NSG 6430 MIDTERM STUDY GUIDE
Contraceptive Methods: types, instructions for use, benefits, side effects,
contraindications, ideal candidates, managing method problems, predicting ovulation
with natural family planning
Abstaining from penile–vaginal intercourse is the only certain way to avoid pregnancy.
Abstinence is most often practiced in conjunction with FAB methods or prior to becoming
sexually active. Although abstinence is generally promoted as the method of choice for
adolescents, counseling should include all contraceptive options. Abstinence is 100% effective
at preventing pregnancy. Coitus interruptus, also known as withdrawal, is the removal of the
penis from the vagina prior to ejaculation. Coitus interruptus prevents pregnancy by keeping
sperm from entering the vagina. While only 3% of women in the United States using
contraception employ coitus interruptus as their primary method, 60% of women in the 2010
National Survey of Family Growth report having used withdrawal at some time in their lives.
The theoretical efficacy of coitus interruptus is high, but the estimated typical use failure rate
is around 22%. The long-held belief that preejaculatory fluid contains sperm, which could
theoretically cause pregnancy even if withdrawal were used correctly, has been subjected to
small clinical studies, with conflicting results. Coitus interruptus is readily available, requires
no supplies or cost, and is user controlled. Couples can use coitus interruptus intermittently
when other methods are unavailable. Disadvantages include the need to use this method with
every act of intercourse, and the need to exert the self-discipline and control necessary to stop
intercourse. Coitus interruptus does not prevent STI transmission because penile–vaginal
contact occurs, and HIV and other STIs can be present in pre-ejaculatory fluid. Women who
use coitus interruptus should be educated about emergency contraception as a backup method.
Lactational Amenorrhea Method: Infant suckling during breastfeeding increases maternal
prolactin levels, which in turn inhibit ovulation; this is the physiologic basis of the lactational
amenorrhea method (LAM) of contraception. Three conditions must be met for LAM to be
effective: (1) exclusive or near-exclusive breastfeeding, (2) amenorrhea, and (3) infant
younger than 6 months. Efficacy and Effectiveness: Breastfeeding is an extremely effective
method of contraception if the conditions for its use are met. Failures typically occur when
breastfeeding is nonexclusive or after the infant reaches 6 months of age. In these instances,
the likelihood of ovulation increases and the woman may be unaware of her return to fertility.
Women who breastfeed their infants have decreased risk of ovarian, endometrial, and breast
cancers. Breastfeeding also has numerous benefits for infant health. The disadvantages of
LAM are that it is available only to women who are breastfeeding, its duration of use is
limited, and women may have difficulty sustaining the patterns of breastfeeding required to
maintain contraceptive effectiveness. In addition, LAM does not provide protection from STIs.
Fertility Awareness-Based Methods: FAB methods involve determining when a woman is
most fertile during each month and using either abstinence or barrier contraception during that
time to prevent pregnancy. The “fertile window” or time when intercourse is most likely to
result in pregnancy comprises the 5 days before plus the day of ovulation. FAB methods are
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,also referred to as natural family planning and the rhythm method. Among women in the
United States who use contraception, 1% use FAB methods. Signs and symptoms of ovulation
include a rise in the basal body temperature (BBT) and changes in cervical mucus. The BBT
increases at the time of ovulation and remains elevated for the rest of the cycle. Using BBT
charting in conjunction with the postovulation observations is beneficial, but predicting the
fertile period with BBT is difficult because ovulation has already occurred once the rise in
temperature is observed. Advantages and Disadvantages: Women may have to pay for FAB
methods training or supplies (e.g., basal body thermometer, CycleBeads), but there is no
ongoing cost unless a barrier contraceptive is used during the fertile window. These methods
are user controlled and may be the only acceptable form of contraception for members of some
religions and cultures. Disadvantages include the need for detailed education, ongoing
attention to identifying the fertile window, and abstaining from intercourse or using an
additional contraceptive method several days each month. FAB methods do not protect either
partner from STIs, and users should be educated about emergency contraception. Barrier
Methods: All barrier methods are coitus dependent. They must be applied at the time of
intercourse, before any penile penetration, and ideally before any genital contact to avoid
disruption in sex play. This requirement may be a problem for some couples due to the need to
plan ahead, or for others who find application disruptive. Couples can be taught to make
application or insertion of the barrier method part of their sex play. The coitus-dependent
nature of barrier methods may be an advantage for couples who have infrequent intercourse.
