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Barkleys Curriculum Review for Family Nurse Practitioners Thomas W. Barkley Jr. PhD ACNP-BC ANP FAANP President Barkley Associates Los Angeles California and Professor Director of Nurse Practitioner Programs California State University Los Angeles School of Nursing International Standard Book Number 978-0-9864021-2-8 Printed in the United States of America Managing Editor Taylor Spining Staff Coordinator Christopher Cud Cover Design Andres Morgan Contributing Writers Andrey Gordienko Roberto A. Rael Justin R. Searles Kaitlyn C. Sullivan P.O. Box 69901 West Hollywood CA 90069 BARKLEYS CURRICULUM REVIEW FOR FAMILY NURSE PRACTITIONERS NATIONAL CERTIFICATION ISBN 978-0-9864021-2-8 Copyright 2015 by Barkley Associates All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical including photocopying recording or any information storage and retrieval system without permission from the publisher. Permissions may be sought directly from Barkley Associates by the following phone 1.866.938.5557 or 1.323.656.1606 fax 1. 323.656.1620 e-mail Contact_Usnpcourses.com. Notice Knowledge and best practices are subject to change as new research and further experience expand knowledge. Changes in practice treatment and drug therapy may be warranted or appropriate. It is recommended that readers verify the most up-to-date information regarding procedures featured or check the manufacturers of administered products so as to verify the recommended dose formula methods of administration and contradindications. It is the duty of practitioners relying on their experience and knowledge of the patients circumstances to determine dosages and the best treatment for each patient while taking all safety precautions. To the fullest extend of the law neither the Publisher nor the Editor Contributors or Reviewers assume any liability for any injury andor damage to persons or property arising out of or related to any use of the content in this book. The Publisher Preface Barkleys Curriculum Review for Family Nurse Practitioners is a long-overdue resource in advanced practice nurse practitioner education. The text is written at a level appropriate for family nurse practitioner FNP students faculty and practicing nurse practitioners. For students and faculty the text can be strategically utilized in several ways to enhance nurse practitioner curricula. First the text can be used as an excellent culminating work to review key subject areas of the entire FNP curriculum prior to national certification. For most faculty who adopt a modular approach to systems and special topics learning the book can be extremely valuable throughout the FNP students entire course of studies. Assigning chapter by chapter in conjunction with course topical outlines serves to reinforce classroom lectures and other learning activities as either pre- or post-class assignments. For the certified FNP a comprehensive review of the FNP curriculum is always rewarding to assist in revisiting those not-so-commonly seen patient diagnoses in individual practice. Whether being used by student faculty or certified nurse practitioner Barkleys Curriculum Review for Family Nurse Practitioners is an outstanding asset. In light of the varied needs of the readers the text is designed for both practicality and flexibility. Barkleys Curriculum Review for Family Nurse Practitioners is essentially two books in one comprising a Practice QuestionRationale Section and a comprehensive Discussion Section. Extensive question rationales feature not only why the correct answer is correct but also why all other answer choices are either incorrect or not the best answer. After the Practice Question Section in each chapter an extensive Discussion Section includes the following Overview incidencepredisposing factors Presentation signs and symptoms Workup laboratorydiagnostic tests and Treatment management options for all common diagnoses presented in the chapter. Further the book is supplemented with relevant figures tables and diagrams in color. Unique to other nurse practitioner review texts two chapters are especially noteworthy Special Considerations in Gerontology along with Evidence-based Practice and Health Care PolicyIssues. With todays increasing need to particularly focus on the care of older adults in addition to the need to make clinical decisions based on the latest research Barkleys Curriculum Review for Family Nurse Practitioners is especially distinct. As editor I sincerely thank the Distinguished Reviewers of this text who represent some of the most exceptional nurse practitioner experts in the country. In addition I am extremely grateful to the talented staff of Barkley Associates Inc. who tirelessly produced this work with never-ending enthusiasm. I trust that you will find Barkleys Curriculum Review for Family Nurse Practitioners to be an invaluable educational tool. Thomas W. Barkley Jr. PhD ACNP-BC ANP FAANP Editor Acknowledgments We gratefully acknowledge the combined efforts of the staff of Barkley Associates whose knowledge and dedication provided the foundation for this review guide. We would additionally like to thank the outstanding contributors and reviewers of this text. Without the expertise of these scholars this work would not have been possible. We also thank the following people Pediatric Content Experts Sharyn Flavin Molly K. Rothmeyer Joetta D. Wallace Stacey A. Warner Managing Editor Taylor Spining Staff Coordinator Christopher Cud Cover Design Andres Morgan Contributing Writers Andrey Gordienko Roberto A. Rael Justin R. Searles Kaitlyn C. Sullivan whose combined efforts have produced what we believe is a state-of-the-art evidence-based excellent resource for the profession. v Reviewers Molly Bradshaw RN MSN FNP-BC WHNP-BC Family Nurse Practitioner Track Rutgers School of Nursing Newark NJ Latina M. Brooks PhD CNP Associate Professor and Director DNP Program Ashland University Dwight Schar College of Nursing and Health Sciences Mansfield OH Sharon K. Byrne DrNP APN NPC AOCNP CNE Assistant Professor The College of New Jersey Ewing NJ Angela L. Caires MSN RN CRNP FNP-BC Clinical Assistant Professor University of Alabama in Huntsville College of Nursing Huntsville AL Sandy Carollo PhD MSN FNP-BC Associate Professor Washington State University Pullman WA Connie S. Cole DNP RN-BC NP-C Clinical Assistant Professor of Nursing Indiana University-Purdue University Fort Wayne Fort Wayne IN Mary DiGiulio DNP ANP-BC Director of AGPCNP Program Rutgers University School of Nursing New Brunswick NJ Sherry L. Donaworth DNP ACNP-BC FNP-BC Assistant Professor of Clinical Nursing University of Cincinnati College of Nursing Cincinnati OH Cheryl S. Emich MSN ANP-BC Clinical Assistant Professor University of Alabama in Huntsville College of Nursing Huntsville AL Karen D French FNP-C MSN Assistant Professor Azusa Pacific University Azusa CA Melanie Gilmore PhD FNP-BC Associate Professor Department of Advanced Practice College of Nursing The University of Southern Mississippi Hattiesburg MS Patricia Griffith MSN CRNP ACNP-BC Clinical Coordinator and Associate Course Director Senior Lecturer Adult Gerontology Acute Care Nurse Practitioner Program University of Pennsylvania School of Nursing Philadelphia PA Adult-Gerontology Primary Care vi Anna S. Hamrick DNP FNP-C ACHPN Assistant Professor of Nursing Director of FNP Program Gardner-Webb University Boiling Springs NC Addie P. Herrod DNP FNP-BC NE Assistant Professor of Nursing Delta State University Robert E. Smith School of Nursing Cleveland MS Monica M. Jones DNP FNP-BC Assistant Professor of Nursing Delta State University Robert E. Smith School of Nursing Cleveland MS Debora Corison Kilborn RN MSN FNP-BC Department of Nursing Holy Names University Oakland CA Kimberly J Langer MSN APRN ACNP-BC Associate Professor Winona State University Winona MN Shirley Levenson PhD APRN FNP-BC Professor Nurse Practitioner Program Director Texas State University San Marcos TX Kathleen Marollo MS ANP-BC FNP-BC Clinical Instructor State University of New York Polytechnic Institute Utica NY Mary Anne McCoy PhD ACNS-BC ACNP-BC Assistant Professor Wayne State University College of Nursing Detroit MI Helen Miley RN PhD AG-ACNP CCRN Clinical Assistant Professor Director Acute Program Division of Advanced Nursing Practice Rutgers University Newark NJ S. Lori Neal RN MSN ACNP-BC FNP-BC Trauma Nurse Practioner Erlanger Health Systems Chattanooga TN Marilyn Perkowski RN Med MSN Instructor University of Akron School of Nursing Akron OH Lisa R. Roberts Dr.Ph MSN FNP-BC RN FNP and AGNP Program Director Loma Linda University Loma Linda CA Jennifer Ruel DNP FNP-BC ENP-BC Associate Clinical Professor University of Detroit Mercy Detroit MI Debra Lee Servello DNP MSN ACNP RN Assistant Professor Acute Care Nurse Practitioner Coordinator Rhode Island College Providence RI Patricia Sweeney PhD CRNP FNP-BC Assistant Professor of Nursing Wilkes University Wilkes-Barre PA Bernard P. Tadda DNP FNP-BC Clinical Instructor University of Illinois at Chicago UIC College of Nursing Chicago IL Frankie Wallis DNP RN Associate Professor Samford University Ida V. Moffett School of Nursing Birmingham AL Sandra Kay Sexton Welling PhD RN CCM Davenport University Grand Rapids MI vii Mary Ellen Wilkosz RN FNP-BC BSN MSN PhD Director FNP Program Sonoma State University Rohnert Park CA Yakima Kim Young-Shields Ed.D.c APRN ANP-BC Assistant Teaching Professor