Netter\'s Obstetrics and Gynecology

SAVE OFFLINE

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

NETTER’S OBSTETRICS AND GYNECOLOGY, SECOND EDITION Copyright © 2008 by Saunders, an imprint of Elsevier Inc.

ISBN: 978-1-4160-5628-9

All rights reserved. No part of this book may be produced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publishers. Permissions for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing Department in Philadelphia, PA, USA: phone 1-800-523-1649, ext. 3276 or (215) 239-3276, or email [email protected].

Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Authors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data Smith, Roger P. (Roger Perry), 1949– Netter’s obstetrics and gynecology / Roger P. Smith ; illustrations by Frank H. Netter ; contributing illustrators, Carlos A.G. Machado, John A. Craig, Kristen Wienandt Marzejon. – 2nd ed. p. ; cm. Rev. ed. of: Netter’s obstetrics, gynecology, and women’s health / Roger P. Smith. c2002. Includes bibliographical references and index. ISBN 978-1-4160-5682-9 1. Gynecology–Handbooks, manuals, etc. 2. Obstetrics–Handbooks, manuals, etc. 3. Women– Diseases–Handbooks, manuals, etc. I. Netter, Frank H. (Frank Henry), 1906–1991. II. Smith, Roger P. (Roger Perry), 1949–. Netter’s obstetrics, gynecology, and women’s health. III. Title. IV. Title: Obstetrics and gynecology. [DNLM: 1. Genital Diseases, Female–Atlases. 2. Obstetrics–Atlases. WP 17 S658na 2009] RG110.S53 2009 618–dc22 2008030671

Acquisitions Editor: Elyse O’Grady Developmental Editor: Marybeth Thiel Project Manager: Mary Stermel Design Direction: Lou Forgione Illustrations Manager: Karen Giacomucci Marketing Manager: Jason Oberacker Editorial Assistant: Julie Goolsby

Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org

Printed in China Last digit is the print number:

9

8

7

6

5

4

3

2

1

This work is dedicated to my father, who taught me the “art” of medicine and who first introduced me to the art of Dr. Netter.

Preface No student of medicine, past or present, is unaware of the extraordinary series of medical illustrations created by Dr. Frank Netter; it is an incredible body of work that has been carried forward by the talented Carlos Machado, MD, and John Craig, MD, since Dr. Netter’s passing. Older physicians have looked with envy at these images, wishing they had been available when they were learning; established physicians return to them as comfortable sources of information; young physicians seek them out for the wealth of information they contain and their ability to make clear difficult clinical concepts. This spirit of concise reference and resource is the premise of this text. This second edition maintains the same consistent format in presenting topics to facilitate rapid access—the same information is in the same location—that was so well

received in the first edition. Chapters have been organized to provide a quick, concise resource for the diagnosis and treatment of common conditions encountered by anyone who provides care for women. In producing this second edition, more than 40 new topics have been added, a more intuitive organization has been developed, a new section on commonly encountered procedures has been added, new artwork has been developed, and subtle enhancements (such as indications of the level of evidence provided for references) have been made throughout the work. It is our hope that this work will be both a useful resource and celebration of the artistic richness that is clinical medicine. Roger P. Smith, MD

About the Author Although Roger P. Smith, MD, has spent much of his career in academic medicine, and has a curriculum vitae that is appropriately long, he regards himself as a clinician. Dr. Smith received his undergraduate education at Purdue University and his medical education, internship (in General Surgery), and residency at Northwestern University in Chicago. He then spent almost 10 years in a multi-

disciplinary group practice at the Carle Clinic in Urbana, lllinois, before moving to the Medical College of Georgia in 1985, where he was Chief of the Section of General Obstetrics and Gynecology. In 1999, Dr. Smith joined the University of Missouri–Kansas City, where he served as Vice Chair and Residency Program Director until 2008.

vii

About the Artists Frank H. Netter, MD Frank H. Netter was born in 1906 in New York City. He studied art at the Art Student’s League and the National Academy of Design before entering medical school at New York University, where he received his medical degree in 1931. During his student years, Dr. Netter’s notebook sketches attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating articles and textbooks. He continued illustrating as a sideline after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a full-time commitment to art. After service in the United States Army during World War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Pharmaceuticals). This 45year partnership resulted in the production of the extraordinary collection of medical art so familiar to physicians and other medical professionals worldwide. In 2005 Elsevier, Inc. purchased the Netter Collection and all publications from Icon Learning Systems. There are now over 50 publishcations featuring the art of Dr. Netter available through Elsevier, Inc. (in the US: www. us.elsevierhealth.com/Netter and outside the US: www. elsevierhealth.com) Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater part of the more than 20,000 paintings created by Dr. Netter, became and remains on eof the most famous medical works ever published. The Netter Atlas of Human Anatomy, first published in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions students the world over.

