Contraception - Management of Normal and Altered Female Reproductive Function

CONTRACEPTION

Each year, more than half of the pregnancies in the United States are unintended (Centers for Disease Control and Prevention, 1999). Although unintended pregnancies occur in women of all ages, incomes, and racial and ethnic groups, the highest rates occur among adolescents, lower-income women, and African-American women (U.S. Surgeon General, 2001). Adolescents are more likely to experience pregnancy complications and are more prone to have low-birthweight babies. Teen mothers are less likely to obtain a high school diploma and are more likely to live in poverty. Of women undergoing abortions, many did not use contraception in the month they became pregnant, while others never use any method. It seems that women often fail to use ef-fective methods consistently or at all. Nurses can assist with in-formation and support. Women sometimes fear that they will get cancer and fear other risks from contraception. Women often re-port using their contraceptive method inconsistently, which makes all methods less effective.

Many women who are sexually active or who are considering becoming sexually active can benefit from learning about contra-ception. Fewer unwanted pregnancies may reduce the number of abortions, abused children, stressed families, and infant mortal-ity and morbidity. It is important that women receive unbiased and nonjudgmental information, understand the benefits and risks of each method, learn about alternatives and how to use them, and receive positive reinforcement and acceptance of their choice.

Nurses involved in helping patients make contraceptive choices need to listen, educate, spend time answering questions, and assist patients in choosing the method they prefer. Methods and prac-tices to prevent unwanted or unplanned pregnancies and births.

Abstinence

Abstinence, or celibacy, is the only completely effective means of preventing pregnancy. Abstinence may not be a desired or avail-able option for many women because of cultural expectations and their own and their partner’s values and sexual needs

Sterilization

After abstinence, sterilization by bilateral tubal occlusion or va-sectomy is the most effective means of contraception. Both pro-cedures must be considered permanent because neither is easily reversible. Women and men who choose these methods should be certain that they have completed their childbearing, no mat-ter how the circumstances in their life may change. Often, deci-sions are made that may be regretted later. Some gynecologists suggest a waiting period to ensure that the patient is certain about a potentially irreversible decision.

TUBAL LIGATION

Female sterilization by tubal ligation is one of the most common operations performed on women. More than 600,000 tubal li-gations are performed in the United States every year ( Jamieson, Hillis, Duerr et al., 2000). Tubal ligation is usually performed as a same-day surgical procedure. The procedure is carried out by la-paroscopy, with the patient receiving a general or local anesthetic. The laparoscope, a small periscope-like optical instrument, is in-serted through a small umbilical incision. Carbon dioxide is in-troduced to lift other abdominal organs away from the tubal area. The fallopian tubes are visualized and may be coagulated, sutured (Pomeroy procedure), or ligated with a rubber band or a spring clip, thereby disrupting their patency. Many sterilizations are per-formed with bipolar coagulation. Silicone bands and spring clips are also being used. Spring clips have the highest rate of pregnancy following sterilization. A new procedure, selective tubal occlusion procedure, uses a 0.6-inch metal coil or spring that is inserted into the fallopian tubes through the cervix, thus avoiding the need for laparoscopy or a surgical incision (Association of Reproductive Health Professionals, 2002). This method works by inducing ob-struction of the tubes by scar tissue.

Despite a very high rate of effectiveness, any woman who has undergone tubal ligation but misses a period should be tested for pregnancy because ectopic and intrauterine pregnancies, although rare, may occur. Ovulation and menstruation are not affected by sterilization, although some women report heavier menstrual bleeding and more cramping after tubal ligation. Vasectomy and laparoscopic tubal ligation are compared in Chart 46-11.

Before undergoing tubal ligation, the patient should be in-formed that an IUD, if present, will be removed. If the patient is taking oral contraceptives, she usually continues them up to the time of the procedure. Postoperatively, women may experience abdominal or shoulder discomfort for a few days, related to the carbon dioxide gas and the manipulation of organs. The woman is instructed to report heavy bleeding, fever, or pain that persists or increases. The patient should avoid intercourse, strenuous ex-ercise, and lifting for 2 weeks. Risks of the procedure are minimal and are more often related to the anesthesia than to the surgery itself. Risk is increased in women with diabetes, previous ab-dominal or pelvic surgery, or obesity.