Adult-Geriatric Nurse Practitioner Coordinator University of Missouri-St. Louis St. Louis MO Primary Care Pediatrics Sharyn Flavin APRN DNP AGNP CPNP Long Beach Memorial Miller Childrens Hospital Long Beach CA Donna Susan Freeborn PhD FNP Assistant Professor Coordinator FNP Program Brigham Young University Provo UT Jane T. Garvin PhD RN FNP-BC Assistant Professor of Nursing Georgia Regents University Augusta GA Gay L. Goss PhD APRN-BC Professor Cal State University Dominguez Hills Carson CA Paula Gray FNPDNP CRNP NP-C Clinical Assistant Professor of Nursing Director Family Individual Across the Lifespan CRNP Program Widener University School of Nursing Chester PA Yvonne L. Joy MBA MSN APRN Assistant Professor of Nursing University of Saint Joseph West Hartford CT Vanessa M. Kalis DNP PNP-AC ACNP-BC CNS RN Assistant Professor Director Acute Care DNP Programs Pediatric and Adult-Gerontologic Brandman University Irvine CA Pamela L. King PhD FNP PNP FAANP MSN Program Director Spalding University School of Nursing Louisville KY Deborah Lee-Ekblad MSN FNP ACNP-BC Clinical Instructor Acute Care Nurse Practitioner Program University of Michigan School of Nursing Ann Arbor MI Denise M. Linton DNS FNP-BC Assistant Professor and Nurse Practitioner Coordinator University of Louisiana at Lafayette College of Nursing and Allied Health Professions Lafayette LA Ildiko E. Monahan MS ANP-C FNP Instructor SUNY Institute of Technology College of Health Sciences and Management Utica NY viii Stacey A. Warner RN MSN CPNP Assistant Professor California State University Los Angeles Los Angeles CA Ann Weltin DNP FNP-BC CNM Assistant Professor of Nursing DNP Program Coordinator Clarke University Dubuque IA Johnnie Sue Wijewardane PhD APRN FNP-BC Associate Professor Mississippi University for Women Columbus MS Mary Ellen Wilkosz RN FNP-BC BSN MSN PhD Director FNP Program Sonoma State University Rohnert Park CA Alyssa N. Wislander MS BSN APN RN ACNP CPNP University of Illinois at Chicago Quad Cities Regional Campus Moline IL Carmen Wycoff DNP MBA ARNP CPNP Pediatric Nurse Practitioner Assistant Professor of Nursing Clarke University Dubuque IA Martha J. Morrow PhD FNP-BC CNE Associate Professor Graduate Nursing Program Shenandoah University Eleanor Wade Custer School of Nursing Winchester VA Mary B. Neiheisel BSN MSN EdD FNP-BC CNS-BC FAANP FNAP Professor University of Louisiana at Lafayette Lafayette LA Michelle Pardee DNP FNP-BC Clinical Assistant Professor University of Michigan School of Nursing Ann Arbor MI Gloria M. Rose PhD NP-C FNP-BC Assistant Professor Coordinator of FNP Program Prairie View AM University Prairie View TX Molly K. Rothmeyer DNP APRN FNP-BC CPNP-AC Assistant Professor University of Alaska Anchorage AK Sharon L. Stager DNP FNP-BC Assistant Professor of Nursing Salve Regina University Newport RI Twila Sterling-Guillory RN FNP-BC PhD Associate Professor McNeese State University Lake Charles LA Joetta D. Wallace RN MSN NP-C Program Coordinator Pediatric Palliative Care Service Miller Childrens and Womens Hospital Long Beach CA Frankie Wallis DNP RN Associate Professor Samford University Ida V. Moffett School of Nursing Birmingham AL Table of Contents Adult-Gerontology Primary Care 1. Contraceptive Options 3 2. Obstetrics and Pregnancy Pearls 20 3. Eye Ear Nose and Throat Disorders 40 4. Integumentary Disorders 60 5. Endocrine Disorders 92 6. Musculoskeletal Disorders 118 7. Sexually Transmitted Infectious Diseases 136 8. Gynecologic ConcernsMens Health Issues 153 9. Hematologic and Oncologic Disorders 182 10. Psychosocial Issues 198 11. Neurologic Disorders 219 12. Gastrointestinal Disorders 241 13. Respiratory Disorders 261 14. Cardiovascular Disorders 278 15. Evidence-Based Practice and Health Care PolicyIssues 301 16. Special Considerations in Gerontology 320 Primary Care Pediatrics 1. Growth and Development 349 2. Immunization Recommendations 365 3. Genetic Evaluation 372 4. Prenatal AssessmentScreening 379 5. Infant Health and Issues 391 6. ToddlerPreschool Health and Issues 400 7. School Age Health and Issues 411 8. Adolescent Health and Issues 423 9. Cardiovascular Disorders 431 10. Gastrointestinal Disorders 441 11. Dermatological Disorders 452 12. Eye Ear Nose and Throat Disorders 472 13. Respiratory Disorders 484 14. Musculoskeletal Disorders 493 15. Neurologic Disorders 503 16. Hematologic and Oncologic Disorders 513 17. Endocrine Disorders 524 18. Genitourinary Disorders 531 S EC T I O N ONE Adult Curriculum Review C hapt er 1 Contraceptive Options 3 QUESTIONS 1. A patient using the calendar method for contraception has determined that her shortest cycle lasts 28 days her longest cycle lasts 32 days and that her cycle starts on day 5 of the month. During which range of days of the month should she abstain from intercourse to best avoid pregnancy a. Day 14 to day 27 b. Day 21 to day 27 c. Day 15 to day 28 d. Day 19 to day 28 2. Which of these statements is true regarding the use of condoms a. There is a higher reported failure rate of female condoms than male condoms. b. Natural skin condoms give the most protection against sexually transmitted diseases. c. The failure rate of condoms is the lowest of all barrier contraceptives. d. Leaving empty space at the end of the condom increases the risk of breakage. 3. A patient with an intrauterine device learns that she is pregnant. If the device is not removed which of these complications is most likely to occur a. Placenta previa b. Ectopic pregnancy c. Spontaneous abortion d. Abruptio placentae 4. An 18-year-old patient comes to your office to inquire about spermicides and asks about the failure rate of spermicides when used alone. As a nurse practitioner you tell her the typical first-year failure rate is a. Approximately 11 b. Approximately 16 c. Approximately 21 d. Approximately 32 5. Which of the following is the least likely undesirable effect to expect in a female patient using spermicides a. Incomplete dissolution of suppositories b. Increased risk for candidiasis c. Vaginal skin irritation d. Unpleasant taste 6. Which of these patients would most likely need to have her diaphragm refitted given that all of these patients already have a diaphragm and want to continue to use one a. A patient who experiences an allergic reaction b. A patient who has gained approximately 25 lb c. A patient who has lost approximately 8 lb d. A patient who has contracted herpes 4 CHAPTER 1 12. For which of the following types of condoms is use of oil-based lubricants most strongly discouraged a. Synthetic condoms b. Polyurethane condoms c. Natural membrane condoms d. Latex condoms 13. Although progestin-only contraceptive pills are not as effective in suppressing unscheduled bleeding these are a more viable option for patients with certain conditions that are exacerbated by estrogen. Which of these conditions does not usually warrant the need for progestin-only pills a. Migraine headaches b. Hypertension c. Endometriosis d. Obesity 14. Which of these most strongly indicates the proper use of a family planning method of contraception a. Engaging in intercourse only when the cervical mucus is thin b. Engaging in intercourse only when the females temperature drops and rises prior to ovulation c. Engaging in intercourse only when there are strawberry patches on the cervix d. Engaging in intercourse only when the female is lactating 15. All of the following are definitive reasons to re-examine and possibly replace a diaphragm as a contraceptive method except a. Use of oil-based lubricants b. Wear and tear c. Being diagnosed with vulvovaginitis d. Gaining weight exceeding 20 lb 7. Patients are at increased risk for what fungal infection when using the sponge a. Toxic shock syndrome b. Candidiasis c. Skin irritation d. Urinary tract infections 8. Which of the following types of contraceptives may be used to prevent the recurrence of Ashermans syndrome a. Injected contraception b. Cervical caps c. Disposable barriers d. Intrauterine devices 9. A patient starting the Ortho Evra patch places her first patch on the first Sunday of the month. Assuming she maintains the recommended schedule she would replace this patch with a new one on each of the following Sundays except a. Second Sunday b. Third Sunday c. Fourth Sunday d. Fifth Sunday 10. What effect does Depo-Provera have specifically on the endometrium a. Creates a thin atrophic lining b. Thickens the cervical mucus c. Promotes local foreign body inflammatory responses d. Causes lysis of implanted blastocysts 11. Depo-Provera and NuvaRing share all of the following mechanisms of action except a. Release of synthetic estrogen and progestin b. Thickening of cervical mucus c. Suppression of follicle-stimulating hormone d. Suppression of luteinizing hormone CONTRACEPTIVE OPTIONS 5 21. Which of these methods of natural family planning uses both the basal body temperature graph and cervical mucus test a. Lactational amenorrhea method b. Symptothermal method c. Calendar method d. Billings test 22. If the sponge is left in place for too long a patient is typically at serious risk for which of the following conditions a. Toxic shock syndrome b. Trichomoniasis c. Anemia d. Amenorrhea 23. High amounts of estrogen may cause several adverse effects associated with oral contraceptive use. Which of the following adverse effects is not typically caused by high amounts of estrogen a. Nausea b. Acne c. Edema d. Breast tenderness 24. Which of the following choices is not a standard advantage of using a diaphragm or cervical cap a. It is relatively safe and easy to use. b. It provides immediate protection. c. When used with spermicidal gel it may protect against sexually transmitted diseases. d. It remains in place during intercourse. 