A 30-year-old woman presents to your office for her well-woman examination and contraception. She has two prior vaginal deliveries without any complications. Her medical history is significant for DVT in her right leg after her last delivery. Her family history is significant for coronary artery disease in her father, and breast cancer in her mother diagnosed at the age of 62 years.
After a discussion of her choices for contraception, she opts for a mini-pill. Which of the following is true regarding the use of mini pills?
Mini-pills are ideal for women with contraindications to estrogen and increased risk of cardiovascular complications, such as women with a history of thrombosis, hypertension, migraine headaches, or smokers older than 35 years. They are also a good choice for lactating women. Mini-pills do not reliably inhibit ovulation and their effectiveness relies more heavily on cervical mucus alterations and endometrial effects. Irregular bleeding is a common side effect, as is the risk of contraceptive failure. They have a higher pregnancy rate than combination pills or other methods such as injectable progestins or intrauterine devices. With failures, there is an increased risk of ectopic pregnancy. Another disadvantage is that it needs to be taken at the same time every day. If a mini-pill is taken even 4 hours late, an additional contraceptive must be used for the next 2 days. The mini-pill does not improve acne and may actually worsen it, with reports of a “acne flare.” Functional ovarian cysts develop with a greater frequency in women using mini pills, but intervention is rarely needed.
A 19-year-old patient calls in your office requesting emergency contraception because a condom she and her boyfriend were using broke during intercourse last night. You counsel the patient appropriately and provide a suitable method of contraception.
Which of the following statements correctly describes emergency contraception?
Emergency contraception is warranted for prevention of unwanted pregnancy following unprotected sexual intercourse. Two hormonal methods are available. These are: the Yuptze method (estrogen and progestin pills) and plan B (progestin only). A number of combined (estrogen-progestin) contraceptives are FDA-approved for use as emergency contraception. The tablets are taken within 72 hours of intercourse, in two doses 12 hours apart. This method is highly effective and decreases pregnancy by 94%. Typically if 100 women had unprotected intercourse during the second or third week of their menstrual cycle, 8 would become pregnant. If they used this emergency contraception regimen, only two would conceive. Nausea and vomiting are common due to the high doses of estrogen; therefore, it is common to prescribe an anti-emetic to take before each dose. Plan B is a progestin-only emergency contraceptive method which contains 0.75 mg of levonorgestrel. The first dose is taken within 72 hours, and a second dose is repeated in 12 hours. Since it does not contain estrogen, nausea and emesis are not common, and it is better tolerated than the Yuptze method. It also has a slightly higher efficacy (1.1 pregnancies). Plan B is FDA-approved to be sold over the counter to women 18 years of age and older without a prescription. The major mechanism of action of both of these methods is inhibition or delay of ovulation. Other mechanisms suggested are endometrial effects that prevent implantation, sperm penetration, or tubal motility. Established pregnancies are not harmed by either method. Another method of emergency contraception is to insert a copper-containing IUD up to 5 days after unprotected intercourse. The failure rate is about 1%. Mifepristone (RU-486) is a potent anti-progesterone that can be used as emergency contraception. It interferes with implantation and a single dose is more effective and has fewer side effects than the Yuptze regimen.
A couple presents to your office to discuss sterilization. They are very happy with their four children and do not want any more. You discuss with them the pros and cons of both female and male sterilization. The 34-year-old man undergoes a vasectomy.
Which of the following is the most frequent immediate complication of this procedure?
Vasectomy is performed by isolating the vas deferens, cutting it, and closing the ends by either fulguration or ligation. It may be performed in the office setting under local anesthesia. Complications that may arise include hematoma (5%), sperm granulomas (inflammatory responses to sperm leakage), spontaneous reanastomosis, and, rarely, infections. Sexual function following healing is rarely affected. Vasectomy should not be considered effective until an examination of the ejaculate is spermfree on two successive occasions. The failure rate is 1%. It has a lower complication rate and cost than outpatient laparoscopic sterilizations in females.
A woman with Wilson disease.
For this female patient seeking contraception, select the method that is medically contraindicated for her.
Mini pills are contraindicated in women with unexplained uterine bleeding or breast cancer. Both condoms and the diaphragm, used in conjunction with spermicides, are effective contraceptives. The diaphragm should carefully fit in the vagina and is therefore not applicable to women with anatomic distortion of the vagina. Latex condoms should not be used in women with a known latex allergy. Manufacturer’s contraindications to IUD use include history of acute PID, unexplained genital bleeding, suspected pregnancy, uterine cavity distortion, or recent postpartum endometritis. Wilson disease or a copper allergy are contraindications to the use of a coppercontaining IUD. Although tubal ligation may be considered in the patient with chronic obstructive lung disease, the risk of general anesthesia and surgical intervention in this patient is probably high enough to indicate a more conservative approach, such as the use of an IUD.
A woman with a history of breast cancer.
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