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Hormonal methods of birth control

imagesINTRODUCTION

Hormonal methods of birth control contain estrogen and progestin, or progestin only, and are a safe and reliable way to prevent pregnancy for most women. There are several ways that the hormone(s) can be delivered:

A daily pill taken by mouth
A skin patch that is changed weekly
An injection that is given once every three months
An implant that is worn under the skin for up to three years
A ring worn in the vagina that is changed every month
This topic discusses hormonal methods of birth control, including birth control pills, injectable contraception, skin patches, vaginal rings, and contraceptive implants. A discussion of long-term and barrier birth control methods are available separately. (See “Patient information: Long-term methods of birth control (Beyond the Basics)” and “Patient information: Barrier methods of birth control (Beyond the Basics)”.) An overview of all birth control methods is also available. (See “Patient information: Birth control; which method is right for me? (Beyond the Basics)”.)

CHOOSING A BIRTH CONTROL METHOD

It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does not cause bothersome side effects. Other factors to consider include:

Efficacy
Convenience
Duration of action
Reversibility and time to return of fertility
Effect on uterine bleeding
Frequency of side effects and adverse events
Affordability
Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person’s preferences are provided in the table (table 1).

BIRTH CONTROL PILLS

Most oral contraceptives, also referred to as “the pill,” contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). The combination pill reduces the risk of pregnancy by:

Preventing ovulation
Keeping the mucus in the cervix thick and impenetrable to sperm
Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in:

Menstrual cramps or pain (dysmenorrhea)
Ovarian cancer
Cancer of the endometrium (uterine lining)
Acne
Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, birth control pills are a very effective form of contraception. Although the failure rate is 0.1 percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 9 percent over the first year, due primarily to missed pills or forgetting to restart the pill after the seven-day pill-free interval.

Missed pills are a common cause of pregnancy. In general, an active pill should be taken as soon as possible after a pill has been missed. Backup birth control should be used for seven days if more than two pills are missed.

Side effects — Possible side effects of the pill include:

Nausea, breast tenderness, bloating, and mood changes, which typically improve within two to three months without treatment.
Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. This almost always resolves without any treatment within two to three months. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.

Complications — When the pill was first introduced in the 1960s, the doses of both estrogen and progestin were quite high. Because of this, cardiovascular complications occurred, such as high blood pressure, heart attacks, strokes, and blood clots in the legs and lungs.

Reduced doses of progestin and estrogen in the currently available oral contraceptives have decreased these complications. Therefore, birth control pills are now considered a reliable and safe option for most healthy, non-smoking women. Blood clots occur in approximately 4 women per 10,000 using pills over a year’s time. This compares to approximately two blood clots per 10,000 women who are not using pills and 6 blood clots per 10,000 women who are pregnant.

The majority of studies suggest that taking (or previously taking) the pill does not increase the risk of breast cancer.

Who should not take the pill? — Women who fall into the following categories should NOT take the pill because of an increased risk of complications:

Aged 35 or over who smoke cigarettes (very high risk for cardiovascular complications)
Are pregnant
Have had blood clots or a stroke in the past, because these women are more likely to have blood clots while taking the pill
Have a history of an estrogen-dependent tumor (eg, breast or uterine cancer)
Have abnormal or unexplained menstrual bleeding (the cause of the bleeding should be investigated before starting the pill)
Have active liver disease (the pill could worsen the liver disease)
Have migraine headaches associated with visual or other neurologic symptoms (eg, aura)
Special concerns — Some women may take the pill under certain circumstances, but need close monitoring:

Women with high blood pressure can experience a further increase in blood pressure and should be monitored more frequently while on the pill.
Women who take certain medication for seizures (epilepsy) and take the pill have a slightly higher risk of pill failure (pregnancy) because the seizure medicines change the way the pill is metabolized. (See ‘Medication interactions’ below.)
Women with diabetes mellitus who are on the pill may need a slightly higher dose of insulin or oral diabetes medication. Women with diabetes and vascular complications from diabetes should not use the pill.
Medication interactions — The effectiveness of the pill may be reduced in women who take certain medications.

Anticonvulsants — Some anticonvulsants, including phenytoin (Dilantin®), carbamazepine (Tegretol®), barbiturates, primidone (Mysoline®), topiramate (Topamax®) and oxcarbazepine (Trileptal®) decrease the effectiveness of hormonal birth control methods (pill, patch, ring). As a result, women who take these anticonvulsants are advised to avoid hormonal birth control methods (with the exception of depo-medroxyprogesterone acetate [Depo-Provera®]). (See ‘Injectable birth control’ below.)

Other anticonvulsants do not appear to reduce contraceptive efficacy, including gabapentin (Neurontin®), lamotrigine (Lamictal®), levetiracetam (Keppra®), and tiagabine (Gabitril®). However, there is some concern that oral contraceptives may reduce the effectiveness of lamotrigine, potentially increasing the risk of seizures.

Antibiotics — Rifampin, which is sometimes used to treat tuberculosis, can decrease the efficacy of hormonal birth control. As a result, women who take rifampin should not use any hormonal birth control method (pill, patch, ring, implant, injection). Other methods (condom, diaphragm, IUD, sterilization) are recommended.

