Obstentrics_Williams

Obstentrics_Williams. No contraceptive method is completely without side efects, but contraception usually poses less risk than pregnancy. However, some disorders or medications can raise the risks from certain contraceptives. The World Health Organization (2015) has provided and updated evidence-based guidelines, termed Medical Eigibiliy Criteria, for the use of all highly efective reversible contraceptive methods by women with vari ous health conditions. Individual countries have subsequently modiied these guidelines. The United States Medical Eligibiliy Criteria (US MEC) was updated in 2016 by the Centers for Disease Control and Prevention (Curtis, 2016b). These docu ments are available at: http://ww.cdc.govlreproductivehealth/ U nin tendedPregnancy/ Contraception_ Guidance.h tm.


Obstentrics_Williams

Obstentrics_Williams. Disease Control and Prevention (Curtis, 2016b). These docu ments are available at: http://ww.cdc.govlreproductivehealth/ U nin tendedPregnancy/ Contraception_ Guidance.h tm. In the United States MEC, reversible contraceptive methods are organized into six groups by their similarity: combination hormonal contraceptives (CHCs), progestin-only pills (POPs), depot medroxyprogesterone acetate (DMPA), implants, levonorgestrel-releasing intrauterine system (LNGIUS), and copper intrauterine devices (Cu-IUDs). For a given health condition, each method is categorized 1 through 4 (Table 38-2). he score describes the safety proile for a typical woman with that condition: (1) no restriction of method use, (2) method advantages outweigh risks, (3) method risks outweigh advantages, and (4) method poses an unacceptably high health risk.


Obstentrics_Williams

Obstentrics_Williams. lternatively, depending on the underlying disorder or patient desire, male or female sterilization may be a preferred or recommended permanent contraceptive method (American College of Obstetricians and Gynecologists, 20 17b). hese options are fully discussed in Chapter 39.


Obstentrics_Williams

Obstentrics_Williams. Globally, 14 percent of reproductive-aged women use intrauterine contraception, and in the United States, 10 percent of contracepting women use this method (Buhling, 2014; Daniels, 2015). he five intrauterine devices (IUDs) currently approved for use in the United States are chemicaly active and continually elute either copper or levonorgestrel. These all have arT-shaped frame of polyethylene that is compounded with barium to render them radiopaque. Of devices, Mirena and Liletta both measure 32 X 32 mm and contain a 52-mg levonorgestrel-releasing cylinder reservoir in the stem of the T (Fig. 38-1). Two trailing strings that are tan (Mirena) or blue (Liletta) are attached to the distal stem to aid eventual device removal. Skyla-known asJaydess in some countries-contains 13.5 mg of levonorgestrel. It has smaller dimensions-28 X 30 mm-and was sized to more appropriately it a nulliparous uterus (Gemzell-Danielsson, 2012). yleena has the same dimensions but contains 19.5 mg of the same


Obstentrics_Williams

Obstentrics_Williams. It has smaller dimensions-28 X 30 mm-and was sized to more appropriately it a nulliparous uterus (Gemzell-Danielsson, 2012). yleena has the same dimensions but contains 19.5 mg of the same progestin. Two trailing strings of Skyla are tan, and those of yleena are blue. Skyla and yleena can be diferentiated from Mirena and


Obstentrics_Williams

Obstentrics_Williams. Liletta visually and sonographically by a silver ring near the junction of their stem and arms. Mirena and yleena are cur rently approved for 5 years of use following insertion, whereas Skyla and Liletta are approved for 3 years. he third device, the T380A IUD named ParaGar, is wound with copper, and two strings extend from the stem base. Originally blue, the strings are now white. It is currently approved for 10 years of use following insertion (T eva Wom en's Health, 2014). In addition to these ive currently marketed IUDs, women may retain discontinued brands. A Lippes Loop has two "S" shapes stacked one on the other. he Dalkon Shield has a crab form, whereas a Copper 1 mirrors that number. Progestasert is an early T -shaped progestin-releasing IUD. Last, various metaleluting ring devices are common in Asia.


Obstentrics_Williams

Obstentrics_Williams. All these IUDs are efective. Failure rates are well below 1 percent and similar overall to those of tubal sterilization (Thonneau, 2008; Trussell, 2011 b). heir mechanisms have not been precisely deined, but prevention of fertilization is now favored.


Obstentrics_Williams

Obstentrics_Williams. With the LNG-IUS, long-term progestin release leads to endometrial atrophy, which hinders normal implantation (Silverberg, 1986). Moreover, progestins create scant viscous cervical mucus that obstructs sperm motility (Apter, 2014; Moraes, 2016). Within the uterus, an intense local endometrial inlammatory response is induced, especially by coppercontaining devices. Cellular and humoral components of this inlammation are expressed in endometrial tissue and in luid illing the uterine cavity and fallopian tubes. These lead to decreased sperm and egg viability (Ortiz, 2007). Also, in the unlikely event that fertilization does occur, the same inlammatory actions are directed against the blastocyst. Also, with the Cu-IUD speciically, copper levels rise in the cervical mucus of users and act to decrease sperm motility and viability (Jecht, 1973). he above efects are considered primary for contraception because ovulation inhibition is inconsistent with the LNG-IUS and lacking with the Cu-IUD


Obstentrics_Williams

Obstentrics_Williams. decrease sperm motility and viability (Jecht, 1973). he above efects are considered primary for contraception because ovulation inhibition is inconsistent with the LNG-IUS and lacking with the Cu-IUD (Nilsson, 1984).


Obstentrics_Williams

Obstentrics_Williams. FIGURE 38-1 Intrauterine devices (IUDs). A.ParaGard T 380A copper IUD. B. Mirena levonorgestrel-releasing intrauterine system. (Reproduced with permission from Stuart GS: Contraception and sterilization. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 201o6.) TABLE 38-2. Contraindications and Cautions with Specific Contraceptive Methods In this table, a blank space indicates the method is category 1 or 2 Smoking & age ::35 yr 3/4c Active breast cancer 4 4 4 4 4 Breast disease free ::5 yr 3 3 3 3 Systolic BP ::160 or diastolic BP ::100 4 3 Surgery with long immobilization 4 MS with immobilization 3 DM with end-organ disease 3/4d 3 Cirrhosis (severe, decompensated) 4 3 3 3 3 Liver tumors9 4 3 3 3 3 iStartlContinue (S/C). Current r history of ISHD 4 2/3 3 2/3 2/3 Stroke 4 2/3 3 2/3


Obstentrics_Williams

Obstentrics_Williams. DM with end-organ disease 3/4d 3 Cirrhosis (severe, decompensated) 4 3 3 3 3 Liver tumors9 4 3 3 3 3 iStartlContinue (S/C). Current r history of ISHD 4 2/3 3 2/3 2/3 Stroke 4 2/3 3 2/3 Migraine with aura 4 2/3 2/3 2/3 2/3 Unexplained vaginal bleedingl 3 3 4/2 4/2 aCombination hormone contraception (CHC) group includes pills, vaginal ring, and patch. bAssociated risks that increase category score include: age :35, transfusion at delivery, BMI :30, postpartum hemorrhage, cesarean delivery, smoking, preeclampsia. (Smoking : 15 cigarettes/day increases risk category to 4 in this age group. dRisk category score is modified by associated risk factors and disease severity. elncluding superficial thrombosis. fOral agents only. Ring and patch are category 1. gBenign hepatic adenoma or hepatocellular cancer. Focal nodular hyperplasia compatible with hormone use. hThese include phenytoin, barbiturates, carbamazepine, oxcarbazepine, primidone, topiramate.


Obstentrics_Williams

Obstentrics_Williams. gBenign hepatic adenoma or hepatocellular cancer. Focal nodular hyperplasia compatible with hormone use. hThese include phenytoin, barbiturates, carbamazepine, oxcarbazepine, primidone, topiramate. lin those methods under Start/Continue columns, the first US MEC number refers to whether a method may be initiated in an afected patient. For patients who initially develop the condition while using a specific method, the second number refers to risks for continuing that method. JPrior to evaluation. kThose on chronic corticosteroids and at risk for bone fracture.


Obstentrics_Williams

Obstentrics_Williams. JPrior to evaluation. kThose on chronic corticosteroids and at risk for bone fracture. = antiretroviral; BP = blood pressure; BMI = body mass index; CHTN = chronic hypertension; Cu-IUD = copper intrauterine device; DM = diabetes mellitus; DMPA = depot medroxyprogesterone acetate; GC/CT = gonorrhea/chlamydial infection; GTD = gestational trophoblastic disease; ISHD = ischemic heart disease; LNG-IUS = levonorgestrel-releasing intrauterine system; MS = multiple sclerosis; PI = protease inhibitor; PID = pelvic inflammatory disease; POP = progestin-only pills; SLE = system lupus erythematosus; VTE = venous thromboembolism. Compiled from Curtis, 2016b; Merck, 2015; Teva Women's Health, 2014.


Obstentrics_Williams

Obstentrics_Williams. Contraindications to IUD use are few and shown in Table 38-2. In the past, IUDs were perceived to increase the risk of ectopic pregnancy, but this has since been clariied. Speciically, IUDs provide efective contraception and lower the absolute number of ectopic pregnancies by half compared with the rate in noncontracepting women (World Health Organization, 1985, 1987). But, the IUD mechanisms of action are more efective in preventing intrauterine implantation. hus, if an IUD fails, a higher proportion of pregnancies are likely to be ectopic (Backman, 2004; Furlong, 2002).


Obstentrics_Williams

Obstentrics_Williams. Expulsion of an IUD from the uterus is most common during the first month. hus, women are examined approximately 1 month following IUD insertion, usually after menses, to identiy the tails trailing from the cervix. Following this, a woman is instructed to palpate the strings each month after menses. Regardless of IUD type, the cumulative 3-year expulsion rate approximates 10 percent (Madden, 2014; Simonatto, 2016). This rate is higher in those :;25 years Qatlaoui, 2017).


Obstentrics_Williams

Obstentrics_Williams. If the tail of an IUD cannot be visualized, the device may have been expelled, may have perforated the uterus, or may be malpositioned. Alternatively, the device may be normally positioned with its tails folded within the endocervical canal or uterine cavi ty. To investigate, after excluding pregnancy, a cytological brush can be twirled within the endocervical canal to entangle the strings and bring them gently into the vagina. If unsuccessful, the uterine cavity is probed gently with a Randall stone clamp or with a specialized rod with a terminal hook to snare the strings or device.


Obstentrics_Williams

Obstentrics_Williams. One should not assume that a device has been expelled unless it was seen. Thus, if tails are not visible and the device is not felt by gentle probing of the uterine cavity, transvaginal sonography can be used to ascertain if the device lies within the uterus. lthough traditional sonography will document IUD position adequately in most cases, three-dimensional sonography ofers improved visualization, especially with the LNG-IUS (Moschos, 201l). If sonography is inconclusive or if no device is seen, then a plain radiograph of the abdominopelvis is taken. Computed tomography (CT) scanning or, less commonly, magnetic resonance (MR) imaging is an alternative (Boortz, 2012). It is safe to perform MR imaging at 1.5 and 3 Tesla (T) with an IUD in place (Ciet, 2015).