Oral Contraceptives

Oral contraceptive preparations of synthetic estrogen (estradiol) and progesterone (desogestrel, ethynodiol diacetate, lev-onorgestrel, norethindrone, norethindrone acetate or norgestrel) are currently used by many women. They block ovarian stimula-tion by preventing the release of FSH from the anterior pituitary gland. In the absence of FSH, a follicle does not ripen, and ovu-lation does not occur. This is the mechanism of action of oral contraceptives. Progestins (synthetic forms of progesterone) sup-press the LH surge, prevent ovulation, and also render the cervi-cal mucus impenetrable to sperm. Synthetic estrogens and progestin, found in the many oral contraceptive variations avail-able, differ in androgenic activity (Chart 46-12).

BENEFITS AND RISKS

In general, no definite long-term undesirable effects have been ob-served with prolonged oral contraceptive use. Resumption of normal menses is delayed 2 to 3 months in about 20% of oral con-traceptive users. Venous thromboembolism has occurred with use of oral contraceptives, but it occurs less now than years ago, when estrogen concentrations in oral contraceptives were higher. Ve-nous thromboembolism is less than half as likely to occur with oral contraceptives than with pregnancy. Desogestrel, a new progestin, may be slightly more likely to be associated with venous throm-boembolism, but the risk is still very low. 

Gallbladder problems (eg, cholestasis) may occur. Fetal anomalies do not appear to be a concern, and normal reproductive tract function and fertility are restored after oral contraceptive use is discontinued. However, most health care providers recommend that women use a barrier contraceptive method for 1 to 2 months after stopping the pill before becoming pregnant so that the accurate date of the last menstrual period is available to date the pregnancy.

Some of the benefits of using oral contraceptives include a re-duction in the incidence of benign breast disease, improvement in acne, reduced risk of uterine and ovarian cancers, anemia, and pelvic infection.

A few patients experience adverse reactions when using oral contraceptives. These include nausea, depression, headache, weight gain, leg cramps, and breast soreness. Usually, these symp-toms subside after 3 or 4 months. Because such symptoms are sometimes related to sodium and water retention caused by es-trogen, a smaller dose of the hormone or a different hormonal combination may alleviate the problem. Many patients experience spotting in the first month taking the pill or if they take it irregularly, so they need to be reassured and advised to take a pill every 24 hours, as prescribed. Chart 46-13 describes the benefits and risks of oral contraceptive use.

CONTRAINDICATIONS

Absolute contraindications include current or past thromboem-bolic disorder, cerebrovascular disease, or artery disease; known or suspected breast cancer; known or suspected current or past estrogen-dependent neoplasia; pregnancy; current or past benign or malignant liver tumor; impaired liver function; congenital hy-perlipidemia; and undiagnosed abnormal vaginal bleeding.

Relative contraindications include hypertension, bile-induced jaundice, acute phase of mononucleosis, and sickle cell disease. Women older than 35 who smoke are at risk for cardiac problems and should not use oral contraceptives. Occasionally, neuro-ocular complications arise, but a cause-and-effect relationship has not been established. If visual disturbances occur, oral contra-ceptives should be discontinued (Chart 46-14).

Some gynecologists allow patients with migraine headaches to take oral contraceptives if the headaches do not worsen with use or so long as the patient has no neurologic symptoms. (A young woman who has blurred vision with a migraine will probably be discouraged from taking oral contraceptives.) Diabetes is also prob-lematic, although some diabetes specialists allow their patients to use oral contraceptives with careful glucose monitoring. Leiomy-omas (fibroid tumors) of the uterus can enlarge with oral contra-ceptive use. Patients with this condition are advised and monitored carefully; if fibroids enlarge, they are advised to discontinue oral contraceptives and choose another contraceptive method.

Injectable Contraceptives

DEPO-PROVERA

An intramuscular injection of Depo-Provera, a long-acting prog-estin, every 3 months inhibits ovulation and provides a reliable and convenient contraceptive method. It can be used by lactat-ing women and those with hypertension, liver disease, migraine headaches, heart disease, and hemoglobinopathies. Women who use this method must be prepared for irregular or no bleeding. With continued use, irregular bleeding episodes and spotting de-crease, and amenorrhea usually occurs.