Other antibiotics (eg, penicillin, tetracycline, cephalexin) do not affect the efficacy of hormonal birth control methods. Back-up contraception is not needed when you take these antibiotics.

St. John’s Wort — St. John’s wort, an herbal supplement sometimes taken to treat depression, may reduce the effectiveness of birth control pills. (See “Patient information: Depression treatment options for adults (Beyond the Basics)”.)

Starting the pill — Ideally, the pill should be started on the first day of the period to provide maximum contraceptive effect in the first cycle; this provides protection from pregnancy immediately.

The pill may also be started on the day it is prescribed (called “quick start), as long as a urine pregnancy test is negative. A back-up form of birth control (eg, condoms) is needed for the first seven days after the quick start.

Many women start their pill on the first Sunday after the period starts (because most pill packs are arranged for a Sunday start). Some form of back-up contraception is needed for the first seven days after the Sunday start.

When to expect a period — Traditionally, the pill is taken on a 28-day cycle with 21 days of hormone pills followed by 7 days of placebo pills (“sugar pills”). Some newer formulations have a longer duration of hormone pills and fewer days of placebo pills (eg, 24/4). It is not necessary to take the placebo pills, but some women find it easier to remember to start their next pill pack if they have taken the placebos. The period should occur during the fourth week of the pill pack, ie, the “placebo week.” However, some women have irregular breakthrough bleeding or spotting in the first few months. (See ‘Side effects’ above.)

Continuous dosing — Some women prefer to take birth control pills continuously. This allows them to have fewer days of menstrual bleeding per year. This regimen is a particularly good treatment for women with painful periods or endometriosis, as well as those who want to avoid a monthly bleed.

Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This can be continued for as long as desired.

Seasonale® is an extended cycle birth control regimen in which an active pill is taken every day for 12 weeks, followed by seven days of inactive (placebo) pills. Seasonique® is another extended cycle pill that contains seven days of a low dose estrogen pills instead of the placebo pills; this is intended to reduce breakthrough bleeding and estrogen withdrawal symptoms.

Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten).

Shorter pill-free interval — Several pill formulations are available with 24 days of hormone pills (rather than 21) and only four days of placebo pills. It is hoped that pill failures and side effects will be minimized with this approach.

Progestin only pills — Some pills contain only progestin (called the mini pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding and within 4 to 6 weeks of delivery or who have worsened migraines or high blood pressure with combination contraceptive pills. Progestin only pills are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A back up method of birth control should be used for seven days if a pill is forgotten or taken more than three hours late.

Progestin only pills are taken on a 28-day cycle, and all 28 pills contain hormone. One pill should be taken every day at the same time, and there is no placebo pill week. Breakthrough bleeding or spotting can occur with progestin only pills.

Emergency contraception — If you have sex and have forgotten to take your pill, patch, or vaginal ring, or you are more than two weeks late for your injection of medroxyprogesterone acetate, you can take a “morning after” pill to reduce the risk of pregnancy. This should be taken as soon as possible after sex, ideally within 120 hours. (See “Patient information: Emergency contraception (morning after pill) (Beyond the Basics)”.)

INJECTABLE BIRTH CONTROL

The only injectable contraceptive currently available in the United States is depot medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available.

DMPA prevents ovulation and thickens the cervical mucus, making the cervix impenetrable to sperm. If the first dose of DMPA is given during the first seven days of the menstrual period, it prevents pregnancy immediately. A woman who receives her first DMPA injection after the seventh day of her period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent when the injection is given on time.

Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during the first few months of use. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection. DMPA is associated with weight gain in some women.

In women who use injectable progestins, there is no increased risk of cardiovascular complications or cancer. Use of DMPA is associated with decreased bone mineral density in current users. This effect is mostly reversed after DMPA is stopped. Studies have not shown an increased risk of bone fractures in women who have used DMPA in the past.

Because DMPA is long-acting, it may not be ideal for women who wish to become pregnant shortly after stopping the medication. Although most women are able to conceive within 10 months, fertility may not return for up to 18 months after the last injection.

There are a number of women who prefer DMPA to the pill, including those who:

Have difficulty remembering to take a pill every day
Cannot use estrogen
Also take seizure medications, which can be less effective with combination hormonal contraceptives.
Additional benefits of DMPA include a decreased risk of uterine cancer and pelvic inflammatory disease (PID).

BIRTH CONTROL SKIN PATCH

Birth control skin patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing. However, the failure rate of the patch is higher for obese women (eg, who weigh more than 198 pounds).

Ortho Evra® is the only skin patch contraceptive available in the United States. Effectiveness is similar to that of oral contraceptive pills. However, the patch appears to deliver a higher overall dose of estrogen than the pill. One study found that this was associated with an approximate doubling of the risk of blood clots while another study found no increase in risk. Further study is needed to define this risk.

The patch is worn for one week on the upper arm, shoulder, upper back, abdomen, or hip (picture 1). After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.

VAGINAL RING

Nuvaring® is a flexible plastic vaginal ring that contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues (picture 2A-B). This prevents pregnancy, similar to an oral contraceptive. It is worn in the vagina for three weeks, followed by one week when no ring is used; a menstrual period occurs during this time. The ring’s position inside the vagina is not important.