Obstentrics_Williams

Obstentrics_Williams. During uterine sounding or IUD insertion, the uterus may be perforated, which is identiied by the tool traveling farther than the expected uterine length based on initial bimanual examination. Rates approximate 1 per 1000 insertions, and risks include puerperal insertion, lactation, provider inexperience, and extremes of uterine lexion (Harrison-Woolrych, 2003; Heinemann, 2015). Although devices may migrate spontaneously into and through the uterine wall, most perforations occur, or at least begin, at the time of insertion (Ferguson, 2016).


Obstentrics_Williams

Obstentrics_Williams. With acute perforation, the fundus is the more common site, and bleeding is typically minimal due to myometrial contraction around the puncture hole. If no brisk or persistent bleeding is noted from the os following instrument or device removal, then patient observation alone is reasonable. Rarely, acute lateral perforations may lacerate the uterine artery, and subsequent brisk bleeding may prompt laparoscopy or laparotomy for control. Following any perforation, although this is not irmly evidence-based, a single dose of broad-spectrum antibiotic may mitigate infection.


Obstentrics_Williams

Obstentrics_Williams. With chronic perforation, a device can penetrate the muscular uterine wall to varying degrees. A patient may be asymptomatic but abdominal pain, uterine bleeding, or missing strings can be clues (Kaislasuo, 2013). hose with a predominantly intrauterine location are usually managed by hysteroscopic IUD removal. In contrast, devices that have nearly or completely perforated through the uterine wall are more easily removed laparoscopically. Notably, an extrauterine Cu-IUD frequently induces an intense local inlammatory reaction and adhesions (Kho, 2014). Laparotomy may be necessary, and bowel preparation is considered. Sigmoid and bladder perforations and small-bowel obstruction have been reported remote from insertion (Sano, 2017; Xu, 2015; Zeino, 2011).


Obstentrics_Williams

Obstentrics_Williams. Dysmenorrhea and bleeding irregularities can complicate IUD use (Aoun, 2014; Grunloh, 2013). These can be treated with some degree of success by nonsteroidal antiinlammatory drugs (NSAIDs) or tranexamic acid, which is an antiibrinolytic (Godfrey, 2013; Madden, 2012; S0rdal, 2013). Of the two IUDs, heavy bleeding more often complicates Cu-IUD use and may cause iron-deiciency anemia, for which oral iron salts are given. With the LNG-IUS, irregular spotting for up to 6 months after placement often gives way to progressive amenorrhea, which is reported by 30 percent of women after 2 years and by 60 percent after 12 years (Ronnerdag, 1999). his is frequently associated with improved dysmenorrhea.


Obstentrics_Williams

Obstentrics_Williams. he risk of upper genital tract device-related infection is greatest during the irst months following IUD insertion (Farley, 1992; Turok, 2016). Pathogens include Neisseria gonorrhoeae, Chlamydia trachomatis, and vaginal lora. Women at risk for sexually transmitted diseases (STDs) should be screened either before or at the time of IUD insertion (Centers for Disease Control and Prevention, 2015; Sufrin, 2012). That said, device insertion need not be delayed while awaiting sexually transmitted disease or Pap test results in asymptomatic women (Birgisson, 2015). If these bacteria are subsequently found and the patient is without symptoms, then the IUD may remain and treatment prescribed as detailed in Chapter 65 (p. 1240). Importantly, routine antimicrobial prophylaxis before insertion is not recommended (Grimes, 2012; Walsh, 1998). And the American Heart Association does not recommend bacterial endocarditis prophylaxis with insertion (Nishimura, 2014).


Obstentrics_Williams

Obstentrics_Williams. Mter the irst month, infection risk is not increased in IUD users who would otherwise be at low risk of sexually transmitted infections. Correspondingly, IUDs appear to cause little, if any, increase in infertility rates in these low-risk patients (H ubacher, 2001). The American College of 0bstetricians and Gynecologists (20 15c, 2016a) recommends that women at low risk for STDs, including adolescents, be considered good candidates for IUDs. he IUD is also safe and efective in women infected with human immunodeiciency virus (HIV) and may be used in others who are immunosuppressed (Centers for Disease Control and Prevention, 2015; Tepper, 2016a).


Obstentrics_Williams

Obstentrics_Williams. If infection does develop, it may take several forms and typically requires broad-spectrum antimicrobials. Pelvic inlammatoy disease (PID) without abscess is treated with antibiotics on an outpatient or inpatient basis, depending on infection severity. here are theoretical concerns that a coexistent IUD may worsen the infection or delay resolution. A provider may choose to remove an IUD in this setting, although some evidence supports allowing a device to remain during treatment in those hospitalized with mild or moderate PID (Centers for Disease Control and Prevention, 2015; Tepper, 2013). Ifinfection fails to improve during 48 to 72 hours of treatment, the device is removed. Tuboovarian abscess can complicate PID and is treated aggressively with intravenous broad-spectrum antibiotics and IUD removal. Last, septic abortion mandates immediate uterine evacuation and antibiotics.


Obstentrics_Williams

Obstentrics_Williams. Actinomyces israelii is a gram-positive, slow-growing, anaerobic indigenous vaginal bacterium that rarely causes suppurative infection. Some have found it more frequently in the vaginal lora or on the Pap smears of IUD users (Curtis, 1981; Kim, 2014). Current recommendations advise that an asymptomatic woman may retain her IUD and does not require antibiotic treatment (American College of Obstetricians and Gynecologists, 2017c; Lippes, 1999; Westhof, 2007a). However, if signs or symptoms of infection develop in a woman who harbors Actinomyces species, then the device is removed and antibiotics are given. Early indings with infection include fever, weight loss, abdominal pain, and abnormal uterine bleeding or discharge. Actinomyces species are sensitive to antibiotics with gram-positive coverage, notably the penicillins. Pregnancy with an IUD


Obstentrics_Williams

Obstentrics_Williams. Pregnancy with an IUD For women who conceive while using an IUD, ectopic pregnancy should be excluded. With intrauterine pregnancy, if the tail is seen, it should be grasped and the IUD removed by gentle outward traction. his action reduces complications such as abortion, chorioamnionitis, and preterm birth (Fulkerson Schaefer, 2017; Kim, 2010). Speciically, in one cohort, a 54-percent abortion rate and 17 -percent preterm delivery rate was noted if the device remained in situ. More favorably, rates of 25 percent and 4 percent, respectively, resulted from prompt Cu-IUD removal (Tatum, 1976). Few data guide management with the LNG-IUS, and most practice extrapolates from copper devices.


Obstentrics_Williams

Obstentrics_Williams. If the tail is not visible, attempts to locate and remove the device may result in abortion. Although not our practice, some case reports and small series describe sonography or hysteroscopy to assist in diicult device removals (Perez-Medina, 2014; Schiesser, 2004). Ater fetal viability is reached, it is unclear whether it is better to remove an IUD whose strings are visible and accessible or to leave it in place. Fetal malformation rates are not greater with a device let in situ (Tatum, 1976; Vessey, 1979).


Obstentrics_Williams

Obstentrics_Williams. Second-trimester miscarriage with an IUD in place is more likely to be infected (Vessey, 1974). Sepsis may be fulminant and fatal. Pregnant women with a device in utero who demonstrate any evidence of pelvic infection are treated with broadspectrum antibiotics and prompt uterine evacuation. Because of these risks, a woman should be given the option of early pregnancy termination if the device cannot be removed early in pregnancy. Last, in women who give birth with a device in place, appropriate steps should be taken at delivery to identiy and remove the IUD. To reduce expulsion rates and perforation risks, IUD insertion 6 weeks after delivery. Women delivered at Parkland Hospital are seen 3 weeks postpartum, and IUDs are inserted 6 weeks postpartum or sooner if involution is complete.


Obstentrics_Williams

Obstentrics_Williams. Alternatively, immediately ater miscarriage, surgical abortion, or delivery, an IUD may be inserted in the absence of overt infection (Lopez, 2015a; Okusanya, 2014). Also, "immediate" insertion 1 week ater mifepristone and completed medical abortion has been described (Saav, 2012; Shimoni, 2011). The risk ofIUD expulsion is slightly higher if it is placed immediately following any of these recent pregnancies (Whitaker, 2017). However, in studies, the number of women in immediate-placement groups who ultimately receive and retain an IUD is greater than in groups scheduled for traditionally timed placement, some of whose members do not return for insertion (Bednarek, 2011; Chen, 2010). With immediate insertion, techniques depend on uterine size. After irst-trimester evacuation, the IUD can be placed using the manufacturer's standard instructions. If the uterine cavity is larger, the IUD can be placed using ring forceps with sonographic guidance (Drey, 2009; Fox, 2011).


Obstentrics_Williams

Obstentrics_Williams. Immediately following vaginal or cesarean delivery, an IUD can be placed by a hand, by its inserter tube, or by ring forceps (Levi, 2015; Xu, 1996). With any of these methods, the arms of the IUD need not be folded into the inserter tube prior to insertion. During cesarean delivery placement, the hand or inserter travels through the unsutured open hysterotomy to deposit the device at the fundus. A second hand cupping the outer fundus can provide back pressure and stabilize the uterus during insertion. Strings are then gently directed toward the cervix. For instrumented insertion following vaginal delivery, the clinician resterilizes the vulva and changes gloves after placental delivery but before perineal repairs. he anterior lip of the loppy cervix is held with ring forceps. A second ring forceps grasp the IUD stem and guides it through the uterine cavity to the fundus. For manual insertion following vaginal delivery, the provider secures the IUD between the index and middle fingers


Obstentrics_Williams

Obstentrics_Williams. forceps grasp the IUD stem and guides it through the uterine cavity to the fundus. For manual insertion following vaginal delivery, the provider secures the IUD between the index and middle fingers to deposit the device. In either case, back pressure against the fundus by an abdominal hand can guide positioning (Stuart, 2017; The ACQUIE Project, 2008).


Obstentrics_Williams

Obstentrics_Williams. For placement not related to pregnancy, insertion near the end of normal menstruation, when the cervix is usually softer and somewhat more dilated, may be easier and also helps exclude early pregnancy. But, insertion is not limited to this time. For the woman who is sure she is not pregnant and does not want to be pregnant, insertion is done at any time. Before insertion, contraindications are sought. Candidates are counseled, and written consent obtained. n oral NSAID, with or without codeine, can be used to allay cramps ater insertion (Ngo, 2015). But NSAIDs, misoprostol, or even paracervical during device placement (Bednarek, 2015; Hubacher, 2006;


Obstentrics_Williams

Obstentrics_Williams. Mody, 2012; Pergialiotis, 2014). Of topical lidocaine products, 2-percent gel is inefective, but a newer gel and a spray both show promise (Aksoy, 2016; Lopez, 2015b; Tornblom-Paulander, 2015). Bimanual pelvic examination delineates uterine position and size. Abnormalities are evaluated, as they may contraindi cate insertion. Mucopurulent cervicitis or signiicant vaginitis is appropriately treated and resolved before IUD insertion. The cervical surface is cleansed with an antiseptic solution, and sterile instruments and a sterile IUD are used. A tenaculum is placed on the cervical lip, and the canal and uterine cavity are straightened by applying gentle outward traction. The cav ity is then probed by a uterine sound to identiy its direction and depth. Speciic steps of ParaGard and Mirena insertion are tive package inserts.