The Netter illustrations are appreciated not only for their aesthetic qualities, but, more important, for their intellectual content. As Dr. Netter wrote in 1949, “. . . clarification of a subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are what inform his paintings and what make them so intellectually valuable. Frank H. Netter, MD, physician and artist, died in 1991. Learn more about the physician-artist whose work has inspired the Netter Reference collection: http://www. netterimages.com/artist/netter.htm Carlos A.G. Machado, MD Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main artist who contributes to the Netter collection of medical illustrations. Self-taught in medical illustration, cardiologist Carlos Machado has contributed meticulous updates to some of Dr. Netter’s original plates and has created many paintings of his own in the style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise and his keen insight into the physician/patient relationship informs his vivid and unforgettable visual style. His dedication to researching each topic and subject he paints places him among the premier medical illustrators at work today. Learn more about his background and see more of his art at: http://www.netterimages.com/artist/machado.htm

ix

1

Puberty: Normal Sequence THE CHALLENGE Adolescence with the onset of puberty is a time of great emotional and physical change. By understanding the normal sequence of events and being sensitive to the presence of abnormalities, the caregiver may be able to make the most of opportunities to improve health and well-being. Scope of the Problem The variety of decisions, concerns, and changes confronting an adolescent are formidable, not the least of which are health issues raised by rapid growth, sexual maturation, and emerging sexuality. Puberty involves physical, emotional, and sexual changes that mark the transition from childhood to adulthood. Despite the potential need for medical education and care, teenagers have the lowest rate of physician office visits of any group. Embarrassment, inability to pay, lack of familiarity with health care delivery options, and legal obstructions to access all contribute to this lack of care. Objectives of Management Understanding the normal sequence of events involved in sexual maturation is important for counseling young women who may be concerned about “being normal.” It is also pivotal to the important task of identifying those in whom the progression is not normal so that timely evaluation and intervention may be achieved. TACTICS Relevant Pathophysiology Hormonally, puberty involves a change from negative gonadal feedback to the establishment of circadian and ultradian gonadal rhythms and the positive feedback controls that result in monthly cycles and fertility. It appears that three elements must be present for puberty to progress normally: adequate body mass, adequate sleep, and exposure to light. These factors appear to facilitate or allow the complex hypothalamic, pituitary, and ovarian changes that must occur. As the hypothalamus matures there is a decrease in its sensitivity to estrogen, resulting in an increase in the production and release of gonadotropin-releasing hormone. Consequently, follicle-stimulating hormone levels begin to increase at about the 8th to the 10th year of life, accompanied by an increase in estrogen levels. As the sensitivity of the hypothalamus to negative feedback further decreases, follicle-stimulating hormone and luteinizing hormone levels continue to rise. Eventually these hormones reach a sufficient level that the follicles can respond, initiating cyclic ovulation and menstruation. Strategies The changes of puberty generally follow a predictable pattern. A growth spurt and the rounding of body curves

4

generally herald puberty. Breast tissue begins to develop; nipples darken; and fat is laid down in the shoulders, hips, and buttocks and in front of the pubic bone (the mons). Body hair begins to appear because of the influence of androgens made in small amounts by the ovary and adrenal glands. Height increases because of accelerated growth in the long bones of the body, capped off by the closure of the growth centers near the end of puberty. Generally this growth spurt begins approximately 2 years before the start of menstruation itself, with growth slowing about the same time menstruation begins. Patient Education American College of Obstetricians and Gynecologists: Growing up (Especially for Teens). ACOG Patient Education Pamphlet AP041. American College of Obstetricians and Gynecologists: Menstruation. ACOG Patient Education Pamphlet AP049. IMPLEMENTATION Special Considerations The average age of first menstruation (menarche) is 11.6 years, with ages 8 to 16 years being the normal range. These age ranges have been gradually declining over the past few years. Puberty occurs as much as 2 years earlier for girls of African-American descent. Menarche generally occurs after the growth spurt and beginning of breast development, while changes in the pubic hair and labia are still under way. Although there is some variation in the normal progression of events, thelarche is the indication of pubertal change for most, followed by adrenarche, then peak growth velocity, and ending with the onset of menstruation. This sequence generally takes 4½ years to run its course, with a range of 1½ to 6 years.