Most women cannot feel the ring, and it is easy to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. If the ring is left out for more than 3 hours, a backup method of birth control (eg, condoms) should be used for the next 7 days.

Risks and side effects are similar to those of oral contraceptives.

BIRTH CONTROL IMPLANT

A single-rod progestin implant, Implanon® or Nexplanon®, has been approved for use in the US and elsewhere. It is inserted under the skin into the upper inner arm by a healthcare provider (picture 3). It is effective for up to three years, but can be removed if pregnancy is desired sooner. Insertion and removal can be done in an office or clinic.

The implant is one of the most effective methods of birth control. It provides three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.

IUD WITH PROGESTIN

There are two intrauterine devices (IUDs) that contain a hormone, called levonorgestrel. One is called Mirena (in the United States) and can be left in place for up to five years. The other is called Skyla and can be left in place for up to three years. Both are highly effective in preventing pregnancy. A complete discussion of IUDs is available separately. (See “Patient information: Long-term methods of birth control (Beyond the Basics)”.)

PREGNANCY AFTER HORMONAL BIRTH CONTROL

The length of time it takes to become pregnant after use of a hormonal method of birth control depends upon which method was used, as well as some individual factors.

Most women are able to become pregnant immediately. For some, it may take several months before ovulation becomes regular and the woman can become pregnant, especially if the her periods were irregular before she used birth control. However, hormonal birth control does not increase the risk of infertility.

Women who use combination estrogen-progestin methods (eg, birth control pill, skin patch, vaginal ring) usually begin to ovulate regularly one to three months after stopping. In one study, the median time for a woman to have a menstrual period after stopping the continuous pill was 32 days, and 185 of 187 women (98.9 percent) had a menstrual period or became pregnant within 90 days [1].
With injectable depot medroxyprogesterone acetate (DMPA or Depo-Provera®), return of fertility can be delayed. Fifty percent of women will become pregnant within 10 months of the last injection. In a small number of women, however, it may take up to 18 months after the last injection to conceive. Women with lower body weights tend to become pregnant sooner than women with higher body weights after discontinuing DMPA.
Women who use contraceptive implants (eg, Implanon) usually begin to ovulate again within one month after the device is removed

Action Steps for Implementing School Health Services

download (1)For all students, health problems impair academic performance. Those students who experience health disparities also often experience education disparities. Some of the major health problems that confront American children and adolescents include overweight and obesity, asthma and other respiratory afflictions, HIV/AIDS, and psychosocial and behavioral disorders. Parents worry, for example, that a child who has had an asthma attack may not receive prompt medical attention at school. Adolescent depression may result not only in sadness, but also by irritability or boredom, with implications for school performance.

Schools can meet these student needs by offering prompt and efficient on-site access to school-based health services. School health services are screening, diagnostic, treatment, and health counseling services provided at the school. Such services are provided by school nurses and by school health centers either on-site or on the campus. Optimally, school nurses and school-based health centers work in partnership, maximizing access to care and use of scarce resources for such care.

School nurses are public health nurses who work in over 50% of America’s schools to provide direct care to students with basic health needs, coordinate health and education services for students with disabilities, and refer to and link with other health providers to ensure that students’ health problems are addressed and do not interfere with their academic activities. There are 58,000 school nurses in the United States. School nursing emerged on October 1, 1902, following the “experimental” placement of a public health nurse, in a New York City school., which resulted in reducing school absenteeism due to communicable diseases, Increasingly, school nurses work on student wellness, disease prevention and health education.

School health centers blend medical care with preventive and psychosocial services as well as organize broader school-based and community-based health promotion efforts. In addition to providing comprehensive primary medical and mental health care, school-based clinic staffs commonly mobilize existing community resources to create referral networks for students, address adolescent sexuality and reproductive health issues, and provide health and nutrition education though comprehensive, multi-disciplinary approaches involving physicians, nurse practitioners or physician assistants, nurses, clinical social workers, and other mental health professionals and counselors. In the 2001-2002 school year, school-based health centers numbered 1,500, a more than ten-fold increase from 120 a decade earlier.

Community health centers are not-for-profit providers of healthcare to America’s poor and medically underserved. For over 30 years, they have been responsible for bringing doctors, basic health services and facilities into the nation’s neediest and most isolated communities. Health centers serve the working poor, uninsured, as well as high-risk and vulnerable populations.

Below, you will find action steps to help you incorporate school-based health services into a coordinated school health program and links to useful websites and documents.