Obstentrics_Williams

Obstentrics_Williams. Following insertion, only the threads should be visible trailing from the cervix. These are trimmed to allow 3 to 4 cm to protrude into the vagina, and their length is recorded. If improper device positioning is suspected, placement should be confirmed, using sonography if necessary. If the IUD is not positioned completely within the uterus, it is removed and replaced with a new device. An expelled or partially expelled device should not be reinserted.


Obstentrics_Williams

Obstentrics_Williams. Contraception can be provided by thin, pliable progestincontaining cylinders that are implanted subdermally and release hormone over many years. One of these, Nepanon is a single-rod implant with 68 mg of etonogestrel covered by an ethylene vinyl acetate copolymer cover. The implant is placed subdermally on the medial surface of the upper arm 8 to 10 cm from the elbow in the biceps groove and is aligned with the long axis of the arm. It may be used as contraception for 3 years, removed, and then replaced at the same site or in the opposite arm (Merck, 2016a).


Obstentrics_Williams

Obstentrics_Williams. Nexplanon is radiopaque, and its inserter device is designed to assist with subdermal positioning and avert deeper placement. This device replaced Implanon, which is not radiopaque. A misplaced Implanon may be identiied with sonography using a 10-to IS-MHz linear array transducer (Shulman, 2006). In some cases, MR imaging may be required if supplemental information is needed despite sonography (Correia, 2012). Both implants are similarly shaped and pharmacologically identical. They are highly efective, and the mechanism of action for progestin-only products is described later (p. 689) (Croxatto, 1998; Mommers, 2012). Implanon is safe and still approved by Flange 1.5cm After slider moved back, inserter tube removed


Obstentrics_Williams

Obstentrics_Williams. FIGURE 38-2 Insertion of the Mirena intrauterine system. Initially, threads from behind the slider are first released to hang freely. The slider found on the handle should be positioned at the top ofthe handle nearest the device. The IUD arms are oriented horizontally. A flange on the outside ofthe inserter tube is positioned from the IUD tip to reflect the depth found with uterine sounding. A.As both free threads are pulled, the Mirena IUD is drawn into the inserter tube. The threads are then tightly fixed from below into the handle's cleft. In these depictions, the inserter tube has been foreshortened. The inserter tube is gently inserted into the uterus until the flange lies 1.5 to 2 cm from the external cervical os to allow the arms to open. B. While holding the inserter steady, the IUD arms are released by pulling the slider back to reach the raised horizontal mark on the handle, but no further. C. The inserter is then gently guided into the uterine cavity until its flange


Obstentrics_Williams

Obstentrics_Williams. the IUD arms are released by pulling the slider back to reach the raised horizontal mark on the handle, but no further. C. The inserter is then gently guided into the uterine cavity until its flange touches the cervix. D. The device is released by holding the inserter firmly in position and pulling the slider down all the way. The threads will be released automatically from the clet. The inserter may then be removed, and IUD strings trimmed. (Reproduced with permission from Stuart GS: Contraception and sterilization. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.)


Obstentrics_Williams

Obstentrics_Williams. Tip of IUD inserter rod Inserter tube Flange A B FIGURE 38-3 Insertion of ParaGard T 380A. The uterus is sounded, and the IUD is loaded into its inserter tube not more than 5 minutes before insertion. A blue plastic flange on the outside of the inserter tube is positioned from the IUD tip to reflect uterine depth. The IUD arms should lie in the same plane as the flat portion of the oblong blue flange. A.The inserter tube, with the IUD loaded, is passed into the endometrial cavity. A long, solid, white inserter rod abuts the base of the IUD. When the blue flange contacts the cervix, insertion stops.


Obstentrics_Williams

Obstentrics_Williams. B. To release the IUD arms, the solid white rod within the inserter tube is held steady, while the inserter tube is withdrawn no more than 1 cm. C. The inserter tube, not the inserter rod, is then carefully moved upward toward the top of the uterus until slight resistance is felt. At no time during insertion is the inserter rod advanced forward. D. First, the solid white rod and then the inserter tube are withdrawn individually. At completion, only the threads should be visible protruding from the cervix. These are trimmed to allow 3 to 4 cm to extend into the vagina. (Reproduced with permission from Stuart GS: Contraception and sterilization. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.) the Food and Drug Administration (FDA), but it is no longer distributed by the manufacturer.


Obstentrics_Williams

Obstentrics_Williams. he irst progestin implants contained levonorgestrel (LNG), and systems are still available outside the United States. Jadelle, originally named Norplant-2, provides LNG and contraception for 5 years through two subdermally implanted Silastic rods. Ater this time, rods may be removed and if desired, new rods inserted at the same site (Bayer Group, 2015). Jadele is approved by the FDA, however, it is not marketed or distributed in the United States. Sino-implant II is a two-rod system with the same amount (150 mg) of LNG and same mechanism of action asJadele but provides 4 years of contraception. Sinoimplant II is manufactured in China and approved for use by 20 countries in Asia and Mrica (FHI 360, 2012).


Obstentrics_Williams

Obstentrics_Williams. Like the etonogestrel implant, these systems are placed subdermally on the inner arm approximately 8 cm from the elbow and have similar removal steps. Implants vary regarding their insertion technique, and manufacturer instructions should be consulted. Both implant systems are highly efective (Sivin, 1998; Steiner, 2010). he forerunner of these implants was the Norpant System, which provided LNG in six Silastic rods implanted subdermally. The manufacturer stopped distributing the system in 2002. Few data compare the LNG and etonogestrel implants. In one, eicacy and discontinuation rates by 2.5 years of use were similar (Bahamondes, 2015).


Obstentrics_Williams

Obstentrics_Williams. Few data compare the LNG and etonogestrel implants. In one, eicacy and discontinuation rates by 2.5 years of use were similar (Bahamondes, 2015). Unscheduled bleeding is common with progestin-only methods and described on page 689. Device-specific adverse efects derive mainly from malpositioning. First, branches of the medial antebrachial cutaneous nerve can be injured during implant or needle insertion that is too deep or during exploration for a lost implant. Clinically, numbness and paresthesia over the anteromedial aspect of the forearm are noted (Wechselberger, 2006).


Obstentrics_Williams

Obstentrics_Williams. Second, nonpalpable devices are not uncommon and require radiological imaging for localization. As an adjunct, one group adopted the hook-wire tagging method used in breast tumor surgery to allow deep-lying implants to be marked prior to extraction (Nouri, 2013). If imaging fails to locate an implant, etonogestrel blood level determination can help veriy that the implant is indeed in situ. his special assay must be coordinated with the manufacturer (1-877-467-5266).


Obstentrics_Williams

Obstentrics_Williams. For those not currently using hormonal contraception, the etonogestrel implant is ideally inserted within 5 days of menses onset. With LNG-releasing implants, contraception is established within 24 hours if inserted within the first 7 days of the menstrual cycle (Sivin, 1997; Steiner, 2010). For transitioning methods, an implant is placed on the day of the first placebo combination oral contraceptive (COC) pill; on the day that the next depot-medroxyprogesterone injection would be due; or within 24 hours of taking the last POP (Merck, 2016a). In women certain that they are not pregnant, insertion at other times of the cycle is followed by alternative contraception for 7 days. Related to pregnancy, an implant may be inserted before discharge following delivery or abortion (Sothornwit, 2017).


Obstentrics_Williams

Obstentrics_Williams. With the patient lying down, her nondominant arm, forearm, and hand are outstretched on the bed with the inner aspects of each exposed upward, and the elbow is flexed. The insertion site is marked with a sterile pen 8 to 10 cm proximal to the medial condyle of the humerus. A second mark is placed 4 cm proximally and delineates the inal path of the implant. he Nexplanon is inserted using sterile technique. The area is cleansed aseptically, and a I-percent lidocaine anesthetic track is injected beneath the sin along the planned insertion path. The implant is then placed as shown in Figure 38-4. Ater placement, both


Obstentrics_Williams

Obstentrics_Williams. FIGURE 38-4 Nexplanon insertion. A sterile pen marks the insertion site, which is 8 to 10 cm proximal to the medial humeral condyle. A second mark is placed 4 cm proximally along the arm's long axis. The area is cleaned aseptically, and a l-percent lidocaine anesthetic track is injected along the planned insertion path. A.The insertion device is grasped at its gripper bubbles found on either side, and the needle cap is removed outward. The device can be seen within the needle bore. The needle bevel then pierces the skin at a 30-degree angle.


Obstentrics_Williams

Obstentrics_Williams. B. Once the complete bevel is subcutaneous, the needle is quickly angled downward to lie horizontally. C. Importantly, the skin is tented upward by the needle as the needle is slowly advanced horizontally and subdermally. D. Once the needle is completely inserted, the lever on the top of the device is pulled backward toward the operator. This retracts the needle and thereby deposits the implant. The device is then lifted away from the skin. After placement, both patient and operator should palpate the 4-cm implant. patient and provider should palpate and identiY both ends of the 4-cm implant. To minimize bruising at the site, a pressure ban dage is created around the arm and is removed the following day.


Obstentrics_Williams

Obstentrics_Williams. patient and provider should palpate and identiY both ends of the 4-cm implant. To minimize bruising at the site, a pressure ban dage is created around the arm and is removed the following day. With implant extraction, the removal site is irst cleansed with antiseptic. he proximal end of the implant is depressed with a finger to allow the distal end to bulge up toward the skin. Ater anesthetizing the skin over this bulge, the skin is incised 2 mm toward the elbow along the long axis of the arm. he proximal butt of the implant is then pushed toward this incision. Once vis ible, the distal end of the implant is grasped with a hemostat and removed. If present, supericial adhesions surrounding an implant may be dissected away with hemostat tips placed into the incision.


Obstentrics_Williams

Obstentrics_Williams. Progestin-only contraceptives include the implants just described, injectables, and pills. s their primary contraceptive action, these progestins suppress luteinizing hormone (LH) and in turn block ovulation. As other efects, cervical mucus is thickened to retard sperm passage, and atrophy renders the endometrium unfavorable for implantation. Fertility is restored rapidly following cessation of progestin-only contraception. n exception is DMPA, as described on page 693 (Mansour, 201l).


Obstentrics_Williams

Obstentrics_Williams. For all progestin-only methods, irregular or heavy uterine bleeding is a distinct disadvantage. It is the most frequently reported adverse event leading to method discontinuation. Often, counseling and reassurance is suicient. Troublesome bleeding may be improved by one to two cycles of combination oral contraceptives, by a 1-to 3-week course of estrogen alone, or by a short course of NSAIDs combined with the established method (Abdel-Aleem, 2013). Fortunately, with prolonged use, progestins induce endometrial atrophy, which leads to sustained amenorrhea. For the well-counseled patient, this is often an advantage.


Obstentrics_Williams

Obstentrics_Williams. Most progestin-only contraceptive methods do not signiicantly afect lipid metabolism, glucose levels, hemostatic factors, liver function, thyroid function, or blood pressure (DorRinger, 2002). However, the increased low-density lipoprotein (LDL) cholesterol and decreased high-density lipoprotein (HDL) cholesterolrlevels seen with DMPA may be less desirable for women with cardiac or vascular disease risks (Kongsayreepong, 1993).


