Updated: 12/11/2019

Contraception

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Overview
 

 
Snapshot
  • A 24-year-old, G0P0, woman presesnts to her gynecologist for a scheduled routine visit. She denies any acute complaints and reports to be in excellent health. She is sexually active with only one male partner and uses condoms consistently, which is her only method of contraception. Both her and her partner were recently tested for sexually transmitted infections and results were negative. She reports concern because approximately 2 days ago, she had intercourse and the condom broke. She feels that she is not prepared to care for a child and inquires about the "morning after pill."  After a discussion, she requests the copper intrauterine device as emergency contraception and as a contraceptive method to decrease the risk of future pregnancy.
Barrier Contraceptives
  • Male condom
    • creates a barrier that prevents contact with genital lesions, penile, vaginal, and anal discharges
      • if used correctly and consistently, condoms may reduce the risk of pregnancy and acquiring or transmitting sexually transmitted infections (STIs)
    • effectiveness
      • with typical use, there is an 18% pregnancy rate
    • advantages
      • reversible
      • accessible
      • protection against STI 
      • cost
    • disadvantages
      • reduced sensitivity during intercourse
      • latex sensitivity
  • Female condom
    • another barrier mode of contraception that may reduce the risk of pregnancy and STIs
    • effectivness
      • with typical use, there is a 21% pregnancy rate
Contraceptive Pills
  • Estrogen-progestin contraceptive
    • can also be a ring and patch
    • mechanism of action
      • inhibition of the midcycle luteinizing hormone (LH) surge 
        • impairs ovulation
    • effectiveness
      • with typical use, there is a 9% pregnancy rate
    • side effects include
      • hypercoagulability (DVT and PE)
      • elevated triglycerides
      • hypertension
      • cholelithiasis and cholecystitis 
        • caused by increased gallbladder stasis
      • depression
      • nausea
      • drug interactions
        • metabolized via CYP450 
      • hepatic adenoma 
    • contraindications 
      • ≥ 35 years of age and smoking ≥15 cigarettes/day
      • venous thromboembolism
      • ischemic heart disease
      • stroke history
      • breast cancer 
      • cirrhosis
      • migraine with aura
    • non-contraceptive benefits
      • reduce the risk of ovarian and endometrial cancer
      • can treat acne and hirsutism
      • first-line for endometriosis-related pain
  • Progestin-only contraceptive
    • can also be injected and implanted subcutaneously
    • mechanism of action
      • endometrial decidualization and eventual atrophy leads to
        • endometrium being less suitable for implantation
      • thickening of cervical mucous leading to
        • decreased permeability for sperm
      • impairs tubal peristalsis and motility
    • effectiveness
      • with typical use, there is a 9% pregnancy rate
    • benefits
      • can serve as an alternative contraceptive in women with contraindications to estrogen or if estrogen causes additional health risks
      • can be used immediately post-partum   
      • protective against the development of endometrial cancer
Etonogestrel implant
  • A small progestin rod that is a reversible mode of contraception
    • placed subdermally in the upper arm to provide long-acting (three years) contraception
  • Efficacy
    • with typical use, there is a <1% pregnancy rate 
Intrauterine Device (IUD)
  • Types of IUDs
    • copper IUD 
      • mechanism of action
        • sterile inflammatory reaction due to foreign body exposure
          • this is toxic to the sperm and ova
        • copper also results in an enhanced cytotoxic inflammatory response in endometrial tissue and impairs
          • migration of sperm and its viability
          • acrosomal reaction
      • efficacy
        • with typical use, there is a 0.5-0.8%
      • provides contraception for up to 10-years
      • also has post-fertilization contraceptive effects
    • levonorgestrel IUD
      • mechanism of action
        • sterile inflammatory reaction due to foreign body exposure
          • this is toxic to the sperm and ova
        • levonorgestrel also results in cervical mucus thickening, endometrial decidualization, and glandular atrophy
          • results in impairment of implantation
      • efficacy
        • with typical use, there is a 0.1-0.2% pregnancy rate
      • provides contraception for up to 5-years
  • Contraindications
    • uterine cavity distortions
      • e.g., bicornuate uterus and cervical stenosis
    • pelvic infection of acute onset
      • e.g., pelvic inflammatory disease, mucopurulent cervicitis, and endometritis
    • pregnancy
    • Wilson's disease
      • also in patients with a copper allergy
      • hormone releasing IUD would be preferred in these cases
    • unexplained uterine bleeding
    • current breast cancer
      • it is contraindicated to use the levonorgestrel IUD
Emergency Contraception (EC)
  • EC involves the use of drugs or a device to prevent pregnancy
    • EC is also known as "postcoital contraception" and "morning-after pill"
  • Indications
    • recent unprotected intercourse
    • recent possible failure of a different mode of contraception (e.g., condom breakage)
  • Options
    • copper IUD
      • the most effective method of emergency contraception 
      • must be inserted within 5-7 days of unprotected intercourse
      • requires office visit for placement
    • ulipristal
      • a progestin receptor modulator and delays ovulation
      • must be taken within 120 hours after intercourse
        • remains highly effective
      • the most effective oral EC 
      • requires a prescription
    • levonorgestrel
      • recommended to be taken within 72 hours after intercourse
        • still is effective up to 120 hours after intercourse
          • efficacy is reduced
      • available over-the-counter
      • preferred over the estrogen-progestin regimen
  • Efficacy trend
    • copper IUD > ulipristal > levonorgestrel