Actions for Schools and Communities

Form a Healthy School Team comprised of students, parents and other caregivers, community representatives, and key school staff to assess student needs, map community and school resources, identify gaps, and develop action plans to improve health outcomes for students
Establish an interdisciplinary school health services team comprised of well-qualified, including school nurses, pediatricians, and other school-based health personnel, appropriately educated health providers, providing physical and mental health services that emphasizes prevention and early intervention
Ensure that schools employ professional healthcare personnel, such as nurses, based in the school or school-based health center
Develop strong school-community health partnerships with a health center, public health entity and/or hospital
Appoint a school health services coordinator who has access to the superintendent, principal, or other senior school administrator
Work with the school-based health services team and school administration to develop and achieve a shared vision for healthy youth
Use the results of mapping to identify the most appropriate school health services configuration
Adopt generally accepted guidelines for clinical practice
Assess child and adolescent health care needs and available resources through formal evaluation methods
Solicit community input to address unmet health needs and support the operations of the program
Encourage student’s active, age appropriate participation in decisions regarding health care and prevention services
Involve parents as supportive participants in the student’s health care
Coordinate and integrate efforts with existing systems to optimize complementary programs, improve continuity of care, reduce fragmentation, prevent duplication, and maintain affordable services
Actions for National and State Organizations and Colleges and Universities

Establish certification processes and educational opportunities that can prepare diverse school health professionals to function effectively as members of interdisciplinary, results-oriented teams
Develop and disseminate guidelines, best practices, and model policies for school health services that focus on a range of service delivery models
Provide technical assistance and position statements that support the development of a coordinated service system
Provide data, funding, training, and statistical support for mapping or community assessment
Educate staff to help schools blend funding streams, accept consolidated applications and reports from communities, establish program objectives rather than program design, and ensure that new initiatives relate to and build on one another
Conduct or fund research that examines the impact of school health services on student well-being and academic performance
Encourage participation in national and local conferences that focus on adolescent and child health

Types of Health Services

images (1)Resources on several types of health services important for children, youth, and families, including dental health services; Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services; HIV/AIDS care; American Indian health services; prenatal care; teen pregnancy prevention; and Women, Infants, and Children (WIC).

Dental health services
EPSDT services
HIV/AIDS care
American Indian health services
Prenatal care
Teen pregnancy prevention
WIC Dental health services

Medicaid Dental Coverage
Overview of dental services under Medicaid. An optional service for adults, dental care is required for most Medicaid-eligible individuals under age 21, as a component of the Early and Periodic Screening, Diagnostic and Treatment benefit.

National Maternal and Child Oral Health Resource Centerexternal link
Supports health professionals, program administrators, educators, policymakers, and others with the goal of improving oral health services for infants, children, adolescents, and their families.

EPSDT services

Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit
Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid’s comprehensive and preventive child health program for individuals under age 21. EPSDT includes periodic screening, vision, dental, and hearing services.

HIV/AIDS care

AIDS.gov
Provides an overview of the history and impact of AIDS, social media tools, information on Federal resources, and links to other organizations providing information and resources related to the HIV/AIDS epidemic.

HIV/AIDS Bureau
Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services
The Ryan White CARE Act provides health care for people with HIV by filling gaps in care faced by those with low-incomes and little or no insurance. HRSA’s HIV/AIDS Bureau administers the program through hundreds of grantees, who serve 571,000 people each year.

National Abandoned Infants Assistance Resource Centerexternal link
Works to enhance the quality of social and health services delivered to infants and young children affected by drugs or HIV as well as to their parents and caregivers by providing training, technical assistance, research, resources, and information to the professionals who serve these children and families.

The Program Archive on Sexuality, Health & Adolescence (PASHA)external link
Sociometrics
A collection of promising teen pregnancy and STD/HIV/AIDS prevention programs that assist prevention practitioners around the country by identifying and facilitating access to effective prevention programs.

American Indian health services

Indian Health Service
U.S. Department of Health and Human Services
Provides information on Federal health services available to American Indians and Alaska Natives.

Prenatal care

A Healthy Start: Begin Before Baby’s Born
Maternal and Child Health Bureau, U. S. Department of Health and Human Services
Information on the importance of prenatal care and how to find services. En Español.

Healthy Start, Grow Smart
U.S. Department of Health and Human Services, U.S. Department of Agriculture, & U.S. Department of Education (2002)
A 13-pamphlet series on infant health care and child development, one for newborns and one for each of the first 12 months. Pamphlets, available in English or Spanish, are provided to mothers who are receiving Medicaid benefits when their babies are born.

National Healthy Mothers, Healthy Babies Coalitionexternal link
Provides quality information on prenatal and infant care to health care professionals, parents, and policymakers. The website includes information on the text4babyexternal link campaign.

Prenatal Care FAQ
National Women’s Health Information Center
Frequently asked questions and answers about basic prenatal care.

Teen pregnancy prevention

4Parents.gov
U.S. Department of Health and Human Services
A guide to help parents, grandparents, mentors, and guardians discuss with pre-teens and mid-teens important yet difficult issues about healthy choices, abstinence, sex, and relationships.

Copy That: Guidelines for Replicating Programs to Prevent Teen Pregnancyexternal link (PDF – 388 KB)
National Campaign to Prevent Teen Pregnancy
Guide for replicating teen pregnancy prevention programs that have been shown to have positive results.

GirlsHealth.gov
National Women’s Health Information Center, U.S. Department of Health and Human Services
Aims to help girls ages 10-16 learn about health, growing up, and issues they may face. Focuses on health topics that girls are concerned about and helps motivate them to choose healthy behaviors by using positive, supportive, and nonthreatening messages.

The Office of Population Affairs Clearinghouse
Office of Population Affairs, U.S. Department of Health and Human Services
Offers free educational materials on abstinence, contraception, sexually transmitted diseases (including HIV/AIDS), and other reproductive health and family planning topics. Some materials available in Spanish.

