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How is the contraceptive sponge used
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What are the side effects of the cervical sponge What type of spermicide is available over the counter in the United States How is spermicide used
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INTRAUTERINE DEVICES
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What are IUDs and how are they administered T-shaped devices placed by a clinician through the cervix and into the uterus They have a small string that hangs down from the external cervical os into the vagina for removal (see Fig 4-2) They can be left in place for 1 10 years (depending on specific device) Copper IUDs (Paragard) prevent sperm from reaching the fallopian tubes by inducing a sterile inflammatory reaction in the endometrium They can be left in place for up to 10 years Levonorgestrel-releasing IUDs (Mirena) prevent sperm from reaching the ovum by causing the cervical mucus to become thicker Also can cause anovulation after 1 year as well as decreased menstrual flow and amenorrhea They can be left in place for up to 5 years
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What are the two types of IUDs available and how do they work
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4: General Gynecology
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Figure 4-2 Examples of commonly used intrauterine devices
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What are the benefits of IUDs
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Very effective (typical use failure rate in first year <01%); Decreased risk for ectopic pregnancy (compared to non-contraception users); possible protective effect against endometrial and cervical cancer; highly costeffective over a 5-year period; immediate return to baseline fertility after removal; menorrhagia and dysmenorrhea improvement (with Mirena*) Mirena may help reduce the risk of pelvic inflammatory disease (PID) because of its cervical mucus effects *It has the highest level of user satisfaction of any contraception being used by women
What are the risks of IUD placement
Uterine perforation; infection (risk of PID highest in first 20 days after placement); expulsion (patients should be encouraged to look/feel for string monthly); potential complications if pregnancy does occur Menorrhagia and dysmenorrhea (with Paraguard); can be relieved with NSAIDs; amenorrhea (with Mirena); no protection from STIs or HIV
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Section II: Topics in Gynecology
What are the contraindications to IUD placement
Absolute contraindications: pregnancy, endometrial cavity distortion, undiagnosed uterine bleeding, active, recent, or recurrent pelvic infection, copper allergy/Wilson disease (for Paraguard only), pelvic malignancy Relative contraindications: multiple sexual partners, dysmenorrhea/ menorrhagia (for Paraguard only)
What is the relationship between IUD use and PID
PID development risk is greatest in the first 20 days after IUD insertion and rare thereafter If a woman develops a gonococcal or chlamydial infection, she is much more likely to develop PID if she has an IUD in place IUD use is related to the development of PID with actinomycosis infection Yes, and the patient must be treated promptly 1 Cramping 2 Vaginal discharge 3 Irregular spotting 4 Dyspareunia However, expulsion may be asymptomatic and so it is important to check monthly for elongation or absence of the vaginal string to ensure continued placement
Should the IUD be removed if a woman is found to have a positive gonorrheal or chlamydial culture What are the four signs of IUD expulsion and what should be done
What should be done if expulsion occurs
The patient should immediately begin to use another form of contraception until she sees her physician
ELECTIVE ABORTION
How common is elective abortion Very common; in the United States 50% of all pregnancies are unintended and half of these are terminated No there is no evidence to prove that a single termination has any
Is there an impact of elective abortion on future pregnancies
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4: General Gynecology
impact on future fertility or the risk of spontaneous abortion However there is an increased risk of Asherman syndrome (intrauterine synechiae) if the dilation and curettage (D&C) is done in the presence of infection or if multiple procedures are done What examinations/tests need to be done before an elective termination of pregnancy Pelvic examination (to assess uterine size and position); -hCG or ultrasound (to confirm pregnancy); ultrasound (to assess dates and confirm intrauterine pregnancy); hematocrit and Rh(D) status Some providers screen and treat for STIs prior to the procedure What are the surgical procedure options for evacuation of products of conception (POC) Manual vacuum aspiration (MVA); suction dilation and curettage (suction D&C); dilation and evacuation (D&E); dilation and extraction (D&X) Risks of anesthesia Infection Hemorrhage Embolus (pulmonary or other) Cervical laceration Uterine perforation with/ without pelvic Organ damage Potential for adhesion development Does an abortion increase the risk of breast cancer What are the mortality rates associated with elective terminations No In the United States, mortality rates for first trimester abortions are 01 04 per 100,000 and 17 89 per 100,000 in the second trimester However, internationally, where many abortions are done illegally, one in eight maternal deaths is because of abortion-related complications
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