25. Which of the following contraceptive methods should not typically be suggested to a woman who weighs more than 90 kg a. Depo-Provera b. Implanon c. Ortho Evra d. Mirena 16. Which of the following contraceptives has two products commonly named ParaGard and Mirena a. Diaphragm b. Disposable barriers c. The patch d. Intrauterine device 17. Which of the following is not a typical advantage of contraceptive rings a. Alleviation of depression symptoms b. Lighter menstrual periods c. Fewer mood swings than oral contraceptives d. Decreased menstrual cramps 18. Undesirable side effects of oral contraceptives such as depression fatigue and decreased libido usually primarily result from a. Excessive estrogen b. Estrogen deficiency c. Excessive progesterone d. Progesterone deficiency 19. In which of the following patients would the NuvaRing be contraindicated a. A 32-year-old female who was just undergone a first trimester abortion b. A 33-year-old female who gave birth 8 weeks ago and is not breastfeeding c. A 34-year-old female who uses tampons d. A 36-year-old female who smokes 20. What is the typical initial dosage of ethinyl estradiol for combined oral contraceptives a. Dose of 35 mcg or less b. Dose of 40 mcg or less c. Dose of 45 mcg or less d. Dose of 50 mcg or less 6 CHAPTER 1 30. A patient taking oral contraceptives may be at increased risk for which of the following conditions as the patients age dose and length of therapy increase a. Hypertension b. Type 2 diabetes c. Abnormal menstrual bleeding d. Hypercholesterolemia 31. Jennifer an 18-year-old female arrives at your clinic seeking emergency contraception. She claims that she was engaging in intercourse with her boyfriend last night and the condom broke during the act. You believe that levonorgestrel would best address her concerns. Which of the following statements would be most accurate a. You will likely need a prescription to get the drug. b. This pill works by terminating an implanted fertilized egg. c. You may experience menstrual irregularities during your next cycle. d. The drug should work up to 4 days after intercourse. 32. Nancy a 24-year-old female was engaging in intercourse with her boyfriend 3 days ago when the condom broke. She seeks emergency contraception however in the past she has experienced severe nausea and vomiting after using levonorgestrel products. Which of the following products would be best suited for Nancy at this time a. ParaGard b. Implanon c. Mirena d. Ortho Evra 26. A patient arrives for a regular injection of Depo- Provera. However in consulting your records you find that it has been 14 weeks since the patient received her last injection. When you ask when her cycle begins she says I dont know. After administering the injection you should caution her to use backup contraception for how long a. During the first 2 days after injection b. During the first 5 days after injection c. During the first week after injection d. During the first 2 weeks after injection 27. Which of the following contraceptives almost always contains the chemicals nonoxynol-9 and octoxynol a. The sponge b. Condoms c. Diaphragms d. Spermicides 28. Ashley a 22-year-old female is discussing various forms of contraception with you. She says she has heard some great things about intrauterine devices IUDs but would like to be informed about the disadvantages about such devices. Which of the following disadvantages is most commonly associated with IUDs a. Increased risk of pelvic inflammatory disease after insertion b. Annual need for maintenance and reinsertion c. Increased risk of Ashermans syndrome d. High levels of adverse estrogenic effects 29. When using intrauterine devices which of the following mechanisms of action is typically caused by local foreign body inflammatory responses a. Lysis of the blastocyst b. Thickening of cervical mucus c. Atrophy of the endometrial lining d. Inhibition of sperm binding to egg CONTRACEPTIVE OPTIONS 7 37. Implanon usually offers continuous birth control for how long a. Three years b. Four years c. Five years d. Six years 38. A patient arrives at your clinic to discuss long- term options for contraception. In evaluating her circumstances you decide that Implanon might work best for her. You might tell her all of the following regarding the implant except a. Odds are you will be able to maintain a regular cycle. b. I would hold off on agreeing to Implanon before I tell you everything about it. c. This drug will be more expensive than the pill at least at first. d. The implant may be visible so take that into consideration. 39. A 19-year-old patient is using a cervical cap as a contraceptive. She asks you how long must the cervical cap be left in the vagina following intercourse. You should tell her which of the following a. Two hours at most b. Three hours at most c. At least 4 hours d. At least 6 hours 40. Sharon a 24-year-old female calls the clinic inquiring about her NuvaRing. She says that her ring which had been in place for 2 weeks fell out about 4 hours prior. She is worried that this will throw off her contraceptive schedule. What instructions would be most effective in helping Sharon continue on her contraceptive schedule a. Rinse the ring with cool water reinsert and use a spermicide or barrier for 1 week. b. Reinsert the ring immediately. c. Discard the ring and insert a new ring immediately. d. Wait until the current 21 day period is over and start a new ring. 33. How should a spermicide be applied in conjunction with use of a diaphragm for maximum efficacy a. The spermicide should be applied to the uterus immediately following intercourse while leaving the diaphragm in place. b. The spermicide should be placed around the outside of the diaphragm which is then removed immediately after intercourse. c. The spermicide should be placed inside the diaphragm which is then removed at least 6 hours after intercourse. d. The diaphragm should be removed immediately following intercourse so that spermicide can be applied. 34. A patient who has recently started on the Ortho Evra patch mentions that she is also pursuing an herbal regimen for various health issues. Which of the following herbs would be most likely to affect her treatment with the patch a. St. Johns Wort b. Ginger c. Echinacea d. Ginseng 35. A patient is using the NuvaRing as a contraceptive and asks you how long she is allowed to have the ring in her vagina at one time. As a nurse practitioner you would know that this contraceptive could typically be left in place for how many days a. As long as 11 days b. As long as 16 days c. As long as 21 days d. As long as 26 days 36. As a practitioner you know that the approximate theoretical and actual failure rates for oral contraceptives are a. Perfect use 0.1 typical use 1015 b. Perfect use 5 typical use 10 c. Perfect use 13 typical use 1.53 d. Perfect use 0.1 typical use 35 8 CHAPTER 1 5. b Although spermicides may increase a patients risk of developing candidiasis this risk is not significant compared to the risk of other undesirable effects. Instead spermicides significantly increase a female patients risk for urinary tract infections. Vaginal or penile skin irritation incomplete dissolution of suppositories and unpleasant taste are other common undesirable effects of spermicides. 6. b Although guidelines may vary it is often considered necessary to refit a diaphragm if the patient using it gains or loses weight in excess of 20 lb. Whether or not a patient contracts a sexually transmitted infection would not directly affect whether the patient needs to have her diaphragm refitted. Although an allergic reaction may result from exposure to latex or spermicides such reactions may require a change of formulation or removal of the diaphragm not a refitting. 7. b The risk of candidiasis is increased when the sponge is used as a contraceptive. Toxic shock syndrome may ensue from leaving the sponge in for too long but this condition is bacterial not fungal in nature. Although the sponge may produce vaginal irritations and urinary tract infections these reactions are not typically fungal in nature. 8. d An intrauterine device can be used to prevent the recurrence of Ashermans syndrome because of the ability to be placed in the uterine cavity to create a barrier between the walls of the uterus. Implantation after the initial removal of scar tissue in the uterus may help with healing and facilitate separation of the tissues. Injected contraceptive methods are not a form of physical barriers and would not help prevent Ashermans syndrome. Cervical caps and disposable barriers are placed over the cervix to prevent sperm from entering the uterus but there is no evidence of their effectiveness in preventing recurrences of Ashermans syndrome. RATIONALES 1. a A patient using the calendar method whose cycle begins on day 3 of the month whose shortest cycle lasts 28 days and whose longest cycle lasts 32 days should avoid intercourse between days 12 and 23 of the month to best avoid pregnancy. When using the calendar method the patient should subtract 18 days from her shortest cycle and 11 days from her longest cycle. Both those totals should be added to the day of the month her cycle begins counting that day as part of the totals thus determining the window of fertility. 