REFERENCES Level II Lee PA: Normal ages of pubertal events among American males and females. J Adolesc Health Care 1980;1:26. McDowell MA, Brody DJ, Hughes JP: Has age at menarche changed? Results from the National Health and Nutrition Examination Survey (NHANES) 1999–2004. J Adolesc Health 2007;40:227. Epub 2007 Jan 24. Zacharias L, Rand WM, Wurtman RJ: A prospective study of sexual development and growth in American girls: The statistics of menarche. Obstet Gynecol Surv 1976;31:325. Level III American College of Obstetricians and Gynecologists: Breast concerns in the adolescent. ACOG Committee Opinion 350. Washington, DC, ACOG, 2006. Reindollar RH, McDonough PG: Pubertal aberrancy: Etiology and clinical approach. J Reprod Med 1984;29:391.

1 • Puberty: Normal Sequence

Female

Higher cerebral centers "trigger" adeno– hypophysis

Higher cerebral centers "trigger" adeno– hypophysis

Pituitary mammotropic Acne appears Axillary hair appears Breasts develop Uterus enlarges

hormones produced Pituitary gonadotropins increased FSH LH (ICSH) Adrenal Adrenal androgens cortices increased

Menstruation begins

Reticular zone enlarges

Pubic hair appears

Vaginal epithelium cornifies Body contours rounded Epiphysial union hastened

Ovaries

hormones produced ACTH (plus second tropic hormone?) Adrenal cortices

Adrenal androgens increased

Reticular zone enlarges Testes

ACTH, adrenocorticotropic hormone; FSH, follicle-stimulating hormone; ICSH, interstitial cell stimulating hormone; LH, luteinizing hormone.

Hair line recession begins Acne appears Facial hair appears Musculature develops Larynx enlarges (voice deepens) Axillary hair appears

Pubic hair appears

Testosterone increased Follicle ripening accelerated: ovulation and luteinization take place

Male

Some breast enlargement may occur

Estrogen produced

Estrogen increased Pro– gesterone produced

Pituitary mammotropic

5

Interstitial cells reappear (stimulated by ICSH) seminiferous tubules proliferate because of FSH and testosterone stimulation

Penis, prostate, and seminal vesicles enlarge Epiphysial union hastened

Health Maintenance: Ages 12–18 Years IMPORTANT CONSIDERATIONS (PHYSIOLOGIC CHANGES) The 12- to 18-years age group is notable for the development and consolidation of reproductive capacity, sexual identity, and expressiveness. Changing life roles and selfawareness present both challenges and opportunities for the development of good health practices. The first visit to the obstetrician–gynecologist for screening and the provision of preventive health care services and guidance should generally take place between the ages of 13 and 15 years; however, this visit should not be viewed by anyone involved, patient or caregiver, as the right time for the first internal pelvic examination, unless indicated by the medical history. Health care for the adolescent should include review of normal menstruation; diet and exercise; healthy sexual decision-making; the development of healthy, safe relationships; immunizations; and injury prevention. (Most of the health problems facing this age group are the result of risk-taking behaviors such as unsafe sexual practices, reckless driving, poor or distorted eating patterns, and substance use such as alcohol and drugs.) Leading Causes of Death • Motor vehicle accidents • Malignant neoplasms • Homicide • Suicide • Congenital anomalies • Leukemia Leading Causes of Morbidity: • Nose, throat, and upper respiratory conditions • Viral, bacterial, and parasitic infections • Sexual abuse • Musculoskeletal and soft tissue injuries • Acute ear infections • Digestive system and acute urinary conditions • Obesity • Sexually transmitted diseases (STDs) • Vaginitis Screening History • Reason for visit • Health status: medical, surgical, family • Dietary/nutritional assessment • Physical activity • Tobacco, alcohol, other drugs (including complementary and alternative medicines) (Data from the 2003 Youth Risk Behavior Surveillance Report indicate that many adolescents will begin engaging in risk-taking behaviors by age 13 years: 27.8% of adolescents report alcohol use before age 13 years.) • Abuse/neglect (20% to 40% of adults report abuse or sexual victimization before age 18 years) • Sexual practices 6