The Program Archive on Sexuality, Health & Adolescence (PASHA)external link
Sociometrics
A collection of promising teen pregnancy and STD/HIV/AIDS prevention programs that assist prevention practitioners around the country by identifying and facilitating access to effective prevention programs.

Putting What Works to Work (PWWTW)external link
National Campaign to Prevent Teen Pregnancy
Funded in part by the Centers for Disease Control and Prevention, PWWTW translates research on teen pregnancy prevention and related issues into user-friendly materials for practitioners, policymakers, and advocates.

 

Oatmeal Raisin Cookies

pic6wodKWIngredients:

Serves: 36Yield: 36
cookies Units: US | Metric
Whisk together and set aside
2 cups all-purpose flour
1 teaspoon baking soda
1 teaspoon baking powder
1 teaspoon kosher salt
Cream wet ingredients
1 cup unsalted butter, softened
1 cup sugar
1 cup dark brown sugar, firmly packed
2 large eggs
2 teaspoons vanilla
Then stir in
3 cups oats (not instant)
1 1/2 cups raisins
Directions:

1
Preheat oven to 350°.
2
Whisk dry ingredients; set aside.
3
Combine wet ingredients with a hand mixer on low.
4
To cream, increase speed to high and beat until fluffy and the color lightens.
5
Stir the flour mixture into the creamed mixture until no flour is visible.
6
(Over mixing develops the gluten, making a tough cookie.) Now add the oats and raisins; stir to incorporate.
7
Fill a #40 cookie scoop and press against side of bowl, pulling up to level dough (to measure 2 tablespoons of dough).
8
Drop 2-inches apart onto baking sheet sprayed with nonstick spray.
9
Bake 11-13 minutes (on center rack), until golden, but still moist beneath cracks on top.
10
Remove from oven; let cookies sit on baking sheet for 2 minutes before transferring to a wire rack to cool.

Introduction to birth control

nonhormonalbirthcontrolmethodsIf a woman is sexually active and she is fertile and physically able to become pregnant, she needs to ask herself, “Do I want to become pregnant now?” If her answer is “No,” she must use some method of birth control (contraception).

Terminology used to describe birth control methods include contraception, pregnancy prevention, fertility control, and family planning. But no matter what the terminology, sexually active people can choose from a variety of methods to reduce the possibility of their becoming pregnant. Nevertheless, no method of birth control available today offers perfect protection against sexually transmitted infections (sexually transmitted diseases, or STDs), except abstinence.

In simple terms, all methods of birth control are based on either preventing a man’s sperm from reaching and entering a woman’s egg (fertilization) or preventing the fertilized egg from implanting in the woman’s uterus (her womb) and starting to grow. New methods of birth control are being developed and tested all the time. And what is appropriate for a couple at one point may change with time and circumstances.

Unfortunately, no birth control method, except abstinence, is considered to be 100% effective.

“Natural” methods of contraception

Natural methods of contraception are considered “natural” because they are not mechanical and not a result of hormone manipulation. Instead, these methods require that a man and woman not have sexual intercourse during the time when an egg is available to be fertilized by a sperm.

The fertility awareness methods (FAMs) are based upon knowing when a woman ovulates each month. In order to use a FAM, it is necessary to watch for the signs and symptoms that indicate ovulation has occurred or is about to occur.

On the average, the egg is released about 14 (plus or minus 2) days before a woman’s next menstrual period. But because the egg survives 3 to 4 days (6 to 24 hours after ovulation) and the sperm can live 48 to 72 hours (up to even 5 days in fertile mucus), the actual time during which a woman may become pregnant is measured not in hours, not in days, but in weeks.

FAMS can be up to 98% effective, but they require a continuous and conscious commitment with considerable monitoring and self-control. Although these methods were developed to prevent pregnancy, they can equally well be used by a couple to increase fertility and promote conception.

Introduction to Family Planning

579813-Familyplanning-1374349174-360-640x480What is Family Planning?

Family planning is the voluntary planning and action taken by individuals to prevent, delay or achieve a pregnancy. Family planning services include counseling and education, preconception care, screening and laboratory tests, and all FDA approved methods of contraception.

Why is family planning part of the health department?

The Centers for Disease Control characterizes family planning as one of the top 10 public health achievements of the 20th century. In 1800, women had an average of 7 children; today women average 2.1 children. A woman is fertile for an average of 35 years of her life; if she has two children, she will spend about 30 years of her life avoiding pregnancy. Family planning information and services help individuals maintain their overall health and improve family and community health by supporting men and women to have children when their health, financial conditions, and personal situations are optimal. Access to family planning services is an important factor in planning for healthy pregnancies.

Healthy People 2020

Healthy People 2020 is a national 10-year agenda for improving the health of all Americans. Its purpose is to identify nationwide health improvement priorities, and provide measurable objectives and goals that are applicable at the national, State, and local levels. Healthy People 2020 identifies Family Planning as a key area to improve the health of Americans, with the following goal: Improve pregnancy planning and spacing, and prevent unintended pregnancy.

What is unintended pregnancy?

An unintended pregnancy is one that is unwanted or mistimed at the time of conception. It does not mean an unwanted birth or an unloved child. It does mean that there is less opportunity for the parents to prepare physically and financially, take advantage of pre-pregnancy risk identification and management, and initiate needed changes in diet, exercise, smoking and drinking that help ensure a healthy pregnancy.