Obstentrics_Williams

Obstentrics_Williams. Progestin-only methods do not impair milk production and are an excellent choice for lactating women. here are no increased risks of genital tract, liver, or breast neoplasia (Samson, 2016; Wilailak, 2012; World Health Organization, 1991a,b, 1992). Weight gain and bone fracture are not prominent side efects of this contraceptive group, except for depot progesterone, discussed on page 693 (Lopez, 2012a, 2013a). Functional ovarian cysts develop with a greater frequency in women using progestin-only agents, although they do not usually necessitate intervention (European Society of Human Reproduction and Emblyology, 2001; Hidalgo, 2006; Nahum, 2015). Last, an association between depression and DMPA or POPs is unclear (Civic, 2000; Pagano, 2016; Svendal, 2012; Westhof, 1995). Women with depression may be prescribed these methods, but surveillance following initiation is reasonable.


Obstentrics_Williams

Obstentrics_Williams. These methods are ideal for most women, but contraindications and cautions are associated with a few conditions listed in Table 38-2. Current breast cancer and pregnancy are the only two absolute contraindications. In a few instances, manufacturer restrictions difer from the US MEC. First, manufacturer prescribing information lists thrombosis or thromboembolic disorders as contraindications (Merck, 2016a; Pizer, 2015a,b). However, for individuals with these disorders, US MEC considers progestin-containing methods category 2. Moreover, evidence does not link progestin-only methods with thromboembolism, stroke, or cardiovascular disease (Mantha, 2012; Tepper, 2016b; World Health Organization, 1998). Second, for many progestin products, manufacturers note prior ectopic pregnancy as a contraindication. his is secondary to progesterone's efect of slowing fallopian tube motility and thereby delaying fertilized egg transport to the endometrial cavity. hat said, efective contraception lowers


Obstentrics_Williams

Obstentrics_Williams. his is secondary to progesterone's efect of slowing fallopian tube motility and thereby delaying fertilized egg transport to the endometrial cavity. hat said, efective contraception lowers pregnancy rates overall. Thus, for those with prior ectopic pregnancy, US MEC considers progestin injectables and implants category 1, and progestin-only pills are category 2.


Obstentrics_Williams

Obstentrics_Williams. These currently are available in forms that contain both estrogen and progestin or contain only progestin. Progestin-only injectables and pills are considered very efective, yet secondtier agents, due to the need for increased patient compliance. Similarly, products containing both estrogen and progestin, often termed combination hormonal contraception (CHC), are considered in this tier. These may be supplied as pills, transvaginal rings, or transdermal patches. • Combination Hormonal Contraceptives Mechanism of Action


Obstentrics_Williams

Obstentrics_Williams. • Combination Hormonal Contraceptives Mechanism of Action Actions of combination hormonal contraceptives are multiple, but the most important efect is suppression of hypothalamic gonadotropin-releasing factors. his in turn blocks pituitary secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and thereby inhibits ovulation. The progestin component of CHCs provides ovulation prevention by suppressing LH; it thickens cervical mucus and thereby retards sperm passage; and it renders the endometrium unfavorable for implantation. Estrogen blocks ovulation by suppressing FSH release. To promote cycle control, estrogen stabilizes the endometrium, which prevents intermenstrual bleeding-also known as breakthrough bleeding. The net efect is an extremely efective yet highly reversible method (Mansour, 2011).


Obstentrics_Williams

Obstentrics_Williams. hese pills are the most frequently used reversible birth control method in the United States. In a 2006 to 2010 survey, 16 percent of contracepting women in the United States were using these (Daniels, 2015). COCs are marketed in a wide variety of estrogen and progestin combinations. lvlost are available as generics, and the FDA (2016) confirms the bioequivalence of COC generics. The merican College of Obstetricians and Gynecologists (2015a) supports the use of either branded or generic preparations. Pharmacologically, ethinyl estradiol is the most common estrogen present in COC formulations in the United States. Less frequently, mestranol or estradiol valerate is used. Unwanted efects most often attributed to the estrogen component include breast tenderness, weight gain, nausea, and headache.


Obstentrics_Williams

Obstentrics_Williams. COCs also contain one of several progestins that are structurally related to progesterone, testosterone, or spironolactone. hus, these progestins bind variably to progesterone, androgen, glucocorticoid, and mineralocorticoid receptors. hese ainities explain many pill-related side efects and are often used to compare one progestin with another. Most progestins used in COCs are related to testosterone and may impart androgenic side afects such as acne and adverse HDL and LDL levels. To avoid these efects, antiandrogenic progestins have been introduced and include dienogest and nomegestroL acetate. he latter is used in a COC approved outside the United States. Despite these pharmacological differences, the true advantage of one progestin over another is less apparent clinically (Lawrie, 2011; Moreau, 2007).


Obstentrics_Williams

Obstentrics_Williams. Another progestin, drospirenone, is structurally similar to spironolactone. he doses in currently marketed COCs have efects similar to 25 mg of this diuretic (Seeger, 2007). Drospirenone displays antiandrogenic activity, provides an antialdosterone action to minimize water retention, and has antimineralocorticoid properties that may, in theory, cause potassium retention and hyperkalemia (Krattenmacher, 2000). hus, it is avoided in women with renal or adrenal insuiciency or with hepatic dysfunction. Moreover, serum potassium level monitoring is recommended in the first month for patients chronically treated concomitantly with any drug associated with potassium retention. hese include NSAIDs, angiotensinconverting enzyme (ACE) inhibitors, angiotensin II antagonists, heparin, aldosterone antagonists, and potassium-sparing diuretics (Bayer HealthCare Pharmaceuticals, 2015).


Obstentrics_Williams

Obstentrics_Williams. Since the development of COCs, their estrogen and progestin content has dropped remarkably to minimize adverse efects. Currently, the lowest acceptable dose is limited by the ability to prevent pregnancy and to avoid unacceptable breakthrough bleeding. hus, the daily estrogen content varies from 10 to 50 1g of ethinyl estradiol, and most contain 35 j.1g or less. In a few COCs, inert placebo pills have been replaced by tablets containing iron. These have the suix Fe added to their name. In addition, Beyaz has a form of folate-levomefolate calcium-within both its active and placebo pills.


Obstentrics_Williams

Obstentrics_Williams. With COCs termed monophasic piLs, the progestin dose remains constant throughout the cycle. In others, the dose frequently is varied, and term biphasic, triphasic, or quadriphasic piL is used depending on the number of dose changes within the cycle. In some formulations, the estrogen dose also varies. In general, phasic pills were developed to reduce the total progestin content per cycle without sacrificing contraceptive eicacy or cycle control. he theoretical advantage of a lower total progesterone dose per cycle, however, has not been borne out clinically (Moreau, 2007). Cycle control also appears to be comparable among mono-through triphasic pills (van Vliet, 2011a,b,c). Hormones are taken daily for a specified time (21 to 81 days) and then replaced by placebo for a speciied time (4 to 7 days), which is called the "pill-free interval." During these pill-free days, withdrawal bleeding is expected.


Obstentrics_Williams

Obstentrics_Williams. With the trend toward lower estrogen doses to minimize side efects, follicular development and ovulation may occur. To counter this, the active-pill duration in some formulations is extended to 24 days. In comparison, these 24/4 regimens perform similarly to higher-estrogen-dose 21/7 regimens (Anttila, 2011; Marr, 2012). Alternatively, longer durations of active hormone, designed to minimize the number of withdrawal episodes, have similar eicacy and safety proiles as more traditional administration (Edelman, 2014). These extended-cycle products produce a 13-week cycle, that is, 12 weeks of hormone use, followed by a week for withdrawal menses. The product Amethyst provides continuous active hormone pills for 365 days each year. Such extended or continuous regimens may be especially suited for women with significant menstrual symptoms (Mendoza, 2014).


Obstentrics_Williams

Obstentrics_Williams. For general initiation, women ideally begin COCs on the first day of a menstrual cycle. In such cases, a supplementary contraceptive method is unnecessary. With the more traditional "Sunday start," women begin pills on the irst Sunday that follows menses onset, and an additional method is needed for 1 week to prevent conception. If menses begin on a Sunday, then pills are begun that day and no supplemental method is required. Alternatively, with the "quick start" method, COCs are started on any day, commonly the day prescribed, regardless of cycle timing. An additional method is used during the first week (Westhof, 2002, 2007b). If the woman is unknowingly already pregnant during quick start initiation, COCs are not teratogenic (Lammer, 1986; Rothman, 1978; Savolainen, 1981). However, a missed menses following COC initiation should prompt pregnancy testing. Similar same-day initiation can be implemented with the contraceptive vaginal ring or patch (Murthy, 2005; Schafer, 2006).


Obstentrics_Williams

Obstentrics_Williams. For maximum eiciency, pills are best taken at the same time each day. If one dose is missed, the missed pill is taken immediately; the scheduled dose for that day is taken on time; and then daily pills are continued. If two or more doses are missed, the most recent missed pill is taken immediately; the scheduled dose for that day is taken on time; and an efective barrier technique used for 7 days while daily pills are then continued (Curtis, 2016a). If withdrawal bleeding fails to occur during the pill-free interval, a woman should continue her pills but seek attention to exclude pregnancy. With initiation of COCs, spotting or bleeding is common. It does not relect contraceptive failure and typically resolves within one to three cycles. If unscheduled bleeding persists, those with bleeding during the first part of a pill pack may beneit from an increase in the estrogen dose, whereas those with bleeding during the second part may improve with a higher progestin dose (Nelson, 2011).


Obstentrics_Williams

Obstentrics_Williams. Some drugs decrease COC efectiveness, and choosing another contraceptive method is preferable. However, if a COC is selected for concurrent use in these instances, a preparation containing a minimum of 30 �g ethinyl estradiol is ideally chosen. Conversely, some COCs interfere with the actions of certain drugs (see Table 38-2). In obese women, COCs are efective (Lopez, 2016). Some studies point to lowered hormone bioavailability, but over all eicacy remains high (Nakajima', 2016; Westhof, 2010; Yamazaki, 2015). With the transdermal patch method, how ever, evidence is more robust that obesity may alter pharmaco kinetics and lower eicacy, as discussed on page 692.


Obstentrics_Williams

Obstentrics_Williams. Yamazaki, 2015). With the transdermal patch method, how ever, evidence is more robust that obesity may alter pharmaco kinetics and lower eicacy, as discussed on page 692. Combination oral contraceptives alter lipid synthesis and in general raise serum levels of triglycerides and of total cholesterol, HDL, and very-low density lipoprotein (VLDL) cholesterol. Estrogen lowers LDL cholesterol concentrations. Oral contraceptives are not atherogenic, and their efect on lipids is clinically inconsequential for most women (Wallach, 2000). In women with dyslipidemias, limited data suggest that COCs increase the risk for myocardial infarction and minimally so for venous thromboembolism or stroke (Dragoman, 2016). For those with multiple additional risk factors for vascular disease, alternative contraceptive methods are recommended.