2

Physical • Height • Weight (body mass index) • Blood pressure • Secondary sexual characteristics (Tanner staging) • Pelvic examination (yearly 3 years after becoming sexually active or by age 21 years) • Skin Laboratory (only as dictated by the patient’s history) Periodic: • Pap test (within 3 years of becoming sexually active or by age 21 years and annually thereafter until at least three negative test results, then the interval may be increased. Note: Many patients are unaware of the difference between a Pap test and a pelvic examination for any other reason; this can be a good opportunity to discuss the difference.) • Cholesterol, high-density lipoprotein cholesterol (every 5 years) As Indicated by Risk Factors: • Hemoglobin • Bacteriuria testing • STD testing: Chlamydia and gonorrhea (If the patient has had sexual intercourse, screening for STDs is important, but urine-based STD testing, if available, can be an efficient means for doing so without a speculum examination.) • Human immunodeficiency virus testing • Genetic testing/counseling • Rubella titer • Tuberculosis skin test • Lipid profile • Fasting glucose Imaging • None indicated as routine care COUNSELING It is important to discuss issues of confidentiality with both the patient and her parent or guardian; concerns over confidentiality often are a barrier to the delivery of health care services, especially reproductive health care, for adolescents. To overcome this obstacle, a discussion of this topic at the initial visit, along with advice about relevant state and local statutes, is important. For example, if the patient discloses any evidence or risk of bodily harm to herself or others, confidentiality must be breached. Furthermore, state laws may mandate the reporting of physical or sexual abuse of minors. (Physicians should be familiar with state and local statutes regarding the rights of minors to health care services and the federal and state laws that affect confidentiality.) The main purpose of the initial reproductive health visit is preventive health, including educational information, rather than problem-focused care. Preventive

2 • Health Maintenance: Ages 12–18 Years

counseling for parents or other supportive adults can include discussions about physical, sexual, and emotional development; signs and symptoms of common conditions affecting adolescents; and encouragement of lifelong healthy behaviors. • Sexuality (inclusion of topics such as prevention of pregnancy and STDs is important because more than 85% of adolescent females will have had some form of sexual contact (vaginal, anal, oral, or same-sex) by age 19 years; nearly one third of all 9th graders report having had sexual intercourse, and more than 60% of all 12th graders report having had sexual intercourse.) • Development • High-risk behaviors • Preventing unwanted/unintended pregnancy • Postponing sexual involvement • Contraceptive options (should also include emergency contraceptive options) • STDs • Partner selection • Barrier protection • Date rape prevention • Fitness • Hygiene (including dental); fluoride supplementation/ treatment • Dietary/nutritional assessment (including eating disorders, calcium intake, and folic acid supplementation of 0.4 mg of folic acid per day) • Exercise: discussion of program • Psychosocial evaluation • Interpersonal/family relationships • Sexual identity • Personal goal development • Behavioral/learning disorders • Abuse/neglect

7

• Cardiovascular risk factors • Family history • Hypertension • Dyslipidemia • Obesity • Diabetes mellitus • Health/risk behaviors • Injury prevention • Safety belts and helmets • Recreational hazards • Firearms • Hearing damage • Sports • Skin exposure to ultraviolet rays • Suicide: depressive symptoms • Tobacco, alcohol, other drugs COUNSELING RESOURCES American College of Obstetricians and Gynecologists: Birth control (Especially for Teens). ACOG Patient Education Pamphlet AP112. Washington, DC, ACOG, 2005. American College of Obstetricians and Gynecologists: Growing up (Especially for Teens). ACOG Patient Education Pamphlet AP041. Washington, DC, ACOG, 1997. American College of Obstetricians and Gynecologists: You and your sexuality (Especially for Teens). ACOG Patient Education Pamphlet AP042. Washington, DC, ACOG, 1996. American College of Obstetricians and Gynecologists: Your first ob-gyn visit (Especially for Teens). ACOG Patient Education Pamphlet AP150. Washington, DC, ACOG, 2001.