Advantages include reduction of menorrhagia, dysmenorrhea, and anemia. It may reduce the risk of pelvic infection and has been associated with improvement in hematologic status in women with anemia due to heavy menstrual bleeding and women with sickle cell disease; it has also been associated with a reduced frequency of seizures in women with seizure disorders. It also reduces the risk of endometrial cancer (ACOG Technical Bulletin #198, 1995).

Potential disadvantages include irregular menstrual bleeding, bloating, headaches, hair loss, decreased sex drive, and weight loss or weight gain. Fertility may be delayed when women discon-tinue this method; therefore, other methods of contraception may be more appropriate for the woman who wishes to conceive within a year of discontinuing contraception.

Depo-Provera is contraindicated in women who are pregnant and those who have abnormal vaginal bleeding of unknown cause, breast or pelvic cancer, or sensitivity to synthetic progestin. The long-term effects on the infant of a nursing mother who uses Depo-Provera are unknown but are thought to be negligible. Depo-Provera does not protect against STDs. Bone density is temporarily decreased while using this method, but this does not seem to be a long-term health risk.

LUNELLE

Lunelle, a contraceptive that is a combination of medroxyprog-esterone (progestin) and estradiol (estrogen), has been shown to be very effective at preventing pregnancy in clinical trials. An in-tramuscular injection is administered every 28 to 30 days. It pro-vides immediate efficacy if given within the first 5 days following the start of a normal menstrual period. Return to ovulation oc-curs more quickly than with Depo-Provera, usually within 2 to 4 months. The contraindications and cautions are the same as those for oral contraceptives. Effectiveness depends on the woman’s compliance with the regimen. Similar to other nonbarrier con-traceptive methods, Lunelle does not protect against HIV infection or other STDs. Light, regular monthly bleeding occurs.

Implant Contraceptive

The Norplant system is a reversible, low-dose, progestin-only contraceptive device consisting of several soft Silastic capsules or implants that are inserted under the skin of the woman’s upper arm. The implant releases the progestin levonorgestrel over 5 years, thereby inhibiting ovulation. While still FDA-approved, it is anticipated that Norplant will not be available in the future. However, additional implant contraceptives are expected to be-come available in the near future. Contraindications to using these systems are acute liver disease or liver tumors, pregnancy, unexplained vaginal bleeding, breast cancer, and a history of thrombophlebitis or pulmonary embolism.

Common side effects include irregular bleeding, weight gain, acne, and hair growth or hair loss. If patients are aware of these dis-advantages and side effects, they are more likely to tolerate the im-plant and continue using it. The patient should report headaches or visual symptoms to a health care provider because rare instances of idiopathic intracranial hypertension have been associated with the implant. Papilledema must be ruled out if headaches occur.

Insertion, minor surgery that is relatively painless, is per-formed under aseptic conditions in an outpatient setting such as an office or clinic. A small incision is made in the inner upper arm after the patient receives a local anesthetic. The capsule or cap-sules are inserted within the first 7 days of the menstrual cycle to avoid the possibility of a preexisting pregnancy. The contracep-tive effect occurs within 24 hours and lasts for 5 years. Insertion usually takes about 15 minutes. Although the implants can be re-moved at any time, it can be a more difficult and lengthy proce-dure because over time tissue encapsulates the implants. Women who have regular bleeding with an implant method are at higher risk for pregnancy and should be counseled to have a pregnancy test if the regular bleeding stops.

New Hormonal Methods of Contraception

Two new hormonal methods of contraception are Ortho Evra and NuvaRing. Ortho Evra is a thin, beige, matchbook-sized square that releases an estrogen and a progestin continuously. It is changed every week for 3 weeks. The fourth week is patch-free, producing withdrawal bleeding. The effectiveness of Ortho Evra is comparable to that of oral contraceptives. Its risks are similar to those of oral contraceptives and include an increased risk of blood clots. The patch may be applied to the torso, chest, arms, or thighs; it should not be applied to the breasts.