The male condom is a thin sheath that is placed over the erect penis. It serves as a barrier to
pregnancy by trapping seminal fluid and sperm and offers protection against STIs. In fact,
early descriptions of condom use in the 1500s emphasized the condom’s role in protection
from syphilis and other diseases. Efficacy and Effectiveness: When used correctly and
consistently, latex condoms are an effective form of contraception. Condom failures are
commonly related to breakage of the condom, or slippage during intercourse or while
removing the condom. In general, pregnancy rates for nonlatex condoms are slightly higher
than the corresponding rates for latex condoms, but within the range considered acceptable for
barrier methods. As noted, nonlatex condoms have higher reported rates of breakage and
slippage than latex condoms. Latex condoms should not be used by persons with known latex
allergies. Some women report genital irritation and discomfort from the use of condoms, an
issue that may be related either to the condom or to concomitant lubricant use. Some condoms
are lubricated with a spermicide (nonoxynol-9 [N-9]) that may produce genital irritation in
some women (see the section on spermicides). Advantages – Nonhormonal: Do not require
daily action, Some are available without prescription, Some offer protection against STIs.
Disadvantages - Require planning
Require application at the time of intercourse and may be interruptive, Breakage or slippage of
barrier methods at time of intercourse may increase risk of unintended pregnancy. Condoms
have the advantage of being widely available on an over-the-counter basis, without the need
for clinician visit or prescription. The nonlatex condoms tend to be more expensive than their
latex counterparts. The effectiveness of condoms is coitus dependent (Table 11-2). Correct use
is critical to prevent breakage, slippage, and resultant unintended pregnancy. A potential
disadvantage of using condoms as a contraceptive method is that they are male controlled.
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,Women who are in relationships where they cannot negotiate condom use with their partners
need a method they can control. Spermicides are chemical barriers that are used either alone
or in conjunction with a physical barrier (such as a condom, diaphragm, or sponge) to prevent
pregnancy. The most common spermicides currently marketed in the United States contain N-
9. This product may be formulated as a gel, cream, foam, suppository, foaming tablet, or film,
and is generally provided in 50- to 150-milligram (mg) dosages. Formulations containing at
least 100 mg of N-9 are associated with lower unintended pregnancy rates. Although the
effectiveness of spermicides used as a sole agent is less than that of other contraceptive
methods, spermicide use is more effective than using no method at all. N-9 is a surfactant, and
surfactants can disrupt cell membranes. By extension, it was envisioned that the surfactant in
this product would also act against pathogenic organisms and protect the user against
gonorrhea, chlamydia, herpes, and syphilis. The risk of this disruption increases with
frequency of use and dose. Because intact tissue is the first defense against infection, use of N-
9 could, therefore, potentially increase the risk of transmission of infection by causing micro-
abrasions in the epithelium. In addition, strong evidence indicates that N-9 does not reduce
STIs among sex workers or women attending STI clinics. Spermicides containing N-9 are
widely available as over-the-counter products and do not require a prescription or clinician
visit. Disadvantages include the low contraceptive effectiveness and the potential for
symptoms of cervicovaginal irritation. As noted earlier, women who engage in multiple daily
acts of intercourse or who are at high risk for STIs should avoid use of spermicides containing
N-9. Diaphragms: The traditional contraceptive diaphragm is a shallow dome-shaped cup that
is inserted in the vagina to cover the cervix. Currently, fewer than 1% of women in the United
States using contraception use the diaphragm. The contraceptive efficacy of the diaphragm is
similar to that of the male condom. Traditional diaphragms are designed to be used in
conjunction with a spermicide. The diaphragms available in the United States as of this writing
are made of silicone and can be used by women with latex allergies. Water-based products
(rather than those containing silicone) are recommended for women who wish to use a
lubricant with silicone diaphragms. Irritation or even abrasions of the vaginal mucosa have
been noted in women with improperly sized diaphragms or prolonged retention of the
diaphragm in the vagina. diaphragms and other contraceptive barrier devices should not be left
in the vagina for more than 24 hours, and their use during menses is discouraged. Urinary tract
infections are more common in diaphragm users than among women using hormonal
contraceptives. This device must be fit by a clinician and requires a prescription to purchase. A
new one-size-fits-all diaphragm is also available in the United States by prescription. As a
result of the need for a clinician visit, diaphragms have a higher initiation cost than condoms,
but can be used for years with proper care. The only additional cost is the spermicide that must
be used with the diaphragm. Diaphragms are washable and reusable. Proper use is important.