Why is unintended pregnancy a problem?

Research indicates approximately half of all pregnancies are unintended at the time of conception. For some, unintended pregnancies result in healthy children in happy families. For others there are negative health effects from late or inadequate prenatal care, low birth weight, fetal exposure to alcohol, tobacco smoke and other toxins, and maternal depression. Unintended pregnancies are also associated with economic hardship, marital dissolution, poor child health and development, spouse abuse, and child abuse and neglect. Almost half of all unintended pregnancies end with an induced abortion.

How can we reduce the incidence of unintended pregnancy?

A woman’s ability to avoid an unintended pregnancy is related to her level of risk for pregnancy, her choice of methods, the strength of her motivation to avoid pregnancy and her pattern of contraceptive use. These factors, in turn, are often associated with a woman’s demographic and socioeconomic background, characteristics of her sexual partnerships, and her experiences with and attitudes toward pregnancy and contraception.

While slightly more than half of unintended pregnancies occur among women who were not using any method of contraception in the month they conceived; more than four in 10 occur among women who were using a contraceptive method the month they conceived. Issues related to inconsistent or incorrect use of method were the primary reason they conceived.

Research indicates that the most effective family planning method is the one the client is the most comfortable with. Client understanding of various methods and comfort with the one they choose is best accomplished with non-directive counseling and education from a family planning provider they trust. Family planning providers aim at increasing the percentage of clients who use their chosen method consistently and correctly. Recent studies also have shown that when comparing the effectiveness of all family planning methods, Long Acting Reversible Contraceptives (LARCS) are the most effective with less than 1 pregnancy per 100 women in 1 year. LARCS include contraceptive implants and intrauterine devices. LARCS are more effective than other methods such as the Pill because user error is eliminated.

Cost benefit of Publicly Funded Family Planning Services

The Guttmacher Institute estimated the costs necessary to pay for maternity and infant care costs for unplanned births among Medicaid-eligible women. Their cost-benefit analysis indicated that for every $1.00 spent to provide services in publicly funded family planning clinics, a savings of $4.02 was realized in averted Medicaid birth costs

0 Point Weight Watchers Cabbage Soup

picIPI8og3 cups nonfat beef broth (beef is the best) or 3 cups nonfat vegetable broth (beef is the best) or 3 cups nonfat chicken broth (beef is the best)
2 garlic cloves, minced
1 tablespoon tomato paste
2 cups chopped cabbage
1/2 yellow onion
1/2 cup chopped carrot
1/2 cup green beans
1/2 cup chopped zucchini
1/2 teaspoon basil
1/2 teaspoon oregano
salt & pepper
Directions:

1
Spray pot with non stick cooking spray saute onions carrots and garlic for 5 minutes.
2
Add broth, Tomato paste, cabbage, green beans, basil, oregano and Salt & Pepper to taste.
3
Simmer for a about 5-10 minutes until all vegetables are tender then add the zuccini and simmer for another 5 or so minutes.
4
I have tried different variations. Leaving out green beans. Adding chopped green onions in addition to the yellow onion.
5
All very good. You can customise it a bit.

TRACKING NUTRITION TO INCREASE ENERGY

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Short on energy? Always tired? Wondering what is the right balance of carbs to protein to fat for you for sustained energy? Do you have a good idea of what you’re consuming? Would you like to make changes and track what works best FOR YOU?

Factors Contributing to Fatigue

Inadequate sleep: If you are always feeling tired, a number of factors could be contributing to your lack of energy, not the least of which is not getting enough sleep. If you are able to wake yourself up naturally without an alarm clock, you probably are getting enough; if you are always yawning, if you feel the need for a nap after lunch, and if you find you try to “catch up” on sleep during the weekends, the first thing you need to do is find ways to get more sleep each night.

Inordinate stress: If you have a huge presentation to give or paper to finish, and work or school is cutting into not only your sleep time but also your exercise and social time, you need to balance out your current situation and be sure to make time for yourself. Even if that means taking a 10-minute brisk walk or soothing tense muscles for a few minutes in your hot tub, take time to reflect on YOUR OWN NEEDS and regenerate enthusiasm for your task. You may find that you do far better with short regular breaks than plowing forward relentlessly. Be sure you are not turning to food for stress relief, as that can ONLY make things worse.

Being overweight: Think about it. If you had to lug around a 20 pound child 16 hours a day, seven days a week, you’d get pretty tired, pretty quickly. If you’re carrying a lot of extra weight on your frame, any movement is going to require far more energy than if you are at closer to your ideal weight. By moving your body regularly (whether that is from gardening, walking, playing golf, or dancing) you are encouraging your body to release fat stores. Remember, movement is CUMULATIVE and needs to be done for LIFE.

Lack of exercise: Believe it or not, getting in 3-4 sessions a week of 20-30 minutes of continuous movement, as you’d get by walking, biking, or swimming, can help you 1) increase your energy levels, 2) sleep better at night, 3) bust stress, 4) need LESS sleep because you can handle the daily stresses better. By setting aside time to move, you are guaranteeing yourself more “fuel” to get through every day. Stop making excuses, and start moving today!

