Hormonal Methods
Hormonal methods of birth control alter a woman’s normal hormone level to prevent ovulation and thus the chances for conception. These methods are much safer now than in previous decades; however, significant contraindications and side effects exist.
Key Concept Because of ongoing updates in the field of birth control, research using reliable and reputable Internet Websites or institutions is recommended. Sources frequently updated include the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH).
Oral Contraceptives
Oral contraceptives, also called birth control pills (BCPs), are widely used in the United States and Canada. They are prescription drugs containing progestin-only (the “mini-pill”) or estrogen and progestin. They are available in a variety of doses. The pill prevents ovulation; thus, the effectiveness rate for BCPs is between 95% and 99%. A woman must take birth control pills as prescribed to ensure effectiveness.
Rare but serious health problems can occur with BCPs. Blood clots, myocardial infarctions (heart attacks), and cerebrovascular accidents (strokes) can occur. Women older than 35 years who smoke are at the highest risk for these serious conditions.
Noncontraceptive health benefits from oral contraceptives include decreased rates of PID, cancers of the ovary and endometrium, recurrent ovarian cysts, benign breast cysts, and fibroadenomas, and discomfort from menstrual cramps. Minor side effects of oral contraceptives are relatively common. These include:
• Weight gain or loss
• Headache or nausea
• Depression
• Breast tenderness
• Loss of, or irregular, menstrual periods (generally temporary) Contraindications include:
• High blood pressure
• Heart defects
• Blood disorders (drug promotes clotting)
• Women older than 40 years
• Heavy smokers
• Obesity
• Diabetes
Key Concept Many common antibiotics reduce the effectiveness of hormonal birth control when the two are taken together Advise your client to use additional birth control methods while taking antibiotics and for a few days after using them when she is also taking birth control pills. Encourage the client to consult with her care provider
Emergency Contraception (EC). Emergency contraception (EC), incorrectly known as the “morning-after pill,” is generally a combination of estrogen and progestin. EC prevents implantation of a fertilized egg by interfering with the hormone balance. It is not considered an “abortion pill” because the zygote has not been implanted in the uterus.
To be effective, EC must begin within 72 hours of unprotected sex. Two doses of hormonal pills containing estrogen and progestin are taken 12 hours apart. The effectiveness rate is 75% to 89%; it is most effective when the hormone pills are taken within the first 24 hours after intercourse.
Nausea, vomiting, and cramping are the most common side effects. EC offers no protection against STIs.
Emergency contraception should not be confused with the prescription oral medication RU-486 or mifepristone (Mifeprex), which can stop pregnancy (cause an abortion) several weeks after it has begun. There are numerous contraindications and precautions for mifepristone. Healthcare providers must be consulted.
Additional Hormonal Contraceptives
Transdermal Patches. Transdermal patches with time-released hormones are convenient for the woman to use. The patch is worn like an adhesive bandage and is changed once a week for 3 weeks, followed by 1 week in which no patch is worn.
Depo-Provera. Medroxyprogesterone acetate (Depo-Provera) is a hormone similar to progesterone. It is administered by a healthcare provider every 3 months by injection and is about 99% effective in preventing pregnancy. Depo-Provera works by preventing ovulation. When the drug is discontinued, the return of fertility can take anywhere from 3 to 18 months. Depo-Provera is not effective against STIs.
If a pregnancy does occur, it is more likely to be in a fallopian tube (an ectopic pregnancy or tubal pregnancy). Depo-Provera may aggravate diabetes mellitus, kidney disease, seizure disorders, cardiac disorders, and mental illness. Additional possible side effects of Depo-Provera include:
• Weight gain
• Depression
• Headaches
• Abdominal pain
• Irregular or loss of menstrual cycle
• Nervousness
• Increased or decreased libido
• Breast tenderness or excessive enlargement
• Pulmonary embolism
Contraindications of Depo-Provera include:
• Pregnancy
• Cancer of the breast or reproductive organs
• Previous stroke
• History of liver disease
• History of blood clots in legs
Nursing Alert Any woman using hormones is at risk for heart disease, hypertension, cerebrovascular accident (stroke), deep vein thrombosis, emboli, breast cancer, and impaired liver function. The woman must be warned of these possibilities. Women who take hormones have a higher risk of complications if they smoke.
NuvaRing. NuvaRing is a hormonal vaginal contraceptive ring. It slowly releases progestin and estrogen. The client inserts the ring once every 3 weeks; then it is removed for 1 week when menses will occur. The ring is 98% to 99% effective in preventing pregnancy. A prescription is necessary; the ring is contraindicated for women who are breastfeeding because estrogen may decrease the production of breast milk.
Intrauterine Devices
A physician inserts an intrauterine device (IUD) into a woman’s uterus. The IUD prevents the fertilized ovum from implanting in the uterus. One benefit of the IUD is that it offers continuous protection without the need for the woman’s active participation. It is 97% to 99% effective. IUDs give no protection against STIs and may cause an increased incidence of PID, tubal pregnancies, and infertility.