Obstentrics_Williams

Obstentrics_Williams. With COCs, protein metabolism is afected, and estrogens boost hepatic production of various globulins. First, fibrinogen and many of the clotting factor levels rise in direct proportion to the estrogen dose and may lead to thrombosis. Angiotensinogen production is also augmented by COCs, and its conversion by renin to angiotensin I may be associated with "pill-induced hypertension," discussed subsequently. Last, COCs elevate sex hormone-binding globulin (SHBG) levels, which in turn lower concentrations of bioavailable testosterone and lessen androgenic side efects. Regarding carbohydrate metabolism, current low-dose formulations have minimal efects in women who do not have diabetes (Lopez, 2014). And, the risk of developing diabetes is not increased (Kim, 2002). For diabetic women, COCs may be used in nonsmokers with disease duration <20 years and without associated vascular disease, nephropathy, retinopathy, or neuropathy (Curtis, 2016b).


Obstentrics_Williams

Obstentrics_Williams. Of other metabolic changes, thyroid-binding globulin and thyroid-stimulating hormone (TSH) levels are elevated, but free plasma thyroxine (FT4) levels are unchanged (Raps, 2014). Studies have not supported a connection between COCs and weight gain (Gallo, 2014). Despite increased plasma angiotensinogen (renin substrate) levels, women using low-dose COC formulations rarely develop clinically significant hypertension (Chasan-Taber, 1996). However, it is common practice for patients to return 8 to 12 weeks ater COC initiation for evaluation of blood pressure and other symptoms. During initial contraception selection, a history of gesta tional hypertension does not preclude subsequent COC use.


Obstentrics_Williams

Obstentrics_Williams. During initial contraception selection, a history of gesta tional hypertension does not preclude subsequent COC use. Among women with well-controlled hypertension, COC use is linked to greater risks than nonusers for stroke, acute myo cardial infarction, and peripheral arterial disease, and in these women, COCs are considered US MEC category 3 (Curtis, 2016b). Severe forms of hypertension, especially those with end-organ involvement, preclude COC use. For nonsmoking women younger than 35, the risk of stroke is extremely low (World Health Organization, 1996). COCs are associated with a small increased risk for ischemic stroke (Chan, 2004; Lidegaard, 2012). Rates increase signiicantly for women who have hypertension, who smoke, or who have migraine headaches with visual aura or other focal neurological changes and use COCs (MacClellan, 2007; Tepper, 2016c).


Obstentrics_Williams

Obstentrics_Williams. The evidence for stroke risk in migraineurs without aura is less clear (Etminan, 2005; Schurks, 2009). COC initiation may be considered for women with preexisting migraines without aura if they are otherwise healthy, younger, normotensive nonsmok ers. For women with prior stroke, COCs should not be consid ered due to risks for repeat events. For women with prior myocardial infarction, COCs should not be considered. Also, in women with multiple cardiovas cular risk factors, which include smoking, hypertension, older age, and diabetes, the risk for myocardial infarction outweighs the beneits of this method. However, for those without these risks, low-dose oral contraceptives are not associated with an increased risk of myocardial infarction (Margolis, 2007; World Health Organization, 1997).


Obstentrics_Williams

Obstentrics_Williams. The risks for deep-vein thrombosis and pulmonary embolism are increased in women who use COCs (Stadel, 1981). These clearly are estrogen-dose related, and rates have substantively declined with lower-dose formulations containing 10 to 35 �g of ethinyl estradiol. he general-population risk of venous thromboembolism (VTE) is 4 to 5 events per 100,000 woman-years. he incidence ofVTE with COC use increases three-to fivefold compared with nonusers (Shaw, 2013; van Hylckama Vlieg, 2009). Obesity raises the VTE risk, which is compounded by COCs (Horton, 2016; Suchon, 2016). Accordingly, in an obese woman, COCs are considered a US MEC category 2. VTEs are signiicantly increased in women older than 35 years who smoke, and COCs are not recommended. Those most at risk for VTE include women with thrombophilias (ESHRE Capri Workshop Group, 2013). Nloreover, COC use during the month before a major operative procedure appears to double the risk for postoperative VTE (Robinson, 1991). Thus, the


Obstentrics_Williams

Obstentrics_Williams. thrombophilias (ESHRE Capri Workshop Group, 2013). Nloreover, COC use during the month before a major operative procedure appears to double the risk for postoperative VTE (Robinson, 1991). Thus, the merican College of Obstetricians and Gynecologists (2016d) recommends balancing the risks ofVTE and the degree of postoperative immobility with the risk of unintended pregnancy during the 4 to 6 weeks required to reverse the thrombogenic efects of COCs before surgery. In the early puerperium, VTE risks are also increased, and COCs are not recommended for women within the irst 4 weeks after delivery.


Obstentrics_Williams

Obstentrics_Williams. Certain progestins within COC are linked with greater rates of thromboembolism. A slightly higher VTE risk with drospirenone-containing COCs has been shown in two studies. In response, an assessment of benefits and VTE risks in users of these pills has been emphasized (Food and Drug Administration, 2012; Jick, 2011; Parkin, 2011). Desogestrel and gestodene are also implicated and carry similarly elevated risks (Stegeman, 2013; Vinogradova, 2015).


Obstentrics_Williams

Obstentrics_Williams. Most studies indicate that COCs overall are not associated with an increased risk of cancer (Cibula, 2010). In fact, a protective efect against ovarian and endometrial cancer has been shown (Collaborative Group on Epidemiological Studies of Ovarian Cancer, 2008; Tsilidis, 201r1). As an exception, the relative risk of cervical dysplasia and cervical cancer is higher in current COC users, but this declines after use is discontinued. Following 10 or more years, risk returns to that of never users (International Collaboration of Epidemiological Studies of Cervical Cancer, 2007). It is unclear whether COCs contribute to breast cancer development. Major studies show no risk or a small risk among current users, which drops with time following cessation (Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Hannaford, 2007; Marchbanks, 2002).


Obstentrics_Williams

Obstentrics_Williams. Although COC use in the past was linked to development of hepatic ocal nodular hyperplasia and benign hepatic adenoma, large studies do not support this (Heinemann, 1998). Moreover, no evidence supports concern for greater risk of hepatocellular cancer (Maheshwari, 2007). For women with known tumors, COCs may be used in those with focal nodular hyperplasia, but avoided in those with benign hepatic adenoma and hepatocellular carcinoma (Kapp, 2009b). Rates of colorectal cancer appear to be reduced in ever users (Bosetti, 2009; Luan, 2015).


Obstentrics_Williams

Obstentrics_Williams. Cholestasis and cholestatic jaundice are uncommon, but they resolve when COCs are discontinued. In women who have active hepatitis, COCs should not be initiated, but these may be continued in women who experience a flare of their liver disease while already taking COCs. Use of progestin-only contraception in these women is not restricted. Moreover, there is no reason to withhold COCs from women who have recovered. Mild compensated cirrhosis does not limit the use of COCs or progestin-only methods. But in those with severe decompensated disease, all hormonal methods are avoided (Kapp, 2009a).


Obstentrics_Williams

Obstentrics_Williams. Chloasma, which is hyperpigmentation of the face and forehead, is more likely in women who demonstrated such a change during pregnancy (Chap. 4, p. 53). This is less common with lowdose estrogen formulations. Although previously used for treating unctional ovarian cysts, low-dose COC formulations have been shown to have no efects related to cyst resolution or prevention (European Society of Human Reproduction and Embryology, 2001; Grimes, 2014).


Obstentrics_Williams

Obstentrics_Williams. Many noncontraceptive beneits are associated with COC use (American College of Obstetricians and Gynecologists, 20 16c). And indeed, COCs may be used for these efects, even in those without contraceptive needs. Dysmenorrhea and heavy menstrual bleeding lessen with COC use. Another action is to improve androgenic conditions such as acne and hirsutism. For women with premenstrual dysphoric disorder (PMDD), several studies have shown symptom improvement in those who use the drospirenone-containing COC Yaz (Lopez, 2012b; Pearlstein, 2005; Yonkers, 2005).


Obstentrics_Williams

Obstentrics_Williams. he Ortho Evra patch contains ethinyl estradiol and the progestin norelgestromin. It has an inner layer containing an adhesive and hormone matrix, and a water-resistant outer layer. Thus, women can wear the patch in bathtubs, showers, swimming pools, saunas, and whirlpools without decreased eicacy. he patch may be applied to buttocks, upper outer arm, lower abdomen, or upper torso, but the breasts are avoided. Because the hormones are combined with the adhesive, improper skin adherence will lower hormone absorption and eicacy. herefore, if a patch is so poorly adhered that it requires reinforcement with tape, it should be replaced. Initiation of the patch is the same as for COCs, and a new patch is applied weekly for 3 weeks, followed by a patch-free week to allow withdrawal bleeding. Although a patch is ideally worn no longer than 7 days, hormone levels remain in an efective range for up to 9 days. This afords a 2-day window for patch-change delays (Abrams, 2001).


Obstentrics_Williams

Obstentrics_Williams. In general, the transdermal patch and vaginal ring produce metabolic changes, side efects, and eicacy rates comparable to those with COC pills. However, the patch has been associated with a higher thromboembolism risk in some but not all studies (Cole, 2007; Jick, 2010; Lidegaard, 2011). In response, the Food and Drug Administration (2015 b) approved labeling for the patch to state that the risk for VTE may be increased compared with other COCs, and relative risk estimates range from 1.2 to 2.2. Obesity-90 kg or greater-may be associated with a higher risk for patch contraceptive failure (Janssen Pharmaceuticals, 2015; Zieman, 2002). Finally, applicationsite reaction and breast tenderness are more frequent during initial cycles in patch wearers (Urdl, 2005).


Obstentrics_Williams

Obstentrics_Williams. The NuvaRing is yet another form of combination hormonal contraception and is a lexible intravaginal ring. he ring is constructed of ethinyl vinyl acetate, and it measures 54 mm in diameter and 4 mm in cross section (Fig. 38-5). During FIGURE 38-5 NuvaRing: estrogen-progestin-releasing vaginal contraceptive ring. insertion, the ring is compressed and threaded into the vagina, but no specific final orientation within the vagina is required. Its core releases ethinyl estradiol and the progestin etonogestrel, which are absorbed across the vaginal epithelium. Before being dispensed, the rings are refrigerated, and once dispensed, their shelflife is 4 months. he ring is placed within 5 days of menses onset and, after 3 weeks of use, is removed for 1 week to allow withdrawal bleeding. Contraception will still be aforded if a ring is left in place for a fourth week (Merck, 2016b).


Obstentrics_Williams

Obstentrics_Williams. Patient satisfaction is high with this method, although vagi nitis, ring-related events, and leukorrhea are more common (Lopez, 2013b; Oddsson, 2005). Despite this, no deleterious been found (Lete, 2013; Veres, 2004). A ring may be used con currently with vaginal medications or with a tampon (Haring, 2003; Verhoeven, 2004a,b). Approximately 70 percent of part ners feel the ring during intercourse (Dieben, 2002). If this is bothersome, the ring may be removed for intercourse but should be replaced within 3 hours to maintain eicacy.