Overtraining: On the opposite end of the spectrum from sedentary living, if it’s been a while since you’ve taken a day off from exercise (generally not the case for most of the US population!) you may simply need a day or two of active recovery or rest to feel revitalized. For more on this condition, see www.bodyresults.com/e2overtrain.asp and www.bodyresults.com/E2restoration.asp.

Insufficient nutrition: You may be eating too many simple sugars (white foods like pastas, rice, potatoes, sweets, and bread) or you could be lacking in iron, which can lead to iron deficiency anemia (for more information on this medical condition see www.bodyresults.com/E2Anemia.asp as well as a feeling of general fatigue, especially when exercising. Iron in your diet (from such foods as leafy greens, dried fruits, spinach, lean red meats, and fortified cereals) helps your blood transport oxygen to all your working muscles. To assess iron levels, you can have your blood checked at your next physical. Try to avoid foods rich in the amino acid tryptophan (found in turkey and dairy products, for example) during the day; such foods may induce sleepiness and are better in the evening to help you increase the likelihood of falling asleep more quickly.

What is your macronutrient ratio?

To get a better idea of your own nutrition profile, you first need to understand the macronutrient make-up of your own diet, or in other words, how much of your caloric intake is coming from carbohydrates, how much from protein, and how much from fat. Nearly all foods have nutrition information on the food labels that point out how many grams of each you will ingest per serving and how many calories are in each portion. If you tend to buy food in bulk in order to save money, please realize that you may unknowingly be sabotaging your diet. Try buying single servings only, OR if you must buy in bulk, measure our single servings so you won’t be tempted to eat the entire quantity in one sitting. Pay attention to labels! To simplify things for you, there are a number of helpful free websites that you can turn to in order to track your nutrition.

If you are training for increased endurance in running, biking, climbing, trekking, mountaineering, kayaking, skiing, or anything that requires sustained energy for over an hour at a time, you will probably want to start by shooting for a macronutrient ratio of 50-60% complex carbohydrates (the more fibrous, the better; avoid simple sugars – white foods – such as highly refined pasta, potatoes, breads, white rice, and things containing lots of sugar and white flour; select multi-grain alternatives, colorful foods, and fruits and vegetables instead), 20-25% protein, and 20-25% fats. If you are on an eating program such as Atkins, be aware that you may need to increase your carbohydrate intake on days that involving any high-endurance activities or competition days.

Sample Tracking Systems

The system I send nearly all my clients to and which I’ve used myself with great success for several years is the free on-line tracking software offered at www.Fitday.com. FitDay.com is a fantastic tool to help you learn more about your diet and customizing your own personal menu. Be aware that it takes a little time to learn how to use it properly. On that site you can track your activities (calories expended) as well as intake (calories consumed) and you can customize your own dietary goals to reflect those areas of nutrition you’d especially like to track.

For example, if a pregnant woman wanted to be sure she was getting enough iron, folic acid, calcium and protein for sufficient growth for her fetus, she could set those values and use the tracking to help make sure she is getting adequate intake for each. If someone was trying to lose weight and wanted to keep caloric intake to 2000 calories while limiting saturated fats to 10% of his diet and increasing monounsaturated and polyunsaturated fats so that total fats were less than 25% of his total consumption, he could set those parameters as well.

Nutrition Analysis Tools and System (NATS www.nat.uiuc.edu/energy/daily.html) is another useful free website that helps track energy consumption. Visit the Energy Calculator and click on Advanced, and for your age and weight, you can find out: 1) how long you need to do a given activity if you know the amount of calories you wish to burn; 2) how many calories you burned by entering how long you did an activity; or 3) which activities you can do to burn a certain amount of calories in a given length of time.

If self-tracking systems don’t work for you, and you continue to feel low in energy despite changing your sleep habits, nutrition profile, and exercise routine, then you may need to enlist the help of a registered dietitian or visit your doctor to rule out such issues including thyroid disease, clinical depression, or other medical conditions that might be responsible.

Nutrition for Children and Teens

boy-eating-appleHealthy eating can stabilize children’s energy, sharpen their minds, and even out their moods. While peer pressure and TV commercials for junk food can make getting kids to eat well seem impossible, there are steps parents can take to instill healthy eating habits without turning mealtimes into a battle zone. By encouraging healthy eating habits now, you can make a huge impact on your children’s lifelong relationship with food and give them the best opportunity to grow into healthy, confident adults.

Developing healthy eating habits
Children develop a natural preference for the foods they enjoy the most, so the challenge is to make healthy choices appealing. Of course, no matter how good your intentions, it’s always going to be difficult to convince your eight-year-old that an apple is as sweet a treat as a cookie. However, you can ensure that your children’s diet is as nutritious and wholesome as possible, even while allowing for some of their favorite treats.

The childhood impulse to imitate is strong, so it’s important you act as a role model for your kids. It’s no good asking your child to eat fruit and vegetables while you gorge on potato chips and soda.