STI rates increase in women who have many partners. The greatest danger is uterine or cervical perforation, although these situations occur rarely. There are several brands of IUDs (e.g., the nonhormonal Copper-T). Similar is the intrauterine system (IUS) Mirena. The Mirena system releases small amounts of levonorgestrel, which is similar to progesterone; small amounts of the hormone are released every day. This device may be considered if the woman is allergic to copper.
NCLEX Alert Complications of various birth control methods are commonly seen in clinical situations, for example, pregnancy blood clots, or STIs. NCLEX options may include any of these topics.
A physician may decide not to insert an IUD in any of the following situations:
• Recent STI or other pelvic infection—the IUD also may become a site for infection, which can cause scarring and later infertility.
• Possible pregnancy—insertion of the IUD may cause a spontaneous abortion. The IUD may be inserted during the menstrual period as a safeguard.
• Abnormally heavy menstrual flow, spotting between periods, or copious vaginal discharge
• Severe menstrual cramps
• Anemia, a bleeding disorder, or fainting spells
• Severely displaced or flexed uterus or another gynecologic problem
• Diabetes, circulatory problems, or atherosclerosis
In Practice: Educating the Client 70-1 provides information that you can share with clients about the IUD.
Nursing Alert If a woman becomes pregnant with an IUD in place, the device is usually removed immediately to avoid spontaneous abortion, ectopic pregnancy septic abortion, or premature labor
IN PRACTICE :EDUCATING THE CLIENT 70-1
CONSIDERATIONS RELATED TO AN INTRAUTERINE DEVICE (IUD)
• The client may feel a sharp pain when the IUD is inserted.
• The client may have cramps for a few days, but these should not continue.
• Menstrual flow may be heavier, or last longer than normal, after IUD insertion.
• The device may be expelled within the first few months. (If the client does not expel it within 2 to 3 months, it probably will remain in place.)
• The client should check monthly to make sure the IUD is in place. (Slender threads attached to the device can be felt protruding from the cervix.)
• The client should have a yearly Pap test and pelvic examination to assure there is no irritation from the IUD.
Barrier Methods
Barrier methods interfere with conception by physically preventing sperm from fertilizing ova. Barriers work through mechanical and chemical means. Mechanical devices are more effective when used in combination with chemical barriers.
For barrier methods to be effective, those who use them must be consistent and follow appropriate instructions. Some people object to the use of barrier methods, saying they interfere with the spontaneity of sexual arousal.
Mechanical Barriers
Male Barrier Methods. These consist of various types of condoms, which are sheaths made of latex, plastic, or animal tissue. A condom is applied to the erect penis before sexual intercourse. Latex condoms help to protect against the human immunodeficiency virus (HIV) as well as other STIs. Condom effectiveness ranges from about 85% to 98%. The addition of a spermicide (a form of physical and chemical barrier to sperm) increases birth control effectiveness.
Condoms are relatively inexpensive (or free at some clinics) and easily obtainable without a prescription. Some partners may complain of a loss of sensation. Breakage and latex allergies are possible problems.
Nursing Alert The most commonly used spermicide is roroxyrol-9 (N-9). It is considered an effective spermicide, but many women may develop sensitivities to the drug, leading to irritation and breakdown of protective mucosa. The irritation may result in an increase in susceptibility to STIs and HIV or acquired immunodeficiency syndrome (AIDS).
Female Barrier Methods. These include the cervical cap, diaphragm, and female condom. A physician must fit a woman for the cap and the diaphragm, which the woman must insert each time before intercourse. The latex female condom attaches to a flexible ring and is inserted into the vagina like a diaphragm. The condom protrudes from the vagina, providing protection for the external genitalia as well. The female condom and vaginal microbicides provide better STI prevention as well as act as barrier methods for birth control.
The vaginal sponge is a barrier method made of a polyurethane foam and the spermicide nonoxynol-9, commercially called the Today Sponge. It is effective for as long as 24 hours. In a woman who has not had any children it is between 84% and 91% effective. In a woman who has had children, the effectiveness rate decreases to 68% to 80%. It is an over-the-counter product, so it is important to advise the woman to read and follow all instructions carefully. It needs to remain in place at least 6 hours after intercourse, but be removed within 30 hours of insertion. A risk of toxic shock syndrome (TSS) exists if it is left in more than 30 hours. TSS is a serious acute systemic disease caused by infection with strains of Staphylococcus aureus. The sponge does not protect against STIs or HIV/AIDS, and the woman can become sensitive to the spermicide, which can cause mucosal irritation.
Chemical Barriers
Chemical barriers include spermicidal creams, vaginal foams, jellies, suppositories, and tablets. They offer added contraceptive protection when used with the mechanical barriers discussed above. The foams are most effective when used with a diaphragm or condom. However, frequent use can irritate vaginal tissues.