NuvaRing is a vaginal ring that is inserted in the vaginal for 3 weeks and then removed, resulting in withdrawal bleeding. It is as effective as oral contraceptives and has the same risks. It is flexible, does not require sizing or fitting, and is effective when placed anywhere in the vagina.

Although both of these contraceptive methods increase the options for women, neither protects against STDs. Women using these methods should be instructed not to smoke. Chart 46-15 lists hormonal methods of birth control approved by the FDA.

Intrauterine Device

An IUD is a small plastic device, usually T-shaped, that is inserted into the uterine cavity to prevent pregnancy. A string attached to the IUD is visible and palpable at the cervical os. An IUD pre-vents conception by causing a local inflammatory reaction that is toxic to spermatozoa and blastocysts, thus preventing fertiliza-tion. The IUD does not work by causing abortion.

Paraguard, a copper-bearing IUD, is effective for 10 years. Copper has an antispermatic effect. The Levonorgestrel Intra-uterine System (LNG-IUS; Mirena) is an IUD that releases levonorgestrel, a synthetic progestin used in oral contraceptives, and has been found to reduce heavy bleeding. 

Limited studies show that IUDs may prevent the need for hysterectomy in some women by reducing bleeding, may be an adjunct in HRT, may protect women from endometrial cancer, and may prevent cervi-cal cancer.

The IUD method is effective over a long time, appears to have no systemic effects, and reduces the possibility of patient error. This reversible method of birth control is as effective as oral con-traceptives and more effective than barrier methods.

Disadvantages include possible excessive bleeding, cramps, and backaches and a slight risk of tubal pregnancy, pelvic infec-tion, displacement of the device, and, rarely, perforation of the cervix and uterus. If a pregnancy occurs with an IUD in place, the device is removed immediately to avoid infection. Spontaneous abortion (miscarriage) may occur on removal. An IUD is not usu-ally used in women who have not had children because the nul-liparous uterus may be too small to tolerate it. Women with multiple partners, women with heavy or crampy periods, or those with a history of ectopic pregnancy or pelvic infection are en-couraged to use other methods. Some clinicians test for chlamy-dia and gonorrhea prior to insertion to prevent PID.

Mechanical Barriers

DIAPHRAGM

The diaphragm is an effective contraceptive device that consists of a round, flexible spring (50 to 90 mm wide) covered with a dome-like latex rubber cup. A spermicidal (contraceptive) jelly or cream is used to coat the concave side of the diaphragm before it is inserted deep into the vagina, covering the cervix. The di-aphragm is a spermicide holder; the spermicide inhibits sperma-tozoa from entering the cervical canal. The diaphragm is not felt by the user or her partner when properly fitted and inserted. Be-cause women vary in size, the diaphragm must be sized and fitted by an experienced clinician. The woman is instructed in using and caring for the device. A return demonstration ensures that the woman can insert the diaphragm correctly and that it covers the cervix.

Each time that the woman uses the diaphragm, she should ex-amine it carefully. By holding it up to a bright light, she can en-sure that there are no pinpoint holes, cracks, or tears in the diaphragm. Spermicidal jelly or cream is applied, and the di-aphragm is then positioned to cover the cervix completely. The diaphragm should remain in place at least 6 hours (but no more than 12 hours) after coitus. Additional spermicide is applied ifmore than 6 hours have passed before intercourse occurs and before each act of intercourse. On removal, the diaphragm is cleansed thoroughly with mild soap and water, rinsed, and dried before it is stored in its original container.

Disadvantages include allergic reactions in those who are sensi-tive to latex and an increased incidence of urinary tract infections. Toxic shock syndrome has been reported in some diaphragm users.

CERVICAL CAP

The cervical cap is much smaller (22 to 35 mm) than the di-aphragm and covers only the cervix; it is used with a spermicide. If a woman can feel her cervix, she can usually learn to use a cer-vical cap. The chief advantage is that the cap may be left in place for 2 days.

Although convenient to use, the cervical cap may cause cervi-cal irritation; therefore, before fitting a cap, most clinicians ob-tain a Pap smear and repeat the smear after 3 months. The cap can stay in place for 48 hours and does not require additional spermicide for repeated acts of intercourse.