The ages of 12–18 represent a time of extreme changes in body, body image, personality, and personal interactions. The physician must be aware of these changes, initiate a frank and open dialogue and assure confidentiality except in those cases where safety or bodily harm are involved.

8

SECTION 1 • General Health Considerations and Counseling

INTERVENTIONS: IMMUNIZATIONS If not already accomplished, this age group should receive a human papillomavirus and hepatitis B vaccine series. Meningococcal conjugate vaccine is now recommended. For adolescents who have not received meningococcal conjugate vaccine, the Centers for Disease Control and Prevention now recommend vaccination before entry into high school, at approximately 15 years of age. Periodic • Tetanus–diphtheria booster (once between ages 14 and 16) High-Risk Groups • Measles, mumps, rubella vaccine • Hepatitis B vaccine

REFERENCES Level II Grunbaum JA, Kann L, Kinchen S, et al: Youth risk behavior surveillance—United States, 2003 MMWR Surveill Summ 2004; 53:1. Errata MMWR Morb Mortal Wkly Rep 2004;53:536 and 2005; 54:608. Mosher WD, Chandra A, Jones J: Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Adv Data 2005;362:1.

Level III American College of Obstetricians and Gynecologists: Cervical cancer screening in adolescents. ACOG Committee Opinion No. 300. Obstet Gynecol 2004;104:885. American College of Obstetricians and Gynecologists: Confidentiality in adolescent health care. In: Health Care for Adolescents. Washington, DC, ACOG, 2003:25. American College of Obstetricians and Gynecologists: Guidelines for Women’s Health Care, 2nd ed. Washington, DC, ACOG, 2002. American College of Obstetricians and Gynecologists: Initial reproductive health visit. Committee Opinion No. 335. Washington, DC, ACOG, 2006. American College of Obstetricians and Gynecologists: Meningococcal vaccination for adolescents. Committee Opinion 314. Washington, DC, ACOG, 2005. American College of Obstetricians and Gynecologists: Primary and Preventive Care. Clinical Updates in Women’s Health Care. 2007;VI(2):1. American College of Obstetricians and Gynecologists: Primary and preventive health care for female adolescents. In Health Care for Adolescents. Washington, DC, ACOG, 2003, p 1. American College of Obstetricians and Gynecologists: Routine Cancer Screening. Committee Opinion No. 356. Washington, DC, ACOG, 2006. American College of Obstetricians and Gynecologists: Tool kit for teen care. Washington, DC, ACOG, 2003. Lentz GM: History, physical examination, and preventive health care. In Katz VL, Lentz GM, Lobo RA, Gershenson DM: Comprehensive Gynecology, 5th ed. Philadelphia, Mosby/Elsevier, 2007, p 148. Ornstein RM, Fisher MM: Hormonal contraception in adolescents: special considerations. Paediatr Drugs 2006;8:25. Zuckerbrot RA, Maxon L, Pagar D, et al: Adolescent depression screening in primary care: Feasibility and acceptability. Pediatrics 2007;119:101.

Health Maintenance: Ages 19–39 Years IMPORTANT CONSIDERATIONS (PHYSIOLOGIC CHANGES) The 19- to 39-years group is notable for more established menstrual function, punctuated for many by one or more pregnancies. Sexuality and sexual expression patterns have generally become well established and comfortable. Health care is directed toward prevention and health promotion because health is generally good in patients during these years. Leading Causes of Death • Malignant neoplasms • Motor vehicle accidents • Cardiovascular disease • Suicide • Acquired immunodeficiency syndrome • Homicide • Cerebrovascular disease • Diabetes mellitus and its complications Leading Causes of Morbidity • Diabetes mellitus • Nose, throat, and upper respiratory conditions • Menstrual disorders • Musculoskeletal and soft tissue including back and upper and lower extremities • Obesity • Sexual assault/domestic abuse • STD SCREENING History • Reason for visit • Health status: medical, surgical, family • Dietary/nutritional assessment • Physical activity • Tobacco, alcohol, other drugs (including complementary and alternative medicines) • Abuse/neglect • Sexual practices Physical • Height • Weight (body mass index) • Blood pressure • Neck: adenopathy, thyroid • Breasts • Abdomen • Pelvic examination • Skin Laboratory Periodic • Pap test (physician and patient discretion after three consecutive normal test results if low risk) • Cholesterol, high-density lipoprotein cholesterol (every 5 years)