Top tips to promote healthy childhood eating
Have regular family meals. Knowing dinner is served at approximately the same time every night and that the entire family will be sitting down together is comforting and enhances appetite. Breakfast is another great time for a family meal, especially since kids who eat breakfast tend to do better in school.
Cook more meals at home. Eating home cooked meals is healthier for the whole family and sets a great example for kids about the importance of food. Restaurant meals tend to have more fat, sugar, and salt. Save dining out for special occasions.
Get kids involved. Children enjoy helping adults to shop for groceries, selecting what goes in their lunch box, and preparing dinner. It’s also a chance for you to teach them about the nutritional values of different foods, and (for older children) how to read food labels.
Make a variety of healthy snacks available instead of empty calorie snacks. Keep plenty of fruits, vegetables, whole grain snacks, and healthy beverages (water, milk, pure fruit juice) around and easily accessible so kids become used to reaching for healthy snacks instead of empty calorie snacks like soda, chips, or cookies.
Limit portion sizes. Don’t insist your child cleans the plate, and never use food as a reward or bribe.
How can I get my picky child to enjoy a wider variety of foods?
Picky eaters are going through a normal developmental stage, exerting control over their environment and expressing concern about trusting the unfamiliar. Many picky eaters also prefer a “separate compartmented plate,” where one type of food doesn’t touch another. Just as it takes numerous repetitions for advertising to convince an adult consumer to buy, it takes most children 8-10 presentations of a new food before they will openly accept it.

Rather than simply insist your child eat a new food, try the following:

Offer a new food only when your child is hungry and rested.
Present only one new food at a time.
Make it fun: present the food as a game, a play-filled experience. Or cut the food into unusual shapes.
Serve new foods with favorite foods to increase acceptance.
Eat the new food yourself; children love to imitate.
Have your child help to prepare foods. Often they will be more willing to try something when they helped to make it.
Limit beverages. Picky eaters often fill up on liquids instead.
Limit snacks to two per day.

Types of Nutrition Care

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Nutrition support gives nutrition to patients who cannot eat or digest normally.

It is best to take in food by mouth whenever possible. Some patients may not be able to take in enough food by mouth because of problems from cancer or cancer treatment. Medicine to increase appetite may be used.

Nutrition support for patients who cannot eat can be given in different ways.

A patient who is not able to take in enough food by mouth may be fed using enteral nutrition (through a tube inserted into the stomach or intestines) or parenteral nutrition (infused into the bloodstream). The nutrients are given in liquid formulas that have water, protein, fats, carbohydrates, vitamins, and/or minerals.

Nutrition support can improve a patient’s quality of life during cancer treatment, but there are harms that should be considered before making the decision to use it. The patient and health care providers should discuss the harms and benefits of each type of nutrition support. (See the Nutrition in Advanced Cancer section below for more information on deciding whether to use nutrition support.)

Enteral Nutrition

Enteral nutrition is also called tube feeding.

Enteral nutrition is giving the patient nutrients in liquid form (formula) through a tube that is placed into the stomach or small intestine. The following types of feeding tubes may be used:

A nasogastric tube is inserted through the nose and down the throat into the stomach or small intestine. This kind of tube is used when enteral nutrition is only needed for a few weeks.
A gastrostomy tube is inserted into the stomach or a jejunostomy tube is inserted into the small intestine through an opening made on the outside of the abdomen. This kind of tube is usually used for long-term enteral feeding or for patients who cannot use a tube in the nose and throat.
The type of formula used is based on the specific needs of the patient. There are formulas for patients who have special health conditions, such as diabetes. Formula may be given through the tube as a constant drip (continuous feeding) or 1 to 2 cups of formula can be given 3 to 6 times a day (bolus feeding).

Enteral nutrition is sometimes used when the patient is able to eat small amounts by mouth, but cannot eat enough for health. Nutrients given through a tube feeding add the calories and nutrients needed for health.

Enteral nutrition may continue after the patient leaves the hospital.

If enteral nutrition is to be part of the patient’s care after leaving the hospital, the patient and caregiver will be trained to do the nutrition support care at home.

Parenteral Nutrition

Parenteral nutrition carries nutrients directly into the blood stream.

Parenteral nutrition is used when the patient cannot take food by mouth or by enteral feeding. Parenteral feeding does not use the stomach or intestines to digest food. Nutrients are given to the patient directly into the blood, through a catheter (thin tube) inserted into a vein. These nutrients include proteins, fats, vitamins, and minerals.

Parenteral nutrition is used only in patients who need nutrition support for five days or more.

The catheter may be placed into a vein in the chest or in the arm.

A central venous catheter is placed beneath the skin and into a large vein in the upper chest. The catheter is put in place by a surgeon. This type of catheter is used for long-term parenteral feeding.

A peripheral venous catheter is placed into a vein in the arm. A peripheral venous catheter is put in place by trained medical staff. This type of catheter is usually used for short-term parenteral feeding.

The patient is checked often for infection or bleeding at the place where the catheter enters the body.

Parenteral nutrition support may continue after the patient leaves the hospital.

If parenteral nutrition is to be part of the patient’s care after leaving the hospital, the patient and caregiver will be trained to do the nutrition support care at home.

Ending parenteral nutrition support must be done under medical supervision.

Going off parenteral nutrition support needs to be done slowly and is supervised by a medical team. The parenteral feedings are decreased by small amounts over time until they can be stopped, or as the patient is changed over to enteral or oral feeding.