FEMALE CONDOM

The female condom was developed to provide women with pro-tection from STDs and HIV as well as pregnancy. The female con-dom (Reality) consists of a cylinder of polyurethane enclosed at one end by a closed ring that covers the cervix and at the other end by an open ring that covers the perineum (Fig. 46-8). Advantages in-clude some degree of protection from STDs (HPV, herpes simplex virus, and HIV). Disadvantages include the inability to use the female condom with some coital positions (ie, standing).

SPERMICIDES

Spermicides are available over the counter as foams, gels, and in-serts and on condoms. Spermicides are effective, relatively inex-pensive chemical contraceptives when used with condoms. When used alone, spermicide is better than no contraception at all; it can be used without a partner’s cooperation and may provide pro-tection from gonorrhea and chlamydia. Burning, a rash, or irri-tation can develop in either partner and is usually temporary. Changing to another brand of spermicide often alleviates the problem. Spermicides are made from nonoxynol-9 or octoxynol. Nonoxynol-9 has been found to be associated with minute tears in vaginal tissue with frequent use, possibly increasing the possi-bility of contracting HIV from an infected partner (Stephenson, 2000). It also may increase the risk of latex allergy when used with a condom by leaching out a natural rubber protein from the latex (Greydanus, Patel & Rimsza, 2001).

MALE CONDOM

The male condom is an impermeable, snug-fitting cover applied to the erect penis before it enters the vaginal canal. The tip of the condom is pinched while being applied to leave space for ejacu-late. If no space is left, ejaculation may cause a tear or hole in the condom and reduce its effectiveness. The penis, with the condom held in place, is removed from the vagina while still erect to pre-vent the ejaculate from leaking.

The condom is an effective method when used with contra-ceptive foam. The latex condom also creates a barrier against transmission of STDs, especially gonorrhea, chlamydial infec-tion, and HIV. Natural condoms (those made from animal tis-sue), however, do not protect against HIV infection. The nurse needs to reassure women that they have a right to insist on their male partner using a condom and a right to refuse sex without condoms, although women in abusive relationships may increase their risk for abuse by doing so. Some women are buying and car-rying condoms with them to be certain that one is available. Nurses should be familiar and comfortable with instructions about using a condom because many women need to know about this way of protecting themselves from HIV and other STDs.

During patient teaching about barrier methods of contracep-tion, nurses need to consider the possibility of latex allergy for themselves and their patients. Contact dermatitis is often the first symptom of latex allergy. Swelling and itching can also occur. Pos-sible warning signs of latex allergy include oral itching after blowing up a balloon or eating kiwis, bananas, pineapples, passion fruits, avocados, or chestnuts. Because many contraceptives are made of latex, patients who experience burning or itching while using a latex contraceptive are instructed to see their primary health care provider. Alternatives to latex condoms may include the female (Reality) and male (Avanti) condoms made of polyurethane.

Condoms do not provide complete protection from STDs, as the HPV virus may be transmitted by skin-to-skin contact. Other STDs may be transmitted if any abraded skin is exposed to body fluids. This information should be included in patient teaching.

Coitus Interruptus

Coitus interruptus (removing the penis from the vagina before ejaculation) requires careful control by the male. Although it is a frequently used method of preventing pregnancy, it is considered an unreliable method of contraception.

Rhythm and Natural Methods

Natural family planning is any method of conception regulation that is based on awareness of signs and symptoms of fertility dur-ing a menstrual cycle. The advantages of natural contraceptive methods include the following: (1) they are not hazardous to health, (2) they are inexpensive, and (3) they are approved by some religions. The disadvantage is that they require discipline by the couple, who must monitor the menstrual cycle and abstain from sex during the fertile phase. In addition, the rhythm method of contraception can be difficult to use because it relies on the woman determining her time of ovulation and on avoiding in-tercourse during the fertile period. The fertile phase (which re-quires sexual abstinence) is estimated to occur about 14 days before menstruation, although it may occur between the 10th and 17th days. Spermatozoa can fertilize an ovum up to 72 hours after intercourse, and the ovum can be fertilized for 24 hours after leaving the ovary. The pregnancy rate with the rhythm method is about 40% yearly.