2. a The failure rate of the female condom is substantially higher than the failure rate of male condoms. Latex condoms provide the greatest degree of protection from sexually transmitted diseases STDs whereas natural skin condoms do not protect against STDs. Condoms do not have the lowest failure rates of the barrier contraceptives which include spermicides and the sponge. The sponge has the lowest possible failure rate of these whereas spermicides used alone have a higher failure rate than male condoms. Leaving a -inch of space at the end of the condom decreases the risk of breakage. 3. c In the event of pregnancy spontaneous abortion occurs in up to 50 of all users of intrauterine devices IUDs if the device is left in the uterus. Ectopic pregnancies on the other hand occur in 5 of all pregnancies in IUD users. Pregnant patients with IUDs are at increased risk for abruptio placentae compared to other pregnant patients but this outcome does not occur in 50 of all such patients. Placenta previa is not associated with use of an IUD. 4. c The typical first-year failure rate of spermicides is approximately 21. When combined with other barrier contraceptives such as condoms or diaphragms the failure rate is reduced to approximately 5. Male condoms have an estimated failure rate of 11. The cervical cap has an estimated 16 failure rate in patients who have not given birth and an estimated 32 failure rate in patients who have. CONTRACEPTIVE OPTIONS 9 14. d Engaging in intercourse only when the female patient is lactating is a natural family planning method of contraception known as the lactational amenorrhea method. The cervical mucus method indicates that couples should engage in intercourse when the cervical mucus is thick not thin. The basal body temperature method of contraception instructs couples to not engage in sexual intercourse during the expected rises and drops in basal body temperature. Lastly strawberry patches on the cervix usually indicate trichomoniasis. 15. c Although use of a diaphragm may increase the risk of contracting vulvovaginitis contraction of the disease is not an absolute reason to re- examine or replace the device. Diaphragms should regularly be checked for tears and holes resulting from repeated use. Furthermore latex diaphragms should be examined and possibly replaced following use of oil-based lubricants as such lubricants may weaken the latex. Finally although precise figures vary diaphragms should also be examined for refitting if a patient gains or loses weight in excess of 20 lb. 16. d There are two types of intrauterine devices that have the brand names ParaGard copper-releasing and Mirena progestin-releasing. Diaphragms disposable barriers and the patch do not have two products with these names. 17. a Although the NuvaRing may provide fewer mood swings than oral contraceptives it may worsen not alleviate symptoms of depression and should be used with caution in patients with pre- existing cases of the condition. The NuvaRing may also lead to lighter menstrual periods and decreased menstrual cramps. 18. c Excessive progesterone may produce depression fatigue and decreased libido through its androgenic properties. Undesirable effects that are related to estrogen use include nausea hypertension and increased propensity to develop deep vein thromboses. Some adverse effects such as breast tenderness headaches and hypertension may be caused by a combination of both hormones. 9. c Proper use of the Ortho Evra patch requires changing the patch out once each week on the same day of the week it was first applied on the fourth change day however the patch is removed and not replaced until 1 week later. The patch would be replaced on the second and third change day and the fifth change day would mark a new administration of the patch and the start of a new cycle. 10. a Depo-Provera alters the endometrium by creating a thin atrophic lining. Depo-Provera also thickens the cervical mucus but this mechanism of action does not directly alter the endometrium rather it interferes with sperm transport and penetration. Intrauterine devices not Depo- Provera prevent implantation either by causing lysis of the blastocyst before it implants or by promoting local foreign body inflammatory responses. 11. a Although NuvaRing acts by releasing synthetic estrogen and progestin Depo-Provera is a progestin-only formulation. Both methods of contraception act to prevent fertilization via suppression of follicle-stimulating hormone and luteinizing hormone as well as promote thickening in the cervical mucus. 12. d Oil-based lubricants such as baby oil lotions and petroleum jelly should not be used with latex condoms as these can increase the risk of condom breakage. The other types of condoms such as synthetic natural membrane and polyurethane do not significantly weaken when exposed to oil-based lubricants as compared to latex. 13. c A combination of estrogen and progestin contraceptives actually decreases the pain resulting from endometriosis therefore the use of estrogen is often recommended for endometriosis. Patients who have migraine headaches hypertension or obesity would most likely benefit from progestin. 10 CHAPTER 1 24. d Remaining in place during intercourse is not a standard advantage of using either a diaphragm or a cervical cap as both can be disturbed during the act rather it is an advantage of using the sponge contraceptive. The advantages of being relatively safe and easy to use providing immediate protection and guarding against sexually transmitted infections STIs when used with spermicidal gel are advantages from using the diaphragm. Likewise the cervical cap is relatively safe easy to use and provides immediate protection. Although the cervical caps activity against STIs is limited it may provide some protection from gonorrhea and chlamydia. 25. c Ortho Evra is often less effective than other contraceptive methods in women weighing more than 90 kg which is possibly related to pharmacokinetic differences associated with increased adipose tissue. Obesity is also a predisposing factor for the development of venous thromboembolism and may therefore increase the risk for this adverse effect of hormonal contraception. Intrauterine devices implanted contraceptives and injected contraceptives do not routinely demonstrate significantly reduced efficacy in obese women. As such Depo-Provera Implanon and Mirena are contraceptive options better suited for women who are obese. 26. d For full efficacy the Depo-Provera shot must be administered every 1213 weeks should the patient miss this window she is encouraged to use backup contraception for 2 weeks after the shot is administered. For patients who receive the Depo-Provera shot within the first 7 days of the menstrual cycle or within the first 5 days following abortion or miscarriage the drug should typically provide immediate protection from pregnancy. For all others backup contraception is recommended for 1 week following administration. 27. d Spermicides may contain the chemicals nonoxynol-9 and octoxynol for the purpose of destroying sperm cells. The sponge typically contains nonoxynol-9 but does not typically contain octoxynol. Some condoms come with spermicides but most do not and the diaphragm regularly requires outside administration of spermicides to be fully effective. 19. d NuvaRing is contraindicated in smokers 35 years of age and older as these patients are at an increased risk for arterial or venous thrombotic diseases that may be exacerbated by the content of the NuvaRing. Females may start the NuvaRing within the first 5 days after a first trimester miscarriage or abortion or after 4 weeks postpartum if not breastfeeding. Studies show that tampons do not affect the placement or hormonal agents of the NuvaRing. 20. a The typical initial dose of ethinyl estradiol estrogen in a combined oral contraceptive is 35 mcg. Products containing less than 50 mcg of estrogen are considered low-dose and are considered less likely to cause significant adverse events. Higher doses do not typically invoke a higher efficacy rate in most women but may cause more adverse effects associated with hormonal contraceptives as such initial doses greater than 35 mcg are not typically prescribed. 21. b The symptothermal method of natural family planning uses both the basal body temperature graph and cervical mucus test as mechanisms. These two mechanisms are not typically used in either the calendar method which records serial cycles or the lactational amenorrhea method in which patients rely on breastfeeding for natural family planning. Lastly the Billings test is another name for the cervical mucus test. 22. a A patient is at serious risk for toxic shock syndrome if the sponge is left in place for too long. Using the sponge may also increase risk for candidiasis. Intrauterine devices not the sponge may increase the risk of anemia due to increased menstrual bleeding whereas Depo- Provera can increase the risk of amenorrhea. 