Obstentrics_Williams

Obstentrics_Williams. Both intramuscular depot medroxyprogesterone acetate-DepoProvera (DMPA)-150 mg every 3 months, and norethisterone enanthate, 200 mg every 2 months, are injectable progestin contraceptives used worldwide. Of the two, DMPA is available in the United States. DMPA is injected into the deltoid or gluteus muscle, but massage is avoided to ensure that the drug is released slowly. lternatively, a subcutaneous version, depo-subQprovera 104, is also available and is injected into the subcutaneous tissue of the anterior thigh or abdomen every 3 months.


Obstentrics_Williams

Obstentrics_Williams. DMPA is efective, and as with other progestin-only methods, contraception is provided by ovulation inhibition, greater cervical mucus viscosity, and creation of an endometrium unfavorable for ovum implantation. Initial injection is given within the irst 5 days following menses onset. Serum levels suicient for contraception are observed by 24 hours. Thus, no additional contraceptive method is required for initiation within this window. Alternatively, limited data support a "quick weart," or initiation of DMPA regardless of cycle day. If so implemented, investigators recommend an initial negative pregnancy test result before injection, a supplemental contraceptive method during the 7 days following injection, and a second pregnancy test after 3 to 6 weeks to identiy an early pregnancy (Rickert, 2007; Sneed, 2005). Pregnancies conceived during DMPA use are not associated with a higher risk of fetal malformation (Katz, 1985). For women who present for intramuscular DMPA reinjection more


Obstentrics_Williams

Obstentrics_Williams. 2007; Sneed, 2005). Pregnancies conceived during DMPA use are not associated with a higher risk of fetal malformation (Katz, 1985). For women who present for intramuscular DMPA reinjection more than 13 weeks or for subcutaneous DMPA reinjection more than 14 weeks ater the prior dose, the manufacturer recommends exclusion of pregnancy before reinjection (Pfizer, 2015a,b).


Obstentrics_Williams

Obstentrics_Williams. Injected progestins ofer the convenience of a 3-month dosing schedule, contraceptive eicacy comparable with or better than COCs, and minimal to no lactation impairment. Irondeiciency anemia is less likely in long-term users because of amenorrhea, which develops in up to 50 percent after 1 year and in 80 percent after 5 years. Similar to other progestin-only contraceptive, irregular menstrual bleeding is common, and a fourth of women dis continued DVIPA in the irst year because of this (Cromer, 1994). Unique to DMPA, prolonged anovulation can follow discontinuation, which results in delayed fertility resumption. After injections are stopped, a fourth of patients do not resume regular menses for up to 1 year (Gardner, 1970). Accordingly, DMPA may not be ideal for women who plan to use birth control only brieRy before attempting conception.


Obstentrics_Williams

Obstentrics_Williams. DMPA may not be ideal for women who plan to use birth control only brieRy before attempting conception. As with other progestins, DMPA has not been associ ated with cardiovascular events or stroke in otherwise healthy women. However, in those with severe hypertension, a higher risk of stroke has been found in DMPA users (World Health Organization, 1998). Moreover, the US MEC authors express levels from DMPA in women with vascular disease or multiple risks for cardiovascular disease.


Obstentrics_Williams

Obstentrics_Williams. Weight gain is generally attributed to DMPA, and these increases are comparable between the two depot forms (Bahamondes, 2001; Vickery, 2013; Westhof, 2007c). In long-term users, loss of bone mineral density is also a potential problem (Petitti, 2000; Scholes, 1999). In 2004, the FDA added a black box warning to DMPA labeling, which notes that this concern is probably most relevant for adolescents, who are building bone mass, and perimenopausal women, who will soon have increased bone loss during menopause. That said, World Health Organization (1998) and American College of Obstetricians and Gynecologists (20 16b) believe that DMPA should not be restricted in those high-risk groups. And, it seems prudent to reevaluate overall risks and beneits during extended use. It is somewhat reassuring that bone loss appears to be reversible after discontinuation of therapy, although reversal is still not complete after 18 to 24 months (Clark, 2006; Scholes, 2002).


Obstentrics_Williams

Obstentrics_Williams. So-called mini-pils are progestin-only contraceptives that are taken daily. hese contraceptives have not achieved widespread popularity and are used by only 0.4 percent of reproductive-aged American women (Hall, 2012). Unlike COCs, they do not reliably inhibit ovulation. Rather, their efectiveness depends more on cervical mucus thickening and endometrial atrophy. Because mucus changes are not sustained longer than 24 hours, mini-pills should be taken at the same time every day to be maximally efective. If a progestin-only pill is taken even 4 hours late, a supplemental form of contraception must be used for the next 48 hours. Progestin-only pills are contraindicated in women with known breast cancer or pregnancy. Other cautions are listed in Table 38-2. For many years, male and female condoms, vaginal diaphragms, and periodic abstinence have been used for contraception with variable success (see Table 38-2). When used properly, condoms


Obstentrics_Williams

Obstentrics_Williams. For many years, male and female condoms, vaginal diaphragms, and periodic abstinence have been used for contraception with variable success (see Table 38-2). When used properly, condoms FIGURE 38-6 FC2 Female Condom insertion and positioning. A. diaphragm. B. The inner ring is pushed inward with an index finger. provide considerable but not absolute protection against a broad range of sexually transmitted diseases, including HIV (Eaton, 2014). Contraceptive eicacy of the male condom is enhanced appreciably by a reservoir tip and probably by the addition of a spermicide. Such agents, as well as those used for lubrication, should be water-based because oil-based products degrade latex condoms and diaphragms.


Obstentrics_Williams

Obstentrics_Williams. For individuals sensitive to latex, condoms made from lamb intestines are efective, but they do not provide infection protection. Fortunately, nonallergenic condoms have been developed that are made of polyurethane or of synthetic elastomers. Polyurethane condoms are efective against STDs but have a higher breakage and slippage rate compared with latex condoms (Gallo, 2012a).


Obstentrics_Williams

Obstentrics_Williams. The only female condom available in the United States is marketed as the FC2 Female Condom. It is a synthetic nitrile sheath with one lexible polyurethane ring at each end. Its open ring remains outside the vagina, whereas its closed internal ring is fitted under the symphysis like a diaphragm (Fig. 38-6). The female condom can be used with both water-based and oilbased lubricants. Male condoms should not be used concurrently because simultaneous use may cause friction that leads to condom slipping, tearing, and displacement. Following use, the female condom outer ring should be twisted to seal the condom so that no semen spills. As an added value, the female condom may ofer some protection against STDs (Minnis, 2005). The diaphragm consists of a circular latex dome of variable diameter supported by a circumferential latex-covered metal spring. It is efective when used in combination with spermicidal


Obstentrics_Williams

Obstentrics_Williams. The inner ring is squeezed for insertion. The sheath is inserted similarly to a jelly or cream. The spermicide is applied into the dome cup and along the device rim. The diaphragm is then positioned so that the cup faces the cervix and that the cervix, vaginal fornices, and anterior vaginal wall are partitioned efectively from the remainder of the vagina and the penis. In this fashion, the centrally placed spermicide is held against the cervix. When appropriately positioned, one rim is lodged deep in the posterior vaginal fornix, and the opposite rim its behind the inner surface of the symphysis and immediately below the urethra (Fig. 38-7). If a diaphragm is too small, it will not remain in place. If it is too large, it is uncomfortable when forced into position. A coexistent cystocele or uterine prolapse typically leads to instability and expulsion. Because size and spring flexibility must be individualized, the diaphragm is itted by


Obstentrics_Williams

Obstentrics_Williams. FIGURE 38-7 A diaphragm in place creates a physical barrier between the vagina and cervix. providers and available only by prescription. For use, the diaphragm and spermicide can be inserted hours before intercourse. If more than 6 hours elapse, the diaphragm can remain but additional spermicide is placed in the upper vagina for maximum protection. Spermicide is reapplied before each subsequent coital episode. The diaphragm is not removed for at least 6 hours after intercourse. Because toxic shock syn drome has been described following its use, it may be worth while to remove the diaphragm at 6 hours, or at least the next morning, to minimize this rare event. Diaphragm use is associ ated with a slightly greater rate of urinary infections, presumably from urethral irritation by the ring under the symphysis.


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Obstentrics_Williams. FemCap is currently the only available cervical cap in the United States. Made of silicone rubber, it has a sailor-cap shape with a dome that covers the cervix and a lared brim, which allows the cap to be held in place by the muscular walls of the upper vagina. Available in 22-, 26-, and 30-mm sizes, it is used with a spermicide applied once at insertion to both sides of the dome cup. For contraception, it should remain in place for 6 hours following coitus and may remain for up to 48 hours. Even with proper itting and correct use, pregnancy rates with this method are higher that with the diaphragm (Gallo, 2012b; Mauck, 1999).


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Obstentrics_Williams. These family planning methods attempt to identiY the fertile days each cycle and advise sexual abstinence during these days. Their major drawback is their limited eicacy, which is shown in Table 38-1r. Common forms of these fertility awarenessbased (FAB) methods include Standard Days, Temperature Rhythm, Cervical Mucus, and Symptothermal Methods. Some smartphone applications aim to assist these practices (Fehring, 2013). he Standard Days Method counsels women to avoid unprotected intercourse during cycle days 8 through 19. For successful use, women must have regular monthly cycles of 26 to 32 days. hose who use this method can mark a calendar or can use Cycle-Beads, which is a ring of counting beads, to keep track of their days.


Obstentrics_Williams

Obstentrics_Williams. he Temperature Rhythm Method relies on a sustained O.4°F rise in the basal body temperature, which usually precedes ovulation. For maximum eicacy, the woman must abstain from intercourse from'the irst day of menses through the third day after the temperature increase. he Cervical Mucus Method, also called the Two-Day Method or Billings Method, relies on awareness of vaginal "dryness" and "wetness." hese reflect changes in the amount and quality of cervical mucus at diferent times in the menstrual cycle. With the Billings Method, abstinence is required from the beginning of menses until 4 days after slippery mucus is identified. With the T wo-Day Method, intercourse is considered safe if a woman did not note mucus on the day of planned intercourse or the day prior.


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Obstentrics_Williams. he Symptothermal Method combines changes in cervical mucus-onset of fertile period; changes in basal body temperature-end of fertile period; and calculations to estimate the time of ovulation. This method is more complex to learn and apply, but it does not appreciably improve eicacy. These contraceptives are marketed variously as creams, jellies, suppositories, films, and aerosol foam. \10st can be purchased without a prescription. They are considered a less efective method (see Table 38-1). If pregnancy does occur, they are not teratogenic (Briggs, 2015).


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Obstentrics_Williams. Typically, spermicides function by providing a physical barrier to sperm penetration and a chemical spermicidal action. The active ingredient is nonoxynol-9 or octoxynol-9. Although these are spermicidal, they do not provide STD protection. Ideally, spermicides must be deposited high in the vagina in contact with the cervix shortly before intercourse. Their duration of maximal efectiveness is usually no more than 1 hour, and thereafter, they must be reinserted before repeat intercourse. Douching is avoided for at least 6 hours after coitus.