Nursing Alert Hormonal forms of birth control and most barrier methods of birth control have little or no protection against STIs, including HIV/AIDS and, in some cases, may actually increase the risk for STIs.
Surgical Options
Induced Abortion
Abortion is a controversial means of family planning and is discouraged by healthcare providers as a primary means of controlling pregnancy.
Sterilization
Several permanent sterilization procedures are possible. Partners are encouraged to make the decision together concerning which method they will use.
Vasectomy. A man may have a vasectomy, in which the vas deferens (ductus deferens) is ligated (tied off) and sometimes partially removed. The vas deferens is part of the long tube that transports the viable sperm in the testes to the outside of the man’s body. When it is cut, the sperm cannot reach the ova during intercourse, and pregnancy is prevented.
The man who chooses to have a vasectomy should anticipate that he will remain sterile but will not be impotent. Reversals (reattaching the vas deferens) of vasectomies are not uncommon, but these revision procedures often are unsuccessful.
This procedure is relatively easy and has few complications. It may be performed in the physician’s office under local anesthesia. Only two small scrotal incisions are made, and the postoperative course is usually uneventful.
Postoperative complications of vasectomy may be scrotal tenderness, swelling, and impotence for 1 to 2 days. Infection may occur, but usually it is mild. Sitz baths, ice packs, and analgesics are usually all that are needed to relieve postoperative discomforts.
Regular sperm counts following a vasectomy are important. The client must be told that it may take up to 6 weeks after a vasectomy for the semen to be totally free of sperm because the body stores semen. A sperm count is usually taken 6 weeks to 2 months after the procedure. If the sperm count is zero, the vasectomy was most likely successful.
Client teaching includes reminding the client to use birth control measures until his sperm count remains at zero for 6 weeks. However, a sperm count should be taken again after 6 months and then yearly to assess the continuing effectiveness of the surgery. In rare cases, sperm find an alternate pathway, and the man is then no longer sterile.
The man should feel confident in his decision to have a vasectomy. Emotional aspects of vasectomy can be stressful, even more so than physical concerns. Talking with other men who have had a vasectomy may reassure a man that he will not lose his sexual potency or drive.
Tubal Ligation. Tubal ligation is the most common and effective procedure for permanent sterilization in women. A tubal ligation involves ligating (tying off) the fallopian tubes (also known as the oviducts, uterine, or ovarian tubes). The fallopian tubes transport the ova to the uterus. If the ova cannot travel through the fallopian tubes, the woman will not become pregnant.
Tubal ligation is usually done in a same-day surgery center under epidural, spinal, or general anesthesia via endoscope (laparoscopic tubal ligation). Each tube is usually ligated in two places, cut, and a portion removed. Only one stitch is necessary in one or two incisions, and it is absorbable, so the woman does not need to return to the surgeon for stitch removal. The woman often needs only a minor dressing; therefore, this operation is referred to as the “Band-Aid tubal.”
Often a woman may have a tubal ligation performed after a vaginal delivery. It is easier to perform following childbirth because the fallopian tubes are easily accessible. Tubal ligation may be performed at the time of other abdominal surgery through an abdominal incision; all or part of the tube may be removed. It also may be done vaginally.
Mild postoperative cramping may result from manipulation of the ovaries, or referred pain to the shoulder may occur after abdominal distention with carbon dioxide, which is used for better visualization of the tubes.
The client can expect to leave the healthcare facility as soon as she has recovered from the anesthesia. Someone should be available to drive her home after surgery. She may experience a slight vaginal discharge or spotting for a few days after the procedure. Normal menstrual periods and libido should resume after tubal ligation.
Tubal sterilizations may include methods such as chemical scarring. Phenol (carbolic acid) and quinacrine are introduced into the fallopian tubes. Scar tissue forms, which causes mechanical barriers that prevent conception. Other nonsurgical techniques include the introduction of chemicals and cryosurgery of the tubes. The insertion of liquid silicone that “plugs” the fallopian tubes may also be available in some areas.
Unintended Pregnancies
It may be of interest to note that from one-third to one-half of all pregnancies in the United States are unplanned or unintended. Both planned and unintended pregnancies are areas of concern that may require education of the client by nurses and other healthcare practitioners.
Problems associated with unintended pregnancies include the woman not seeking prenatal care during the early months, as is highly recommended. She also is less likely to adopt healthy behaviors, such as cessation of smoking and abstinence from alcohol. She may not know to increase her folic acid intake, which would decrease the chances of an infant being born with a neural tube defect. The mother of an infant who was not planned is also less likely to breastfeed.
Social, employment, financial, and psychological considerations combine to make unintended pregnancies an area for discussion and education by healthcare providers when working with men and women of reproductive ages. Because unprotected sex and unintended pregnancies are interrelated, the consequences of unintended pregnancies can be linked with STIs and HIV/AIDS, fetal disorders, and maternal prenatal complications.