23. b The development of or worsening of facial acne is typically a result of excess androgens not a higher dose of estrogen. Although earlier progestins commonly promoted androgenic activity some modern progestins have antiadrenergic activity. These progestins are often used alongside estrogen to combat severe acne and other adverse androgenic effects. High amounts of estrogen may cause nausea edema and breast tenderness. CONTRACEPTIVE OPTIONS 11 32. a Copper-releasing intrauterine devices IUDs such as ParaGard may be used as an alternative form of emergency contraception within 56 days of intercourse. Mirena a progestin- releasing IUD is not useful for emergency contraception and would not be recommended for a patient with levonorgestrel hypersensitivity. Implanon an etonogestrel-containing implant and Ortho Evra a patch that releases ethinyl estradiol and norelgestromin are similarly ineffective as emergency contraceptives. 33. c Spermicide should be placed inside rather than outside of the diaphragm before it is inserted into the uterus preceding intercourse once intercourse is complete the diaphragm should remain inside the uterus for at least 6 hours. Spermicide can be applied inside the uterus without removing the diaphragm but this is only recommended for repeated intercourse not first encounters. 34. a St. Johns Wort may diminish the therapeutic effect of estrogens while decreasing the serum concentration of CYP3A4 substrates thus creating the risk of contraceptive failure in treatment with Ortho Evra. Ginseng ginger and echinacea do not typically have any significant interaction with Ortho Evra. 35. c The NuvaRing must be taken out after 21 days to allow the menstrual cycle to continue. Proper usage of the NuvaRing is to keep it in the vagina for 21 days then remove it for a 1 week break. The ring is kept in for 21 days so that it may continually release hormonal contraceptives in low doses to remove it before that time could significantly lower the efficacy of the drugs and keeping the ring in longer than 21 days could throw off the timeline of administration for the next cycle. If the ring is removed accidentally or otherwise within those 21 days it may be reinserted within 3 hours of removal without losing efficacy if too much time has elapsed however the patient should either adopt barrier methods to compensate for reduced efficacy or acquire a new NuvaRing and continue the cycle. 28. a Patients who use intrauterine devices IUDs commonly have a risk of pelvic inflammatory disease for some time after insertion because of the effect of the IUD on the microbiologic environment of the vagina. Although some reports link IUDs with the development of the intrauterine adhesions characteristic of Ashermans syndrome such devices are more commonly used to prevent the formation of such adhesions. Annual maintenance or reinsertion is not a common concern as some IUDs can remain in the uterus for up to 10 years without need for adjustment. Lastly hormonal IUDs typically release levonorgestrel a progestin- like compound instead of estrogen meaning estrogenic side effects are not a common concern. 29. a Intrauterine devices IUDs typically cause lysis of the blastocyst due to local foreign body inflammatory responses. Progestin-producing IUDs typically induce thickening of cervical mucus formation of an atrophic endometrial layer and inhibition of sperm binding to egg however these mechanisms more commonly occur as a result of progestins not as a direct inflammatory response. 30. a The risk of hypertension in patients taking oral contraceptives often increases with age dose and length of therapy. Concomitant use of oral contraceptives in patients with type 2 diabetes and hypercholesterolemia has not been significantly shown to increase the exacerbation of these conditions. Although abnormal menstrual bleeding is also a potential adverse effect of oral contraceptives this effect does not increase specifically because of age or course of treatment. 31. c Oral levonorgestrel as an emergency contraceptive or Plan B may result in changes to the patients menstrual flow and the development of other irregularities such as spotting during the next cycle. Patients under the age of 17 usually require a prescription to get the drug but patients 17 years of age and older can purchase it over-the-counter. Levonorgestrel does not terminate an implanted fertilized egg rather it works by preventing release of eggs from the ovary preventing fertilization of the egg by sperm and by altering the uterine lining to prevent implantation. Levonorgestrel is often effective for up to 72 hours following conception not 96 hours. 12 CHAPTER 1 DISCUSSION Oral Contraceptives Overview Oral contraceptives OCs i.e. the pill are daily tablets that interfere with fertilization and implantation. There are two general categories of OCs based on formulation and dosage. Combination pills e.g. Ortho-Cyclen Ortho Tri-Cyclen Ortho Tri-Cyclen Lo contain a synthetic estrogen and a progestin. Combination pills suppress ovulation and alter the cervical mucus and uterine lining to prevent fertilization. The other type of OC is a progestin-only formulation i.e. minipills that contains a lower dose of progestin than the dose in a combination pill. The minipill is not as effective as the combination pill because it does not always suppress ovulation the minipill prevents fertilization by altering the cervical mucus and cervical lining. Ethinyl estradiol is the most common synthetic estrogen in combination pills followed by mestranol The combination pill and the minipill mainly use norgestimate for progestin other types of progestin used in OCs include norethindrone norethindrone acetate ethanedial diacetate norethynodrel norgestrel levonorgestrel desogestrel and gestodene. The mechanism of action in OCs relies on estrogenic effects and progestational effects. Estrogen causes progesterone levels to drop and inhibits ovulation via suppression of follicle- stimulating hormone FSH luteinizing hormone LH or both. Estrogen also inhibits implantation via alteration of the endometrium acceleration of ovum transport and promotion of luteolysis.1 Progestin promotes the secretion of thick cervical mucus to interfere with sperm transport and inhibits the process of capacitation. Other progestational effects include the suppression of the endometrium and hypothalamic-pituitary-ovarian disturbances that inhibit ovulation.2 Advantages The use of OCs allows women to control their own fertility. Preparations offer excellent reversibility are easy to use and are considered safe for most women. The biggest advantage of using OCs is the excellent protection they provide against unwanted pregnancies OCs have a first-year failure rate of approximately 3 in women older than 22 years of age and a failure rate of approximately 4.7 in women younger than age 22. The use of OCs can provide other benefits such as fuller sexual satisfaction and may help regulate abnormal menstrual cycles and reduce menstrual blood flow. Additional advantages of OCs include decreased 36. d Oral contraceptives OCs are one of the most reliable forms of birth control with a theoretical failure rate of approximately 0.1 however due to the need to take OCs at the same time every day and the associated risk of nonadherence the actual failure rate ranges from approximately 3 to 5. 37. a By suppressing ovulation altering the viscosity of cervical mucus and preventing embryo implantation in the endometrium through controlled release of etonogestrel Implanon usually offers up to 3 years of continuous birth control. After the 3 years have elapsed the device loses its effectiveness and may not successfully prevent pregnancy. 38. a As the Implanon implant may lead to irregular or absent periods a regular menstrual cycle cannot be guaranteed for somebody taking the drug. Informed consent from the patient is required before Implanon can be implanted as such the nurse practitioner should inform the patient about all aspects of the implant which include potentially higher initial expenses than other contraceptive methods and the possibility that the implant will be slightly visible under the skin for a short period following implantation. 39. d The general recommendation is that a cervical cap be left in the vagina for at least 6 hours post intercourse. Studies have not shown the cervical cap to be as effective if removed before this recommended time. 40. a If the NuvaRing is displaced for more than 3 hours within the first 2 weeks of using it the best course of action would be to rinse the ring with cool water reinsert it as soon as possible and use a spermicide or barrier form of contraceptive in conjunction with the ring for the next 7 days. If the ring is displaced for less than 3 hours the ring should be re-inserted as soon as possible as contraceptive effectiveness would not necessarily be decreased however the ring should still be rinsed with cool water before re-insertion to minimize the risk of infection. If the ring is displaced for more than 3 hours during the third week of use the ring should be discarded and a new ring should be inserted immediately. Waiting until the 3 week period is over is not necessary under the circumstances presented. CONTRACEPTIVE OPTIONS 13 pregnancy benign or malignant liver tumor or impaired liver function previous cholelithiasis during pregnancy and undiagnosed abnormal uterine bleeding.4 Management Guidelines The three primary management or prescriptive guidelines for OCs are general considerations patient education and adverse effects. General considerations call for OC regimens to begin with low-dose combined or multiphasic pills 35 mcg or less. Progestin-only pills should be considered for women with a history of migraine