Users should be counseled on the timing of insertion and removal, use of spermicide,
appropriate care of the device, and need for periodic reevaluation of the size. Cervical caps
are cup-like devices that cover the cervix. Smaller than diaphragms, they maintain their
position over the cervix by suction, adhering to the cervix, or via a design that uses vaginal
walls for support. The FemCap was not as effective in preventing pregnancy as the traditional
diaphragm in clinical studies; the extrapolated annual failure rates slightly exceed 20%.
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, Cervical caps may be less effective in women who have had children than in those who have
not. FemCap users had significantly fewer urinary tract infections (7.5%) than those in the
diaphragm group (12.4%). In this same study, there were no differences in vaginitis, irritation,
dysmenorrhea, or Pap test changes between the groups. The cervical cap has possible or
theoretical value in protecting the cervix from infection, but there are no data to support this
benefit. The only barrier methods known to reduce STIs are male and female condoms. Caps
require an initial cost for fitting and purchase, but should last for approximately 2 years with
proper care. Ongoing costs include the purchase of spermicides. Vaginal Sponges: The Today
sponge is a single-use, soft, absorbent, polyurethane device that contains approximately 1,000
mg of N-9 spermicide; when moistened, the sponge gradually releases 125 to 150 mg of
spermicide over 24 hours of use. Its primary contraceptive effectiveness derives from the
gradual release of spermicide, but it also provides a physical barrier to the cervix and absorbs
semen. The vaginal sponge can be used for multiple episodes of coitus over 24 hours without
inserting more spermicide. Typical use pregnancy rates are somewhat higher among parous
women who use contraceptive sponges than among women who use diaphragms, although
rates for nulliparous women are similar. Safety and Side Effects: Women who use the vaginal
sponge tend to discontinue use of their method at higher rates than women who use the
diaphragm; more than 40% of the women who used both methods stopped using the vaginal
sponge in research studies. Allergic-type reactions, such as dermatitis, erythema, irritation, and
vaginal itching, were more common with the sponge, although they occurred in only 4% of
users. Advantages and Disadvantages: The sponge shares the advantages and disadvantages of
other nonhormonal barrier, coitus-dependent methods. It does not require a clinician visit or
fitting and is available on an over-the-counter basis. Its single-use application may prove more
expensive over time than methods that can be reused. Female Condoms: The female condom
is a barrier device designed to protect the cervix, vagina, and part of the vulva and perineum. It
was developed as an alternative to male condoms to give women a nonprescription barrier
contraceptive method that they could control and that would reduce their exposure to STIs.
The female condom should not be used simultaneously with a male condom, as this practice
increases the risk of breakage. It should not be used with the diaphragm, cervical cap, or
contraceptive vaginal ring, as the inner ring of the female condom fits into the same place by
the cervix as those methods. Female condoms are made of a synthetic rubber called nitrile and
so do not present problems for people with latex allergies. Advantages and Disadvantages: The
female condom is a nonhormonal, female-controlled method that is available as an over-the-
counter product. The results of a randomized crossover trial suggested that most users prefer
the male condom to the female condom. Some women find the female condom difficult to
insert, although this problem decreases with proper education. Although it is a female-
controlled method, male partner cooperation may still be necessary for consistent use; the
partner’s lack of acceptance is often cited as a reason for discontinuation. Female condoms can
be used only once, and are more expensive than male condoms, so this method can be costly
over time. Permanent contraception, or sterilization, is one of the most prevalent
contraceptive methods in the United States. People choose sterilization when they are sure
they do not want any children or any more children. Female sterilization involves
permanently blocking the fallopian tubes, which prevents sperm from ascending the
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