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Obstentrics_Williams. The Today contraceptive sponge is an over-the-counter, onesize-fits-all device. The nonoxynol-9-impregnated polyurethane disc is 2.5 cm thick and 5.5 cm wide and has a dimple on one side and satin loop on the other (Fig. 38-8). The sponge can be inserted up to 24 hours prior to intercourse, and while in place, it provides contraception regardless of coital frequency. It should remain in place for 6 hours after intercourse. Pregnancy is prevented primarily by the spermicide nonoxynol-9 and to a lesser extent by covering the cervix and absorbing semen. FIGURE 38-8 Today sponges. The sponge is moistened with tap water and gently squeezed to create light suds. It is then tioned with the dimple directly against the cervix. The fabric loop trails within the vagina and can be hooked with a finger to later extract the sponge. TABLE 38-3. Methods Available for Use as Emergency Contraception Pills per Number of COC Pillsb,c aDoses taken 12 hours apart if multiple.


Obstentrics_Williams

Obstentrics_Williams. TABLE 38-3. Methods Available for Use as Emergency Contraception Pills per Number of COC Pillsb,c aDoses taken 12 hours apart if multiple. bOther COC brands with formulations identical to those above may also be used. (Use of an antiemetic agent before taking the medication will lessen the risk of nausea, which is a common side effect. COC = combination oral contraceptive; EE = ethinyl estradiol; IUD = intrauterine device; LNG = levonorgestrel; PRM = progesterone-receptor modulator.


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Obstentrics_Williams. COC = combination oral contraceptive; EE = ethinyl estradiol; IUD = intrauterine device; LNG = levonorgestrel; PRM = progesterone-receptor modulator. Although the sponge is possibly more convenient than the diaphragm or condom, it is less efective than either (Kuyoh, 2013). Most common causes for method discontinuance are pregnancy, irritation, discomfort, or vaginitis (Beckman, 1989). Although toxic shock syndrome has been reported with the contraceptive sponge, it is rare, and evidence suggests that the sponge may actually limit production of the responsible staphylococcal exotoxin (Remington, 1987). Still, it is recommended that the sponge not be used during menses or the puerperium.


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Obstentrics_Williams. Following unprotected sexual intercourse, many women present for contraceptive care. Several emergency contraception (EC) regimens substantially lower the likelihood of an unwanted pregnancy when used correctly. Current methods include COCs, progestins, progesterone antagonists, and copper-containing IUDs (Table 38-3). Overall, the IUD is most efective, and ulipristal acetate is the most eicient oral regimen (American College of Obstetricians and Gynecologists, 2017a). Patients can obtain information regarding emergency contraception by calling 1-888-NOT-2-LATE or accessing The Emergency Contraception Website: http://not-2-late.com.


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Obstentrics_Williams. Except for allergy to a particular component, no conditions in the US MEC contraindicate hormonal EC methods. With progestin-only regimens, levonorgestrel is taken as a single, onetime 1.5-mg dose (Arowojolu, 2002). his is now recommended instead of two 0.75-mg doses separated by 12 or 24 hours (Ngai, 2005). Dosing begins ideally within 72 hours of unprotected coitus but may be given up to 120 hours. Notably, the singledose regimen is available over-the-counter without a prescription to all reproductive-aged women (Food and Drug Administration, 2013,r2015a). One progesterone-receptor modulator currently available for EC is ulipristal acetate and is marketed as Ela. It is taken as a single 30-mg tablet up to 120 hours after unprotected intercourse (Brache, 2010; Watson, 2010).


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Obstentrics_Williams. Also known as the Yuzpe method, this older EC method provides a minimum of 100 jLg of ethinyl estradiol and 0.5 mg of levonorgestrel in each of two doses. As shown in Table 38-3, a suicient dose may be achieved by two or more pills. he first dose is taken ideally within 72 hours of intercourse but may be given up to 120 hours. The initial dose is followed 12 hours later by a second equivalent dose. The major mechanism with all hormonal regimens is inhibition or delay of ovulation. Of oral methods, failure rates are lowest with ulipristal (1 to 2 percent) and greatest with the Yuzpe method (2 to 3.5 percent) (Cleland, 2014). IfEC fails to prevent pregnancy or is mistimed, no associations with major congenital malformation or pregnancy complications have been noted with these hormonal methods (Jatlaoui, 2016; Levy, 2014).


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Obstentrics_Williams. With EC administration, nausea and vomiting can be an important side efect (American College of Obstetricians and Gynecologists, 2015b; Gemzell-Danielsson, 2013). Accordingly, an oral antiemetic may be prescribed at least 1 hour before each dose (Rodriguez, 2013). If a woman vomits within 2 hours of a dose, the dose is repeated. For women who are candidates, Cu-IUD insertion is the most efective emergency contraceptive method and provides an efective 10-year method of contraception (Cheng, 2012). If an IUD is placed up to 5 days after unprotected coitus, the failure rate approximates only 0.1 percent (Cleland, 2012; Wu, 2010).


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Obstentrics_Williams. For mothers who are nursing exclusively, ovulation during the irst 10 weeks after delivery is unlikely. Nursing, however, is not a reliable method of family planning for women whose infants are on a daytime-only feeding schedule. Moreover, waiting for first menses involves a risk of pregnancy, because ovulation usually antedates menstruation. Certainly, after the first menses, contraception is essential unless the woman desires pregnancy. As shown in Table 38-2, all methods may be suitable for nursing mothers after the initial weeks, during which thromboembolism risks are still great. With all hormonal methods, very small quantities are excreted in breast milk, but no adverse efects on infants have been reported (Phillips, 2015; World Health Organization, 1988). Although not robust, some older studies link decreased infant weight gain or milk volume with early initiation of combination oral contraceptives before 6 weeks postpartum (Lopez, 2015c; Tepper, 2016a).


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Obstentrics_Williams. Abdel-Aleem H, d'Arcangues C, Vogelsong M, et al: Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev 10:CD003449, 2013 Abrams LS, Skee OM, Wong FA, et al: Pharmacokinetics of norelgestromin and ethinyl estradiol from two consecutive contraceptive patches. J Clin PharmacoIn41:1232,n2001 Aksoy H, Aksoy U, Ozyurt S, et al: Lidocaine 10% spray to the cervix reduces pain during intrauterine device insertion: a double-blind randomised controlled trial. J Fam Plann Reprod Health Care 42(2):83,2016 American College of Obstetricians and Gynecologists: Brand versus generic oral contraceptives. Committee Opinion No. 375, August , Reairmed 2015a American College of Obstetricians and Gynecologists: Emergency contraception. Practice Bulletin No. 152, September 2015b


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Committee Opinion No. 642, October 2015c American College of Obstetricians and Gynecologists: Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539, October 2012, Reairmed 2016a American College of Obstetricians and Gynecologists: Depot medroxyprogesterone acetate and bone efects. Committee Opinion No. 602, June 2014, Reairmed 2016b American College of Obstetricians and Gynecologists: Noncontraceptive use of hormonal contraceptives. Practice Bulletin No. 110, January 2010, Reafirmed 2016c American College of Obstetricians and Gynecologists: Prevention of deep vein thrombosis and pulmonary embolism. Practice No. 84, August 2007, Reairmed 2016d American College of Obstetricians and Gynecologists: Access to emergency contraception. Committee Opinion No. 707, July 2017a


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Obstentrics_Williams. No. 84, August 2007, Reairmed 2016d American College of Obstetricians and Gynecologists: Access to emergency contraception. Committee Opinion No. 707, July 2017a American College of Obstetricians and Gynecologists: Beneits and risks of sterilization. Practice Bulletin No. 133, February 2013, Reairmed 2017b American College of Obstetricians and Gynecologists: Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 186, November 2017c Anttila L, Bachmann G, Hernadi L, et a1: Contraceptive eicacy of a combined oral contraceptive containing ethinyl oestradiol 20 !lg/drospirenone 3 mg administered in a 24/4 regimen: a pooled analysis of four open-label studies. Eur J Obstet Gynecol Reprod BioI 155(2):180,n2011 Aoun J, Dines VA, Stovall OW, et al: Efects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 123(3):585,n2014


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Obstentrics_Williams. Aoun J, Dines VA, Stovall OW, et al: Efects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 123(3):585,n2014 Apter 0, Gemzell-Danielsson K, Hauck B, et al: Pharmacokinetics of two lowdose levonorgestrel-releasing intrauterine systems and efects on ovulation rate and cervical function: pooled analyses of phase II and III studies. Ferti! Steriln101(6):1656,n2014 Arowojolu AO, Okewole A, Adekunle AO: Comparative evaluation of the efectiveness and safety of two regimens oflevonorgestrel for emergency contraception in Nigerians. Contraception 66(4):269, 2002 Backman T, Rauramo I, Huhtala S, et al: Pregnancy during the use of levonorgesrrel intrauterine system. Am J Obstet Gynecol 190(1):50, 2004


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Obstentrics_Williams. Backman T, Rauramo I, Huhtala S, et al: Pregnancy during the use of levonorgesrrel intrauterine system. Am J Obstet Gynecol 190(1):50, 2004 Bahamondes L, Brache V, Meirik 0, et a1: A 3-year multicentre randomized controlled trial of etonogestrel-and levo-norgestrel-releasing contraceptive implants, with non-randomized matched copper-intrauterine device controls. Hum Reprod 30(11):2527,n2015 Bahamondes L, Del Castillo S, Tabares G: Comparison of weight increase in users of depot medroxyprogesterone acetate and copper IUD up to 5 years. Contraception 64(4):223, 2001 Bayer Group: Jadelle: data sheet. 2015. Available at: http://www.medsafe.govt. nz/profs/datasheet/jIJadelleimplant.pdf. Accessed October 11n,n2016 Bayer HealthCare Pharmaceuticals: Yaz: highlights of prescribing information. 2015. Available at: http://labeling.bayerhealthcare.com/htmllproducts/pil fhclYAZ_Pl.pdf. Accessed October 11,n2016


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Obstentrics_Williams. Bayer HealthCare Pharmaceuticals: Yaz: highlights of prescribing information. 2015. Available at: http://labeling.bayerhealthcare.com/htmllproducts/pil fhclYAZ_Pl.pdf. Accessed October 11,n2016 Beckman LJ, Murray J, Harvey SM: he contraceptive sponge: factors in initiation and discontinuation of use. Contraception 40:481, 1989 Bednarek PH, Creinin MD, Reeves MF, et a1: Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med 364(23):2208, 2011 Bednarek PH, Creinin MD, Reeves MF, et a1: Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial. Contraception 91(3):193, 2015 Birgisson NE, Zhao Q, Secura GM, et al: Positive testing for Neisseria gonorrhoeae and Chlamydia trachomatis and the risk of pelvic inlammatory disease in IUD users. J Womens Health 24(5):354, 2015


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Obstentrics_Williams. Birgisson NE, Zhao Q, Secura GM, et al: Positive testing for Neisseria gonorrhoeae and Chlamydia trachomatis and the risk of pelvic inlammatory disease in IUD users. J Womens Health 24(5):354, 2015 Boortz HE, Margolis OJ, Ragavendra N, et al: Migration of intrauterine devices: radiologic indings and implications for patient care. Radiographies 32(2):335,n2012 Bosetti C, Bravi F, Negri E, et a1: Oral contraceptives and colorectal cancer risk: a systematic review and meta-analysis. Hum Reprod Update 15(5):489,2009 Brache V, Cochon L, J esam C, et al: Immediate pre-ovulatory administration of 30 mg ulipristal acetate significantly delays follicular rupture. Hum Reprod 25(9):2256, 2010 Briggs GG, Freeman RK: Drugs in Pregnancy and Lactation, 10th ed. Philadelphia, Wolters K1uwer, 2015