headaches who are breast-feeding or who have some contraindication to combination pills.5 Additionally the risk of hypertension increases with age dose and length of therapy. OCs are also known to have drug-to-drug interactions. For example interactions with certain antibiotics and anticonvulsants can reduce the effectiveness of OCs. Alternatively OCs can reduce the effectiveness of warfarin insulin and certain oral hypoglycemics.6 Patients should be educated about the use of OCs and their adverse effects. Breakthrough bleeding and spotting are common with abnormal menstrual bleeding and would require a higher dose if necessary.7 Some OCs are used to manage amenorrhea which is caused by low amounts of progesterone. Immediately discontinue OCs if the patient is pregnant to avoid birth defects caused by excessive estrogen levels. Contraceptive Ring Overview The contraceptive ring is a flexible prescriptive contraceptive that is approximately 2 inches in diameter. The most popular known brand is the NuvaRing. Contraceptive rings are highly effective at preventing pregnancy the typical failure rate is less than 12 and the reported manufacturer effectiveness is 9299.7.8 The four mechanisms of action for the contraceptive ring are the ring releases synthetic estrogen and progestin which provides protection from pregnancy for up to 1 month. Second vaginal contact activates the release of hormones in a sudden burst with concentration gradually decreasing over the course of use. Third the ring suppresses ovulation and thickens the cervical mucus to help with preventing fertilization. Lastly the ring may alter the endometrium to affect implantation.9 Advantages The contraceptive ring is convenient to use and provides advantages over other forms to prevent pregnancy. The contraceptive ring is reversible and discreet and generally cannot be felt by the user or the partner. Use of the contraceptive ring has a once per month insertion which allows for menstrual cramps and pain and improvement in facial acne. In addition to providing some therapeutic benefits OCs have been proven to protect against ovarian and endometrial cancers ectopic pregnancy pelvic inflammatory disease PID functional ovarian cysts endometriosis and uterine fibroids.3 Disadvantages One of the disadvantages of using OCs is that they offer no protection against HIV or other STDs. Pills must be taken every day to ensure full efficacy and the cost of OCs can be a burdensome expense for some women. The use of OCs increases the risk of developing some forms of cancer such as liver tumors and breast cancer as well as rare and potentially dangerous circulatory complications. Possible side effects include mood changes nausea headaches and breakthrough bleeding.4 Side Effects Because OCs affect hormone function the use of OCs can produce side effects associated with excessive levels of estrogen progestin or androgen. Conversely OCs can lead to a deficiency in estrogen or progesterone. Women with an estrogen deficiency could present with complaints of no withdrawal bleeding decreased duration in menstrual bleeding continuous spotting andor bleeding breakthrough bleeding on day of cycle DOC anywhere between days 1 and 9 and atrophic vaginitis. Excessive progesterone could lead to breast tenderness transient hypertension depression fatigue decreased libido decreased duration in menstrual bleeding and increased appetite. A deficiency in progesterone could lead to breakthrough bleeding on DOC 1021 and delayed menses. Signs and symptoms of excessive androgenic side effects include hirsutism acne oily skin edema and an increased libido. Women with a combination of excess estrogen and deficient progesterone could present with dysmenorrhea or menorrhagia nausea vomiting headache irritability bloating with or without edema and syncope.4 Long-term complications associated with OCs include chloasma cerebrovascular accident CVA deep venous thrombosis thromboembolic disease pulmonary emboli telangiectasias hepatic adenoma adenocarcinoma and cervical changes. Contraindications Contraindications for OCs include a history of thromboembolic disorders CVA and coronary artery disease. OCs should not be prescribed to patients with known or suspected breast cancer or other cancers. Other contraindications include known or suspected estrogen-dependent neoplasia 14 CHAPTER 1 mechanism of action for the patch is to prevent ovulation and works similarly to combination OCs.12 The patch has a typical failure rate of less than 12. Advantages The patch also does not interfere with sexual activity. The patch is applied only once per week and can be worn for 3 weeks. It is also easily reversible.12 Disadvantages The patch may cause mild to moderate site reactions and offers no protection from HIVAIDS and other STDs or STIs. Effectiveness is reduced in women who weigh more than 90 kg and is not as effective with concurrent use of certain antibiotics antifungals and other medications. The patch also increases the risk for serious cardioembolic events e.g. myocardial infarction CVA pulmonary embolus.12 The risk for estrogenic side effects is also increased because 60 more estrogen is released in the patch than in OCs. Contraindications The patch should be discontinued or not used in patients who are taking certain antibiotics antifungals or other medications. Also women older than 35 years of age should not use the patch. Other contraindications include smoking high blood pressure and a history of blood clots or any cardioembolic disorder among others.13 Management Guidelines This contraceptive method may be applied to the arm buttocks torso but not breast or abdomen on either the first day of the patients menstrual cycle i.e. day 1 or on the first Sunday following the first day whichever is preferred. The date of application is known from that point on as patch change day. The patch is removed 7 days later and another patch is applied to an approved body location. The process is repeated again on the next patch change day. The patch is removed without being replaced on the following patch change day. After waiting for 7 days a new patch is applied on the next patch change day. If the patch stays off for more than 24 hours restarting a new 4-week cycle is often necessary in addition to using a backup method of contraception.13 Injection Contraception Overview Injection contraception Depo-Provera is a long- acting progestin administered intramuscularly. This method of birth control also provides more control of hormone levels throughout the menstrual cycle. Injection contraception is highly effective as it has a typical first-year failure rate that is less than 1. uninterrupted sexual activity. Another advantage of the contraceptive ring is that it is associated with causing fewer mood swings than those associated with OCs. Therapeutic benefits of the contraceptive ring aside from birth control include the possibility of shorter lighter and more regular menstrual periods. In some patients the contraceptive ring has also been associated with decreased menstrual cramps and an improvement in facial acne among other benefits.10 Disadvantages Side effects of the contraceptive ring are similar to those associated with some OCs e.g. breast tenderness headaches weight gain nausea mood changes breakthrough bleeding but these side effects occur at a lower incidence. The contraceptive ring is known to increase the risk of vaginal discharge irritation or infection in some patients. Some methods of contraception such as diaphragms cervical caps and shields cannot be used simultaneously with the ring. Use of the contraceptive ring is also known to worsen depression in some patients with a history of the disorder. Lastly the contraceptive ring offers no protection against HIVAIDS STDs or other sexually transmitted infections STIs.10 Contraindications Uncontrolled hypertension and smoking are two main contraindications for using the contraceptive ring smoking more than 15 cigarettes a day is a contraindication even in patients with controlled hypertension. A history of blood clots or any cardioembolic disorder e.g. myocardial infarction CVA should be considered as strong contraindications and the risk of side effects increases in women older than 35 years of age. 4 Management Guidelines The contraceptive ring is vaginally inserted once a month the ring is then left in place for 21 days no more no less. The patient should remove the ring after 3 weeks to allow menstruation to occur. A new ring is then inserted for continuous pregnancy protection but must be inserted on the same day of the week as it was inserted in the last cycle or else pregnancy may occur. If the ring falls out it must be reinserted within 3 hours a backup method of contraception must be used if the ring was left out for more than 3 hours. Unopened packages of the ring must be protected from direct sunlight or very high temperatures.11 The Patch Overview Ortho Evra is a transdermal contraceptive patch that releases synthetic estrogen and progestin. The CONTRACEPTIVE OPTIONS 15 patients a backup method of contraception should be implemented during the first 2 weeks after the injection unless the contraceptive was administered by DOC 5. Implant Contraception Overview Implant contraception e.g. Nexplanon is a thin flexible rod that contains etonogestrel. The rod is implanted in the upper arm and diffuses progestin to prevent pregnancy. The typical failure