3

As Indicated by Risk Factors • Bacteriuria testing • Fasting glucose test • Genetic testing/counseling • Hemoglobin • Human immunodeficiency virus testing • Mammography • Rubella titer • STD testing • Thyroid-stimulating hormone test • Tuberculosis skin test Imaging Screening mammography may be started before age 40 years for patients with a strong family history of earlyonset breast cancer or heritable cancer syndromes. COUNSELING For those considering or at risk for pregnancy, counseling regarding preconception testing, immunization, and nutrition is always appropriate. Health care encounters during this period are also an excellent opportunity to discuss long-term health improvement strategies such as weight control, exercise, and nutrition. Sexuality • High-risk behaviors • Contraceptive options • Genetic counseling • Prevention of unwanted pregnancy (including emergency contraceptive options) • STD • Partner selection • Barrier protection • Sexual function Fitness • Hygiene (including dental) • Dietary/nutritional assessment (folic acid supplementation for those at risk for or considering pregnancy; 0.4 mg of folic acid per day has been shown to reduce the risk of neural tube defects) • Exercise: discussion of program Psychosocial Evaluation • Interpersonal/family relationships • Domestic violence (more than 1.5 million cases of domestic violence occur each year; 20% to 40% of adults report abuse or sexual victimization before age 18 years, and 10% to 25% of wives report abuse or sexual victimization) • Job satisfaction • Lifestyle/stress • Sleep disorders Cardiovascular Risk Factors • Family history • Hypertension 9

10

SECTION 1 • General Health Considerations and Counseling

• Dyslipidemia • Obesity/diabetes mellitus • Lifestyle Health/Risk Behaviors • Injury prevention • Safety belts and helmets • Recreational hazards • Firearms • Hearing • Breast self-examination (Although data on the efficacy of breast self-examination are lacking, the possibility of detecting breast disease makes this recommendation reasonable.) • Breast cancer chemoprophylaxis (selective estrogen receptor modulator therapy for women older than age 35 years at high risk) • Skin exposure to ultraviolet rays • Suicide: depressive symptoms • Tobacco, alcohol, other drugs COUNSELING RESOURCES American College of Obstetricians and Gynecologists: Breast Self-Exam. ACOG Patient Education Pamphlet AP145. Washington, DC, ACOG, 2001. American College of Obstetricians and Gynecologists: Cholesterol and your health. ACOG Patient Education Pamphlet AP101. Washington, DC, ACOG, 2004. American College of Obstetricians and Gynecologists: Eating disorders. ACOG Patient Education Pamphlet BP144. Washington, DC, ACOG, 2000. American College of Obstetricians and Gynecologists: Good health before pregnancy. ACOG Patient Education Pamphlet AP056. Washington, DC, ACOG, 2007. American College of Obstetricians and Gynecologists: Staying healthy at all ages. ACOG Patient Education Pamphlet AB006. Washington, DC, ACOG, 2006. INTERVENTIONS: IMMUNIZATIONS If not already accomplished, initiate human papillomavirus and hepatitis B vaccine series. Periodic • Tetanus–diphtheria booster (every 10 years) High-Risk Groups • Measles, mumps, rubella vaccine • Hepatitis B vaccine

During the early reproductive years, girlhood gives way to careers, motherhood, and family responsibilities with all the attendant physical and emotional changes.