Women who carefully determine their “safe period,” based on a precise recording of menstrual dates for at least 1 year, and who follow a carefully worked-out formula may achieve very effective protection. A long abstinence period during each cycle is required. These prerequisites require more time and control than many cou-ples have. Changes in cervical mucus and basal body temperature due to hormonal changes related to ovulation form the scientific basis for the symptothermal method of ovulatory timing. Courses in natural family planning are offered at many Catholic hospitals and some family planning clinics.

Ovulation detection methods (eg, Ovulindex) are available in most pharmacies. The presence of the enzyme guaiacol peroxi-dase in cervical mucus signals ovulation 6 days beforehand and also affects mucosal viscosity. Test kits are available over the counter and are easy to use and reliable, but they can be expen-sive. Ovulation prediction kits are more effective for planning conception than for avoiding it.

Emergency Contraception

DOSE OF ESTROGEN/PROGESTIN

A properly timed, adequate dose of estrogen or estrogen and a progestin after intercourse without birth control, or when a method has failed, can prevent pregnancy by inhibiting or delay-ing ovulation. This method does not interrupt an established pregnancy. Nurses should be aware of this option and the indi-cations for its use. This method obviously is not suitable for long-term contraception because it is not as effective as daily oral contraceptives or other reliable methods used regularly. However, it is valuable in emergency situations such as rape, a defective or torn condom or diaphragm, or other situations that may present the possibility of unwanted conception. It can be prescribed as Preven (estrogen/progestin) or Plan B (progestin) packages of emergency contraception with patient literature or it can be pre-scribed as a specific number of contraceptive pills, depending on the medication and dose used.

Usually, a small dose of oral contraceptives (ie, levonorgestrel and ethinyl estradiol) is given and repeated in 12 hours (called the Yuzpe method after the gynecologist who developed the method). This method must be used not more than 72 hours after inter-course. Nausea, a common side effect, can be minimized by taking the medication with meals and with an antiemetic medication. Other side effects, such as breast soreness and irregular bleeding, may occur but are transient. Any patient using this method should

be advised of the 1.6% failure rate and counseled about other con-traceptive methods. Emergency contraception is related to luteal phase dysfunction, producing an endometrium that is out of phase. There are no known contraindications to the use of this method (Morris & Young, 2000).

The nurse reviews with the patient instructions for taking the pills based on the medication regimen prescribed. If the woman is breastfeeding, a progestin-only formulation is prescribed. To avoid exposing the infant to synthetic hormones through breast milk, she can manually express milk and bottle-feed for 24 hours after treatment.

The woman’s next menstrual period may begin a few days ear-lier or a few days later than expected, and she needs to be in-formed of this. The patient must return for a pregnancy test if she has not had a menstrual period in 3 weeks and should be offered another visit to provide a regular method of contraception if she does not have one currently. This medication may also be dis-pensed by pharmacists without a prescription in some states. All women need to be aware of this option and how to obtain it. Nurses can educate and inform women about it to reduce un-wanted pregnancies and abortions.

POSTCOITAL IUD INSERTION

Postcoital IUD insertion, another form of emergency contracep-tion, involves insertion of a copper-bearing IUD within 5 days of exposure in women who want this method of contraception; however, it may be inappropriate for some women or if other contraindications exist. The mechanism of action is unknown, but it is thought that the IUD interferes with fertilization (Mor-ris & Young, 2000). The patient may experience discomfort on insertion and heavier menstrual periods and increased cramping. Contraindications include a confirmed or suspected pregnancy or any contraindication to regular copper IUD use. The patient must be informed that there is a risk that insertion of an IUD may disrupt a pregnancy that is already present.

NURSING MANAGEMENT

Patients who use emergency contraception may be anxious, em-barrassed, and lacking information about birth control. Nurses must be supportive and nonjudgmental and provide facts and appropriate patient teaching. If a patient repeatedly uses this method of birth control, she should be informed that the failure rate with this method is higher than with a regularly used method. A toll-free telephone information service (1-888-Not-2-Late) operates 24 hours a day in English and Spanish and pro-vides information and referrals to health care providers.