 

 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.17.4769) A 36-year-old female presents to the emergency department with right upper quadrant (RUQ) pain. She describes the pain as dull and getting progressively worse over the last several weeks. She denies any relationship to eating. Her past medical history is significant for endometriosis, which she manages with oral contraceptive pills, and follicular thyroid cancer, for which she underwent total thyroidectomy and now takes levothyroxine. The patient drinks a six pack of beer most nights of the week, and she has a 20 pack-year smoking history. She recently returned from visiting cousins in Mexico who have several dogs. Her temperature is 98.2°F (36.8°C), blood pressure is 132/87 mmHg, pulse is 76/min, and respirations are 14/min. On physical exam, her abdomen is soft and non-distended with tenderness in the right upper quadrant and palpable hepatomegaly. Laboratory testing is performed and reveals the following:

Aspartate aminotransferase (AST, GOT): 38 U/L
Alanine aminotransferase (ALT, GPT): 32 U/L
Alkaline phosphatase: 196 U/L
gamma-Glutamyltransferase (GGT): 107 U/L
Total bilirubin: 0.8 mg/dL

RUQ ultrasound demonstrates a solitary, well-demarcated, heterogeneous 6 cm mass in the right lobe of the liver. CT scan with contrast reveals peripheral enhancement during the early phase with centripetal flow during the portal venous phase. Which of the following is a risk factor for this condition?
Review Topic | Tested Concept

QID: 109072
1

Chronic alcohol abuse

4%

(1/28)

2

Extrahepatic malignancy

4%

(1/28)

3

Recent contact with dogs

11%

(3/28)

4

Recent travel to Mexico

14%

(4/28)

5

Oral contraceptive pill use

68%

(19/28)

L 2 C

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(M2.GN.15.4672) A 22-year-old female presents to her PCP after having unprotected sex with her boyfriend 2 days ago. She has been monogamous with her boyfriend but is very concerned about pregnancy. The patient requests emergency contraception to decrease her likelihood of getting pregnant. A blood hCG test returns negative. The PCP prescribes the patient ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg to be taken 12 hours apart. What is the most likely mechanism of action for this combined prescription? Review Topic | Tested Concept

QID: 107201
1

Inhibition or delayed ovulation

30%

(6/20)

2

Alteration of the endometrium impairing implantation of the fertilized egg

55%

(11/20)

3

Thickening of cervical mucus with sperm trapping

5%

(1/20)

4

Tubal constriction inhibiting sperm transportation

0%

(0/20)

5

Interference of corpus luteum function

0%

(0/20)

L 3 E

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(M2.GN.12.15) A 23-year-old woman presents to her primary care physician for a wellness checkup. She has been treated for gonorrhea and chlamydia 3 times in the past 6 months but is otherwise healthy. She smokes cigarettes, drinks alcohol regularly, and wears a helmet while riding her bicycle. The patient is generally healthy and has no acute complaints. Her vitals and physical exam are unremarkable. She is requesting advice regarding contraception. The patient is currently taking oral contraceptive pills. Which of the following would be the most appropriate recommendation for this patient? Review Topic | Tested Concept

QID: 103378
1

Condoms

15%

(14/91)

2

Etonogestrel implant

5%

(5/91)

3

Intrauterine device

67%

(61/91)

4

Pull out method

4%

(4/91)

5

Tubal ligation

7%

(6/91)

L 3 E

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