rate of Nexplanon is 0.01 and the mechanism of action is the same as other progestins.9 Advantages The advantages of using implant contraception include continuous protection for 3 years with no estrogen-related side effects. Implant contraceptives produce fewer serious system complications than most other birth control methods. Additionally scanty or absent menses may occur with decreased anemia. Use of a contraceptive implant could provide some beneficial effects such as a general reduction in menstrual cramps ovulatory pain and risk of endometrial cancer.4 Disadvantages Some of the side effects associated with implant contraception include irregular menstrual periods prolonged menses spotting between periods and absent periods. Cosmetically the implant may be slightly visible when initially administered. Implant contraception is more expensive than other methods of contraception.13 Management Guidelines Implant contraception requires informed consent with the patient receiving a full briefing on the benefits risks effectiveness and processes associated with the implant.15 Intrauterine Device Overview The intrauterine device IUD is an artificial T-shaped device with either a metal wrapping or chemically-impregnated surface that is inserted into the uterus to prevent pregnancy.17 The first-year failure rate for this type of contraception is between 1 and 3. There are two common types of IUDs the copper-releasing device known as ParaGard and the progestin-releasing device known as Mirena. ParaGard is a plastic device wrapped with fine copper wire that can remain in the uterus for up to 10 years. Mirena also known as a levonorgestrel- releasing intrauterine system is a plastic device that can remain in the uterus for up to 5 years.17 The mechanism of action for IUDs involves the immobilization of sperm IUDs interference with The mechanism of action involves a suppression of FSH and LH thus blocking the LH surge and inhibiting ovulation and altering the endometrium by creating a thin atrophic lining.14 Progestin thickens cervical mucus which interferes with sperm transport and penetration. Advantages Injection contraception is highly effective long- acting and convenient. Prolonged amenorrhea is seen in some patients as well as concomitant effects such as a general decrease in anemia cramps and ovulatory pain. This form of contraception is often useful in reducing pain associated with endometriosis and generally does not cause estrogen-related side effects. Injected contraceptives are known to reduce the risk of PID and other endometrial and ovarian cancers.15 Disadvantages Injection contraception can cause menstrual irregularities usually amenorrhea and can delay fertility for up to 1 year. The injection must be performed every 3 months which can make this method of birth control inconvenient for some patients.15 Side Effects Potential side effects of Depo-Provera include variable and individualized menstrual irregularities adverse effects associated with progestin decreases in high-density lipoprotein cholesterol and possible diminishment of bone density after long-term use. In some patients an anaphylactic reaction can occur immediately after the injection however allergic reactions are rare.16 Contraindications There are two common types of contraindications for the use of Depo-Provera relative contraindications and absolute contraindications. Relative contraindications involve planning pregnancy within a year of receiving the injection and inability to cope with menstrual irregularities. Absolute contraindications include pre-existing allergies to Depo-Provera unexplained abnormal uterine bleeding and pregnancy.13 Management Guidelines Women should be screened regularly to identify risk factors that would contraindicate use of injection contraception. For instance a pregnancy test should be performed if menstruation has not occurred more than 2 weeks after the 3-month contraceptive period of effect has ended. The patient receiving the injection should be warned to avoid massaging the site of injection. The injection must be repeated every 3 months. There is a 2-week grace period any longer and the patient would have to take a pregnancy test before further administration.14 For sexually active 16 CHAPTER 1 DiaphragmCervical Cap Overview A diaphragm or cervical cap is a flexible dome- shaped cup constructed of latex rubber. Its purpose is to prevent pregnancy by blocking the transport of sperm through the cervical os. The typical first- year failure rate for this contraceptive method is approximately 18. The mechanism of action works to make a barrier against sperm transport. When used with spermicidal cream or gel the cell membrane of the sperm is often destroyed as well.19 Advantages Diaphragms and cervical caps are barrier methods of contraception that provide immediate protection against pregnancy and minimal protection against STDs when used with spermicidal gels.19 Both are safe and easy to use and neither option interrupts sexual activity because both forms of birth control are inserted into the vagina prior to sexual intercourse. DisadvantagesSide Effects Diaphragms and cervical caps can cause skin irritations in patients who have an allergic reaction to latex or spermicides and overall increase the risk of urinary tract infections and vulvovaginitis.19 Contraindications The diaphragm or cervical cap should not be used if the patient exhibits an allergy to rubber latex or spermicide or is unable to insert the device.19 Management Guidelines General considerations for the use of a diaphragm or cervical cap include periodically checking for holes and tears. If the patient gains or loses more than 20 lb. while using the diaphragm the diaphragm should be refitted. The use of oil-based lubricants should be avoided because these may destroy the latex of the diaphragm or cervical cap. The cervical cap must remain in the vagina for at least 6 hours following intercourse. If the patient attempts repeated intercourse she must again instill spermicide into the vagina without removing the diaphragm.19 Spermicides Overview Spermicides are preparations that primarily use nonoxynol-9 as the main ingredient to destroy sperm cells.20 Spermicides have a typical first-year failure rate of 21 when used alone. Advantages Spermicides are available for over-the-counter purchase and help to provide immediate protection against pregnancy and transmission of STDs. sperm migration from the vagina to the fallopian tubes. IUDs also accelerate the transport of the ovum through the fallopian tube and inhibits fertilization. Lastly IUDs often cause lysis of the blastocyst andor prevent implantation due to local foreign body inflammatory responses.18 Advantages Mirena has been shown to decrease menstrual loss and dysmenorrhea. This type of IUD can also potentially prevent the severity of Ashermans syndrome which is the formation of scar tissue in the uterine cavity. Disadvantages Side effects of IUDs include pain and cramping up to 40 of all removals of the device are related to pain. An increase in menstrual bleeding that leads to anemia may occur with the use of an IUD. With pregnancy spontaneous abortions occur in up to 50 of all cases if the IUD is left in the uterus and ectopic pregnancies occur in up to 5 of all users.17 Side Effects Possible side effects of IUDs include spotting bleeding hemorrhage anemia cramping and pain. These side effects may also include expulsion of the IUD with an expulsion rate of up to 10 in the first year. A lost IUD string complicates removal of the device and pregnancy can still occur while using the IUD. IUDs increase the risk of developing PID which is often highest in the first 6 weeks after insertion.13 Contraindications The IUD comes with both absolute and strong relative contraindications. Absolute contraindications include active recent or recurrent pelvic infection e.g. gonorrhea chlamydia. Pregnancy is also an absolute contraindication for the IUD. Strong relative contraindications for IUDs include undiagnosed irregular or abnormal uterine bleeding as well as risk for PID.13 Management Guidelines The management guidelines for IUDs should include patient education. Patients should be informed on how the IUD works with instructions that focus on how to check the string monitor bleeding and control pain. IUDs can be inserted anytime during a womans menstrual cycle. It should be noted however that the risk of expulsion is greater during menses. For women who have recently given birth the device may be inserted 48 weeks postpartum. Patients should also be taught to recognize danger signs associated with IUDs such as late menses abdominal pain or dyspareunia fever and chills.13 CONTRACEPTIVE OPTIONS 17 A common brand name for the sponge is Today. The typical failure rate of the sponge is 10 but effectiveness is raised if used in conjunction with a condom. Advantages One of the main advantages of the sponge is not feeling its presence during intercourse. It can be inserted up to 6 hours before intercourse which avoids interrupting foreplay or sexual activity and provides some protection against gonorrhea and chlamydia.22 Disadvantages Common disadvantages of this contraceptive method include increased risk for candidiasis and slight risk for toxic shock syndrome from leaving the sponge in place too long. The sponge also does not protect against most STDs.2223 Contraindications The sponge is contraindicated