A 35-year-old G2P2 presents for a contraceptive counseling visit. She and her husband desire a long-term contraceptive method, and are uncertain if they want more children. She has been happily married for 10 years. Her only medical problem is mild hypertension, for which she takes a diuretic, and she has never had a sexually transmitted disease. She is considering the copper IUD and wants to know how it works.
The patient decided to have the copper IUD placed. It is inserted without difficulty, and she returned 1 month later, at which time it was confirmed that her IUD string was in place. One year later, she returned because she had a positive pregnancy test. On examination, the IUD string is seen protruding from the cervical os. Ultrasound demonstrates a 10-week intrauterine pregnancy. The patient and her husband express a strong desire for the pregnancy to be continued.
What is the best next step in management?
Several mechanisms of action have been proposed for a copper IUD. These include inhibition of sperm migration and viability, change in transport speed of the ovum, and damage to or destruction of the ovum. The data demonstrates that these prefertilization mechanisms constitute the primary mechanism of action for prevention of pregnancy with the copper IUD; however, postfertilization effects, including damage or destruction of the fertilized ovum, may also occur. All of these effects occur before implantation. IUDs have few contraindications, and almost all women are eligible. Paragard should not be used in the following situations: pregnancy or suspected pregnancy, uterine abnormalities resulting in distortion of the uterine cavity, acute pelvic inflammatory disease, postpartum endometritis in the last 3 months, genital bleeding of unknown etiology, known or suspected uterine or cervical malignancy, mucopurulent cervicitis, or Wilson disease. The reported failure rate of a copper IUD at 1 year is very low, at 0.8 per 100 women. Although there is an increased risk of spontaneous abortion, and a small risk of infection, an intrauterine pregnancy can occur and continue successfully to term with an IUD in place. However, if the patient wishes to keep the pregnancy and if the string is visible, the IUD should be removed in an attempt to reduce the risk of infection, abortion, or both. Although the incidence of ectopic pregnancies with an IUD was at one time thought to be increased, it is now recognized that in fact the overall incidence is unchanged. The apparent increase is the result of the dramatic decrease in intrauterine implantation without affecting ectopic implantation. Thus, while the overall probability of pregnancy is dramatically decreased, when a pregnancy does occur with an IUD in place, there is a higher probability that it will be ectopic. With this in mind, in the absence of signs and symptoms suggestive of an ectopic pregnancy, especially after ultrasound documentation of an intrauterine pregnancy, laparoscopy is not indicated. The incidence of heterotopic pregnancy, in which intrauterine and extrauterine implantation occur simultaneously, is not increased.
A 21-year-old G0 presents to your office because her menses is 2 weeks late. She states that she is taking her birth control pills correctly; she may have missed a day at the beginning of the pack, but took it as soon as she remembered. She has no medical problems, but 3 weeks ago she had a “viral stomach flu,” and missed 2 days of work due to nausea, vomiting, and diarrhea. Her cycles are usually regular, even without oral contraceptive pills. She has been on the pill for 5 years, and recently developed some midcycle bleeding, which usually lasts about 2 days. She has been sexually active with the same partner for the past 3 months, and has a history of chlamydia 3 years ago. She has had a total of 10 sexual partners. A urine pregnancy test is positive.
Which of the following is the major cause of unplanned pregnancies in women using oral contraceptives?
The pregnancy rate with birth control pills, based on theoretical effectiveness, is 0.1%. However, the pregnancy rate in actual use is 0.7%. This increase is typically due to incorrect use of the pills. Breakthrough ovulation on combination birth control pills, when the pills are taken correctly, is thought to be a very rare occurrence. Unintended pregnancy in women correctly using oral contraceptive pills is not related to sexual frequency, gastrointestinal disturbances, or the development of antibodies.
A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease (PID) last year, for which she was hospitalized. She has currently been sexually active with the same partner for 1 year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits.
Which of the following statements correctly describes spermicides found in vaginal foams, creams, and suppositories?
Spermicides available in the United States contain nonoxynol-9, which immobilizes or kills sperm on contact. They do not provide protection against sexually transmitted infections. Spermicides provide a mechanical barrier (ie, gel, cream, foam, film) and need to be placed high in the vagina in contact with the cervix before each act of intercourse. They are available without a prescription. They are not highly effective when used alone, and effectiveness increases with concomitant use of barrier methods such as condoms. High pregnancy rates typically associated with spermicides are mostly due to inconsistent use rather than method failure. Their effectiveness increases with increasing age of the women who use them, probably because of increased motivation. The effectiveness of spermicides is similar to that of the diaphragm. Although it has been reported that contraceptive failures with spermicides may be associated with an increased incidence of congenital malformations, this finding has not been confirmed in several large studies and is not believed to be valid.
A 32-year-old woman presents for her annual examination. She is worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners, and was able to achieve orgasm with each of them. Her medications include a combined oral contraceptive (COC) pill for birth control, clonidine for chronic hypertension, and fluoxetine for depression. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago.
Which of the following is the most likely cause of her sexual dysfunction?
Clonidine, an antihypertensive agent, can cause inhibition of orgasm in women. Studies have shown that it decreases vaginal blood volume and inhibits sexual arousal. Selective serotonin reuptake inhibitors usually decrease libido. In women sensitive to hormonal changes, combination contraceptive pills can decrease free testosterone and decrease libido. Masters and Johnson identified the clitoris as the center of sexual satisfaction in women. Orgasm and sexual gratification has been associated with nerve endings in the clitoris, mons pubis, labia, and pressure receptors in the pelvis. Even though the cervix has a rich nerve supply, there is no scientific evidence that it plays a role in the sexual response.
A 22-year-old woman presents to your office for a well-woman examination. She has been sexually active with one male partner for the past year. She is concerned because she has not achieved orgasm with her partner. On further questioning, she reveals that she has never achieved orgasm with any other partners, or with masturbation or the use of a vibrator.
Which of the following statements correctly describes her condition?
Many factors can contribute to the development of primary orgasmic dysfunction in women. By definition, these women will not have been able to achieve orgasm through any means at any time in their lives; reasons for their dysfunction can include the influence of orthodox religious or rigid familial beliefs, dissatisfaction with their partner’s behavioral or social traits, or past trauma such as rape. Sexual dysfunction, particularly premature ejaculation in a male partner, can reinforce a woman’s orgasmic dysfunction.
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