• Influenza vaccine • Pneumococcal vaccine REFERENCES Level II Hahn KA, Strickland PA, Hamilton JL, et al: Hyperlipidemia guideline adherence and association with patient gender. J Womens Health (Larchmt) 2006;15(9):1009. Mosher WD, Chandra A, Jones J: Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Adv Data 2005;362:1. Level III American College of Obstetricians and Gynecologists: Guidelines for Women’s Health Care, 2nd ed. Washington, DC, ACOG, 2002. American College of Obstetricians and Gynecologists: Primary and preventive care. Clinical Updates in Women’s Health Care. 2007;VI(2):1. American College of Obstetricians and Gynecologists: Routine cancer screening. Committee Opinion No. 356. Washington, DC, ACOG, 2006. American College of Obstetricians and Gynecologists: Selective estrogen receptor modulators. ACOG Practice Bulletin No. 39. Obstet Gynecol 2002;100:835. Lentz GM: History, physical examination, and preventive health care. In Katz VL, Lentz GM, Lobo RA, Gershenson DM: Comprehensive Gynecology, 5th ed. Philadelphia, Mosby/Elsevier, 2007, p 148. O’Brien WF: Weight control in women: A challenge to the obstetrician-gynecologist. Obstet Gynecol 1996;88:888.

4

Contraception: Counseling Principles THE CHALLENGE Assisting couples in identifying and using the most appropriate method of controlling fertility is an important challenge. Changing patterns of sexual expression, new technologies, increased consumerism, and heightened cost pressures all affect the choices made in the search for fertility control. The very nature of the topic gives contraception personal, religious, and political overtones that often lead to conflict, emotionality, and confusion.

of the egg (oral and nonoral hormonal contraceptives, long-acting hormonal methods), preventing union of sperm and egg by imposing a mechanical, chemical, or temporal barrier between sperm and egg (condom, diaphragm, foam, intrauterine devices, rhythm, withdrawal, postcoital oral contraception), or altering the likelihood of implantation or growth (RU-486). Relative efficacy (firstyear failure, both real and theoretical) is shown in the accompanying table.

SCOPE OF THE PROBLEM In the United States, more than half (56%) of all pregnancies are unplanned, despite the fact that 90% of women at risk (fertile, sexually active, and neither pregnant nor seeking pregnancy) are using some form of contraception. The 10% or so of women not using contraception account for more than half of these unintended pregnancies. The remaining unplanned pregnancies occur as a result of either failure of the contraceptive method used or the improper or inconsistent use of the method.

Strategies For a couple to use a method, it must be accessible, immediately available (especially in coitally dependent or “useoriented” methods), and of reasonable cost. The impact of a method on spontaneity, or the modes of sexual expression preferred by the patient and her partner, may also be important considerations. A decision tree based on these concepts is presented in the accompanying figure.

OBJECTIVES OF COUNSELING No “ideal” contraceptive method exists. Although efficacy and an acceptable risk of side effects are important in the choice of contraceptive methods, these are often not the factors on which the final choice is made. Motivation to use, or continue to use, a contraceptive method is based on education; cultural background; cost; and individual needs, preferences, and prejudices. Factors such as availability, cost, coital dependence, personal acceptability, and the patient’s perception of the risk all have a role in the final choice of methods. TACTICS Relevant Pathophysiology Currently available contraceptive methods seek to prevent pregnancy by preventing the sperm and egg from uniting or by preventing implantation and growth. These goals are accomplished by preventing the development and release

Patient Education American College of Obstetricians and Gynecologists: Birth Control. ACOG Patient Education Booklet AP005. American College of Obstetricians and Gynecologists: Birth Control (Especially for Teens). ACOG Patient Education Booklet AP112. American College of Obstetricians and Gynecologists: Sterilization for Women and Men. ACOG Patient Education Booklet AP011. American College of Obstetricians and Gynecologists: The Intrauterine Device. ACOG Patient Education Booklet AP014. American College of Obstetricians and Gynecologists: Birth Control Pills. ACOG Patient Education Booklet AP021. American College of Obstetricians and Gynecologists: Barrier Methods of Contraception. ACOG Patient Education Booklet AP022. American College of Obstetricians and Gynecologists: Natural Family Planning. ACOG Patient Education Booklet AP024.

CONTRACEPTIVE USE AMONG U.S. WOMEN, 2002 Method Oral contraceptives Sterilization (female) Condom (male) Sterilization (male) Withdrawal Intrauterine device Periodic abstinence (calendar) Implant Injectable (1 month) Transdermal patch Diaphragm Other (sponge, cervical cap, female condom, etc.) (No method)

Percent of users

Perfect use failure*

Actual use failure*

30.6 27.0 18.0 9.2 4.0 2.0 1.2