in patients who are allergic to spermicides.22 Management Guidelines The management guidelines when using the sponge includes instructing the patient on how to insert the sponge into the vagina while using a cord loop attachment. Patients should understand that the sponge is inserted up to 6 hours before intercourse and that the sponge should be left in place for at least 6 hours after intercourse. The sponge provides protection for up to 12 hours. Lastly patients should know not to leave the sponge in the vagina for more than 30 hours.22 Emergency Contraception Overview Mechanisms of emergency contraception commonly work to prevent either fertilization or the implantation of a fertilized egg in the uterus. Preparations do not cause abortion. Two common types of emergency contraception are levonorgestrel Plan B One Step Ella which is also known as the morning after pill and the copper-releasing IUD. Emergency contraception pills are commonly sold over-the-counter to women 17 years of age and over. Females younger than 17 years of age need a prescription. Plan B should be taken within 72 hours of unprotected intercourse for greatest efficacy. One should stress that Plan B is not the abortion pill i.e. mifepristone. The typical effectiveness of Plan B is 85. The copper-releasing IUD is an alternative form of emergency contraception that must be inserted within 56 days of intercourse.24 The typical effectiveness of the copper-releasing IUD is 99. Spermicides are relatively safe and can be used with barrier methods of birth control to improve effectiveness.20 Disadvantages Temporary vaginal or penile skin irritation is a common side effect. Spermicides that are available in suppository form may not dissolve completely. Lastly spermicides have an unpleasant taste.20 Contraindications The only contraindication for the use of spermicides is an allergy.20 Condoms Overview Condoms have sheath-like coverings that are inserted over the penis or into the vagina to act as an obstructive barrier for sperm. Most condoms are made of latex and are available with or without a spermicide. The failure rate is 12 for male condoms and 21 for female condoms.21 Advantages Condoms are safe and easily available as an over-the-counter birth control option. Condoms provide immediate protection against pregnancy and help to protect against the transmission of most STDs.21 Disadvantages Condoms may interfere with sensation and its possible for some condoms to break upon use. Foreplay and sexual activity are often interrupted when putting on the condom.21 Natural skin condoms provide minimal protection against STDs. Contraindications Allergies to rubber or spermicide are the major contraindications to condom use.21 Management Guidelines Latex condoms provide a greater degree of protection against STDs than natural or lamb skin condoms. Patient education is also very important. Patients who use condoms should be informed of the following to avoid the use of oil-based lubricants that sensation is increased with lubricant use that condom breakage risk is reduced by leaving 12 inch of empty space at the end of the condom and that spermicide use often increases effectiveness.21 The Sponge Overview The contraceptive sponge is a disposable round barrier of soft polyurethane that fits over the cervix similar to a diaphragm and contains spermicides. 18 CHAPTER 1 The basal body temperature BBT graph is another method of natural family planning contraception. This method involves a daily record of BBT prior to rising in the morning over a 3- to 4-month period. The temperature commonly drops 1224 hours prior to ovulation and increases after ovulation due to production of progesterone. It is strongly recommended that patients avoid intercourse from between 2 and 3 days prior to the expected drop and approximately three days following the rise. The cervical mucus test Billings ovulation method involves documenting changes in cervical mucus i.e. spinnbarkeit over a 3- to 4-month period. The patient must also notice when mucus changes from sparse and thick amounts to thin with increasing spinnbarkeit. The patient must abstain from intercourse from the time of mucus change until approximately four days thereafter when mucus will resume its standard thickness. The symptothermal method is a method that uses both the basal body temperature and cervical mucus techniques. The lactational amenorrhea method i.e. prolonged breast-feeding is when the patient plans via breastfeeding for natural family planning because breastfeeding often delays ovulation and menstruation for approximately six months.20 Disadvantages There are a few disadvantages to using the natural family planning method for contraception. Unintended pregnancy is a possibility and this contraceptive method offers no protection against HIVAIDS or STDsSTIs. Sexual activity could also be limited to 25 of the month if this method is rigidly followed.20 Management Guidelines When using the natural family planning method the patient must be properly educated in the mechanisms of action and logistics for this contraceptive method to work.20 References 1. Zieman M. Overview of contraception. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate.comcontentsoverview-of- contraception. Last updated February 24 2015. Accessed March 11 2015. 2. Stone RH Rafie S El-Ibiary SY Karaoui LR Shealy KM Vernon VP. Oral contraceptive pills and possible adverse effects. J Symptoms Signs. 2014 34 282291. 3. Armstrong C. ACOG guidelines on noncontraceptive uses of hormonal contraceptives. Am Fam Physician. 2010 823 288295. httpwww.aafp.org afp20100801p288.html Side Effects Possible side effects of using Plan B and intrauterine devices include nausea and vomiting fatigue headaches dizziness diarrhea breast tenderness and fluid retention. The timing or flow of the patients menstrual period could also change and duration of the menstrual cycle could also increase.24 Sterilization Overview Sterilization is a method of birth control that involves a variety of medical techniques that intentionally interrupt a persons ability to reproduce. Sterilization can be achieved through surgical and non-surgical means. Surgical procedures of sterilization are an effective method of birth control and are intended to be permanent. In females tubal ligation i.e. having ones tubes tied involves closure of the fallopian tubes to prevent fertilization. In males vasoligation i.e. vasectomy is the process in which the vas deferens is cut and closed to prevent the passage of oocytes and sperm in semen. The failure rate for surgical sterilization is low For females the failure rate is often less than 1 for males the failure rate is 1600.13 Advantages The main advantage of using the sterilization method is that it is a permanent form of contraception for both males and females with a low failure rate.13 Disadvantages Indecision regarding future childbearing should be carefully considered because sterilization is meant to be permanent. Procedures to reverse surgical sterilization are both are costly and complicated.13 Sterilization does not provide protection from STDs. Safe sexual practices with a condom should be used to prevent unwanted infections. Natural Family Planning Overview Natural family planning involves planned abstinence from sexual intercourse while the female is most fertile. When used alone the typical first- year failure rate is 20. The mechanisms that comprise natural family planning include the calendar method which consists of recording serial cycles and identifying the longest and shortest cycles. Abstinence occurs during the fertile phase of a womans menstrual cycle which is determined by subtracting 18 days from the shortest cycle which is the earliest day of fertility and 11 days from the longest cycle which is the latest day of fertility. CONTRACEPTIVE OPTIONS 19 15. Kaunitz AM. Depot medroxyprogesterone acetate for contraception. In Basow DS ed. UpToDate. Waltham MA UpToDate 2015. httpwww.uptodate. comcontentsdepot-medroxyprogesterone-acetate- for-contraception. Last updated March 6 2014. Accessed March 11 2015. 16. Barkley TW Jr. Contraceptive options. In Barkley TW Jr. ed. Adult-Gerontology Primary Care Nurse Practitioner Certification ReviewClinical Update. West Hollywood CA Barkley Associates 2014 517. 17. Depo-Provera. Pfizer. httplabeling.pfizer.com ShowLabeling.aspxid522. Revised January 2015. Accessed March 11 2015. 18. Milton SH Karjane NW. Intrauterine device insertion. In Chelmow D ed. Medscape. httpemedicine. medscape.comarticle1998022-overview. Updated April 9 2013. Accessed March 11 2015. 19. Searle ES. The intrauterine device and the intrauterine system. Best Pract Res Clin Obstet Gynaecol. 2014 286 807824. doi 10.1016j.bpobgyn.2014.05.004 20. Barrier contraceptives. In Porter RS Kaplan JL eds. The Merck Manual Online. httpwww. merckmanuals.comprofessionalgynecology_and_ obstetricsfamily_planningbarrier_contraceptives. html. Last full review June 2013. Content last modified August 2013. Accessed March 11 2015. 21. Samra-Latif OM Wood E. Contraception. In Lucidi RS ed. Medscape. httpemedicine.medscape. comarticle 258507-overview. Updated May 2 2014. Accessed March 11 2015. 22. Condoms male. A.D.A.M. Medical Encyclopedia. httpwww.nlm.nih.govmedlineplusency article004001.htm. Updated February 4 2014. Accessed March 11 2015. 23. Mayo Clinic Staff. Contraceptive sponge. 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