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Obstentrics_Williams. Briggs GG, Freeman RK: Drugs in Pregnancy and Lactation, 10th ed. Philadelphia, Wolters K1uwer, 2015 Buhling KJ, Zite NB, Lotke P, et a1: Worldwide use of intrauterine contraception: a review. Contraception 89(3):162, 2014 Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines, 2015. MMWR 64(3):1,2015 Chan WS, Ray J, Wai EK, et al: Risk of stroke in women exposed to low-dose oral contraceptives: a critical evaluation of the evidence. Arch Intern Med 164:741,n2004 Chasan-Taber L, Willett WC, Manson JE, et al: Prospective study of oral contraceptives and hypertension among women in the United States. Circulation 94:483, 1996 Chen BA, Reeves MF, Hayes JL, et al: Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 116(5):1079,2010 Cheng L, Che Y, Gulmezoglu AM: Interventions for emergency contraception. Cochrane Database Syst Rev 2:CDOOI324, 2012


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Obstentrics_Williams. Cheng L, Che Y, Gulmezoglu AM: Interventions for emergency contraception. Cochrane Database Syst Rev 2:CDOOI324, 2012 Cibula 0, Gompel A, Mueck AO, et al: Hormonal contraception and risk of cancer. Hum Reprod Update 16(6):631,n2010 Ciet P, Litmanovich DE: MR safety issues particular to women. Magn Reson Imaging Clin N Am 23(1):59, 2015 Civic 0, Scholes 0, Ichikawa L, et al: Depressive symptoms in users and nonusers of depot medroxyprogesterone acetate. Contraception 61 (6):385,02000 Clark MK, Sowers M, Levy B, et al: Bone mineral density loss and recovery during 48 months in irst-time users of depot medroxyprogesterone acetate. Fertil Steril 86: 1466, 2006 Cleland K, Raymond EG, Westley E, et al: Emergency contraception review: evidence-based recommendations for clinicians. Clin Obstet Gynecol 57(4): 741,n2014


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Obstentrics_Williams. Cleland K, Raymond EG, Westley E, et al: Emergency contraception review: evidence-based recommendations for clinicians. Clin Obstet Gynecol 57(4): 741,n2014 Cleland K, Zhu H, Goldstuck N, et al: he eicacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 27(7):1994, 2012 Cole JA, Norman H, Doherty M, et al: Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstet Gynecol 109:339,n2007 Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, et al: Ovarian cancer and oral contraceptives: collaborative reanalysis of data of 45 epidemiological studies including 23,25 women with ovarian cancer and 87,303 controls. Lancet 371:303, 2008


Obstentrics_Williams

Obstentrics_Williams. Collaborative Group on Hormonal Factors in Breast Cancer: Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet 347: 1 13, 1996 Correia L, Ramos AB, Machado AI, et al: Magnetic resonance imaging and gynecological devices. Contraception 85(6):538, 2012 Cromer BA, Smith RD, Blair JM, et al: A prospective study of adolescents who choose among levonorgestrel implant (Norplant), medroxyprogesterone acetate (Depo-Provera), or the combined oral contraceptive pill as contraception. Pediatrics 94:687, 1994


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Obstentrics_Williams. Croxatto HB, Makirainen L: he pharmacodynamics and eicacy of Implanon. An overview of the data. Contraception 58:915, 1998 Curtis EM, Pine L: Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Am J Obstet Gynecol 140:880, 1981 Curtis M,Jadaoui TC, Tepper NK, et al: U.S. selected practice recommendations for contraceptive use, 2016. MMWR 65(4):1, 2016a Curtis KM, Tepper NK, Jadaoui TC, et al: U.S. medical eligibility criteria for contraceptive use, 2016. MMWR 65(3):1, 2016b Daniels K, Daugherty J, Jones J, et al: Current contraceptive use and variation by selected characteristics among women aged 15-44: United States, 2011-2013. Nat! Health Stat Report 86:1, 2015 Dieben TO, Roumen FJ, Apter 0: Eicacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol 100:585,2002 Dorlinger LJ: Metabolic efects of implantable steroid contraceptives for women. Contraception 65(1):47, 2002 Dragoman M, Curtis M, Gaield


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Obstentrics_Williams. contraceptive vaginal ring. Obstet Gynecol 100:585,2002 Dorlinger LJ: Metabolic efects of implantable steroid contraceptives for women. Contraception 65(1):47, 2002 Dragoman M, Curtis M, Gaield ME: Combined hormonal contraceptive use among women with known dyslipidemias: a systematic review of critical safety outcomes. Contraception 94(3):280, 2016 Drey EA, Reeves MF, Ogawa DO, et al: Insertion of intrauterine contraceptives immediately following first-and second-trimester abortions. Contraception 79(5):397, 2009 Eaton EF, Hoesley CJ: Barrier methods for human immunodeiciency virus prevention. Infect Dis Clin North Am 28(4):585,n2014 Edelman A, Micks E, Gallo MF, et al: Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst Rev 7:CD004695, 2014 ESHRE Capri Workshop Group: Venous thromboembolism in women: a speciic reproductive health risk. Hum Reprod Update 19(5):471,n2013 Etminan M, Takkouche B, Isorna FC, et al: Risk


Obstentrics_Williams

Obstentrics_Williams. Rev 7:CD004695, 2014 ESHRE Capri Workshop Group: Venous thromboembolism in women: a speciic reproductive health risk. Hum Reprod Update 19(5):471,n2013 Etminan M, Takkouche B, Isorna FC, et al: Risk ofischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies. BMJ 330:63, 2005 European Society of Human Reproduction and Embryology-ESHRE Capri Workshop Group: Ovarian and endometrial function during hormonal contraception. Hum Reprod 16(7):1527,n2001 Farley TM, Rosenberg MJ, Rowe PJ, et al: Intrauterine devices and pelvic inlammatory disease: an international perspective. Lancet 339: 85, 1992 Fehring RJ, Schneider M, Raviele K, et al: Randomized comparison of two internet-supported fertility-awareness-based methods of family planning. Contraception 88(1):24, 2013 Ferguson CA, Costescu 0, Jamieson MA, et al: Transmural migration and perforation of a levonorgestrel intrauterine system: a case report and review of the literature. Contraception


Obstentrics_Williams

Obstentrics_Williams. 88(1):24, 2013 Ferguson CA, Costescu 0, Jamieson MA, et al: Transmural migration and perforation of a levonorgestrel intrauterine system: a case report and review of the literature. Contraception 93(1):81, 2016 FHI 360: Sino-implant (II) project. 2012. Available at: https:llwww.urbanreproductivehealth.org/sites/mle/iles/hi360_factsheecsino-implanc5.30.2012. pd. Accessed July 1, 2016 Finer LB, Zolna MR: Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med 374(9):843, 2016 Food and Drug Administration: Citizen petition partial approval and denial response from FDA COER to state of Wisconsin (Department of Justice). 2015a. Available at: https:llwww.regulations.gov/document?D = FDA2001-P-0123-0188. Accessed October 10, 2016 Food and Drug Administration: FDA approves Plan B One-Step emergency contraceptive for use without a prescription for all women of child-bearing potential. 2013. Available at: http://www.fda.gov/NewsEvents/Newsroom/


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Obstentrics_Williams. FDA approves Plan B One-Step emergency contraceptive for use without a prescription for all women of child-bearing potential. 2013. Available at: http://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm358082.htm. Accessed June 21, 2016 Food and Drug Administration: FDA Drug Safety Communication: Updated information about the risk of blood clots in women taking birth control pills containing drospirenone. 2012. Available at: http://www.fda.gov/Drugsl DrugSafety/ucm299305.htm. Accessed July 7,n2016 Food and Drug Administration: FDA MedWatch 2004 Safety Alert-DepoProvera (medroxyprogesterone acetate injectable suspension). 2004. Available at: http://www.fda.gov/Safety/MedWatch/Safetylnformation/SafetyAlertsforHumanMedicalProducts/ucm154784.htm. Accessed October 10, 2016


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Obstentrics_Williams. Food and Drug Administration: Orange book: approved drug products with therapeutic equivalence evaluations. 2016. Available at: http://www.accessdata.fda.gov/scripts/cderlob/defaulr.cfm. Accessed October 10, 2016 Food and Drug Administration: Ortho Evra (norelgestrominl ethinyl estradiol) transdermal system. 2015b. Available at: http://www.fda.gov/Safety/Med �latch/SafetyInformation/ucm211821.htm. Accessed July 7,n2016 Fox Me, Oat-Judge J, Severson K, et al: Immediate placement of intrauterine devices after irst and second trimester pregnancy termination. Contraception 83(1):34, 2011 Fulkerson Schaefer 5, Gimovsky Ae, et al: Pregnancy and delivery with an intrauterine device in situ: outcomes in the National Inpatient Sample Database. J Matern Fetal Neonatal Med October 26, 201 [Epub ahead of print] Furlong A: Ecropic pregnancy risk when contraception fails. J Reprod Med 47:881, 2002


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Obstentrics_Williams. Furlong A: Ecropic pregnancy risk when contraception fails. J Reprod Med 47:881, 2002 Gallo MF, Grimes DA, Lopez LM, et al: Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev 1 :CD003550, 2006, Reassessed 2012a Gallo MF, Grimes DA, Schulz KF: Cervical cap versus diaphragm for contraception. Cochrane Database Syst Rev 4:CD003551, 2002, Reassessed 2012b Gallo MF, Lopez LM, Grimes DA, et al: Combination contraceptives: efects on weight. Cochrane Database Syst Rev 1:CD003987, 2014 Gardner JM, Mishell DR Jr: Analysis of bleeding patterns and resumption of fertility following discontinuation of a long-acting injectable contraceptive. Fertil Steril 21 :286, 1970 Gemzell-Danielsson K, Rabe T, Cheng L: Emergency contraception. Gynecol Endocrinol 29 Suppl 1: 1, 2013


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Obstentrics_Williams. Gemzell-Danielsson K, Rabe T, Cheng L: Emergency contraception. Gynecol Endocrinol 29 Suppl 1: 1, 2013 Gemzell-Danielsson K, Schellschmidt I, Apter 0: A randomized, phase II study describing the eicacy, bleeding proile, and safety of two low-dose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertil Steril 97(3):616, 2012 Godfrey EM, Folger SG, Jeng G, et al: Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review. Contraception 87(5):549,n2013 Grimes DA, Jones LB, Lopez LM, et al: Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev 4:CD006134, 2014 Grimes DA, Schulz KF: Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev 2:CD001327, 2001, Reaffirmed 2012 Grunloh OS, Casner T, Secura GM, et al: Characteristics associated with discontinuation of long-acting reversible contraception within the irst 6 months of use. Obstet Gynecol 122(6):1214,n2013