan B regimen. Women with contraindications for estrogen use should use progestin-only EC. No medical contraindications for EC exist, except pregnancy and undiagnosed abnormal vaginal bleeding. If thye woman does not begin menstruation within 21 days after taking the pills, she should be evaluated for pregnancy. EC is ineffective if the woman is pregnant since the pills do not disturb an implanted pregnancy. Risk of pregnancy is reduced by as much as 75% and 89% if the woman takes EC pills.

IUDs containing copper provide another EC option. The IUD should be inserted within 8 days of unprotected intercourse. This method is suggested only for women who wish to have the benefit of long-term contraception. The risk of pregnancy is reduced by as much as 99% with emergency insertion of the copper-releasing IUD. Contraceptive counseling should be provided to all women requesting EC, including a discussion of modification of risky sexual behaviors to prevent STIs and unwanted pregnancy.
Vasectomy is the sealing, tying, or cutting of a man's vas deferens so the sperm cannot travel from the testes to the penis. Vasectomy is the easiest and most commonly used operation for male sterlization. The surgery can be performed with local anesthesia on an outpatient basis. Pain, bleeding, infection, and other postsurgical complications are considered to be possible disadvantages to the surgical procedure.

Two methods are used for scrotal entry: conventional and no-scalpel vasectomy. The surgeon identifies and immobilizes the as deferens through the scrotum. Then the vas is ligated or cauterized. Surgeons vary in their techniques to occulude the vas deferens: ligation with sutures, division, cautery, application of clips, excision of a segment of the vas, fascial interpostion, or some combination of these methods.

Vasectomy has no effect on potency or volume of ejaculate. Endocrine production of testosterone continues so secondary sex characteristics are not affected. Sperm production continues, but sperm are unable to leave the epidiymis and are lysed by the immune system. Vasectomy does not change the man's transmission of the HIV virus if he is infected. he will need to be instructed to engage in a number of ejaculations until there are no viable sperm remaining above the area of the surgery. Until this occurs, as documented by semen analysis, the couple should use back-up contraception.

Complications after bilateral vasectomy are uncommon and usually not serious. They include bleeding (usually external), suture reaction, and reaction to the anesthetic agent. Men occasionally develop a hematoma, infection, or epididymitits. Less common are painful granulomas from accumulation of sperm. The failure rate for male sterilization is 0.15%.