1: Fertility Control - Contraception Flashcards
1
Q
What guidelines cover contraception in under 16’s
A
Fraser guidelines
2
Q
What do Fraser guidelines state
A
That an under-16 year old may be given contraception if:
a. understand doctor’s advice
b. cannot be persuaded to tell their parents
c. likely to continue intercourse without contraception
d. their mental or physical health will likely suffer
Therefore in their best interest the doctor prescribes contraception without parental consent
3
Q
What age is a child considered unable to consent for sexual intercourse
A
under 13
4
Q
What should happen someone under 13-years comes for contraception advice
A
child protection measures
5
Q
What is the fertility awareness method
A
Individual has awareness of their menstrual cycles and uses this to plan when to have or avoid intercourse
6
Q
If a person is using the fertility method and does not want to get pregnant when should they avoid sex
A
6d before and 2d after ovulation
7
Q
What happens to cervical mucus around ovulation
A
Goes from being thin to becoming thick
8
Q
What are the advantages of fertility awareness method
A
- Can be used in developing countries
- Approved by catholic religion
9
Q
What is the problem with fertility awareness
A
- Heavily user dependent and often fails
- Cannot be used if irregular cycles
10
Q
When do women usually need to start contraception after pregnancy
A
21 days
11
Q
When is lactational amenorrhoea effective
A
If started less than 6 months, no supplementary formula is used and amenorrhoeic
12
Q
When can POP be started post-partum
A
Immediately
13
Q
If POP is started 21 days post-partum what should be done
A
Use additional contraception for two days
14
Q
When is COCP absolutely CI
A
Breast feeding <6W post-birth
15
Q
What is COCP not advised
A
Breast feeding 6W-6m
16
Q
If COCP is started at 21d, what should be done
A
Use additional contraception for 7d
17
Q
When should IUD be inserted
A
Within 48h of childbirth or after 4W
18
Q
How does barrier contraception work
A
prevents sperm and ova meeting
19
Q
What is the advantage of condoms
A
protects against STIs
20
Q
What is a contraindication to condoms
A
latex allergy
21
Q
What is the failure rate of condoms and what is the failure user rate
A
5% failure rate
15% user failure rate
22
Q
What is the femidom
A
one end sits in the vagina and other just outside the vulva
23
Q
What is the advantage of the femidom compared to the condom
A
less risk of tears
24
Q
What does the femidom protect against
A
STIs
25
How long before sexual intercourse is the femidom inserted
8h
26
how effective is the femidom
95%
27
what is a diaphragm
a rubber cap that covers posterior fornix and anterior-inferior uterus - so covers the cervix
28
what is added with a diaphragm
spermicide
29
how long is a diaphragm inserted before intercourse
3h
30
what is the problem with diaphragms
requires fitting. If individual gains/looses weight or is pregnant, the femidom will not fit
31
what does diaphragms increase the risk of
UTI and STI
32
why do diaphragms increase risk of STIs
Diaphragm can irritate the vaginal mucosa increasing risk of STIs
33
what is the failure rate of diaphragms
6%
34
what is a cap
rubber cap that covers the cervix
35
what is given with a cap
spermicide
36
how long before intercourse is a cap inserted
2h
37
how long should a cap be kept in after
6h
38
what are two disadvantages of caps
Increase risk UTIs and STIs
39
why do caps increase risk of STIs
Due to causing inflammation of vagina
40
what is the failure rate of caps
9%
41
what are methods of hormonal contraception
Combined or Progesterone-only
42
what are the methods of combined contraception
- Oral
- Patch
- Injection
- Ring (IUD, IUS)
43
explain MOA of combined contraceptives
High doses of oestrogen and progesterone exert negative feedback on the HPA axis, thus preventing LH surge.
44
what is the role of progesterone on cervical mucus and progesterone
Progesterone thickens cervical mucus preventing passage of sperm. Inhibits endometrial proliferation
45
what happens in pill free interval
Drop in progesterone and oestrogen causes endometrium to shed
46
what is the oestrogen component of combined contraceptives
Ethinyloestradiol
47
what is the standard dose of ethinylestradiol in COCP
30-35ug
48
what is progesterone component of COCP
Norethisterone
| Levonorgestrel
49
what does the combined contraceptive pill contain
Oestrogen and Progesterone
50
what are monophonic pills
Each pill contains same amount of oestrogen and progesterone
51
what are phasic pills
Oestrogen and progesterone levels vary between pills to replicate natural changes in cycle
52
what is most common COCP
Microgynon 30'
53
what does microgynon contain
35ug of ethinylestradiol and 150ug of levonorgestrel
54
explain taking microgynon
Microgynon is taken for 21d with a 7d pill-free interval
55
what is brevinor
35ug ethinylestradiol and 0.5ug levonorgestrel
56
how is brevinor taken
21d with 7d pill-free interval
57
What is the contraceptive transdermal patch
Oestrogen and progesterone patch put on the upper arm, abdomen or buttock to protect against pregnancy
58
What is ortho evra
It delivers 150ug norelgestromin and 25ug ethinyl estradiol
59
Explain ortho evra
Patch changed every 7d for a total of 3W. Then individual has a patch-free interval
60
if a women is in week 1-2 and delays changing the patch less than 48h what should be done
- Change patch as soon as possible
| - No additional protection needed
61
If a women is week 1-2 and delays changing patch by 48h what should be done
- Change patch as soon as possible
| - Contraception for 7d
62
If a women has unprotected intercourse in week 1-2 and patch is delayed change what is required
- Emergency contraception
63
explain what should happen if individual delays changing their patch in week 3
Take the patch free interval and apply patch at the start-date of the new cycle
64
explain what should happen if individual delays changing or applying patch in week 4 (patch free interval)
- Use contraception for 7d
65
What is the nuvaring
Combined contraceptive ring that sits in the vagina
66
Explain the nuvaring
Inserted for 21d and then removes for 7d
67
When should women start the COCP
Day 1-5 of their cycle
68
If taken during which time period is the COCP immediately effective
Day 1-5
69
If COCP is started after day 5 what is required
Contraception for 7d
70
Explain taking the COCP
Take the pill for 21d with 7d pill-free interval
71
How is the COCP taken
Same-time everyday
72
If individual has vomiting or diarrhoea on the COCP what should they do
Use additional contraception for 7d from onset of illness
73
How long should COCP be started post-partum
21-days
74
How long should COCP be started post-termination
7-days
75
If individual has missed one COCP pill what should be done
- Take pill as soon as possible
- Continue pack as normal
- No additional contraception
76
If individual has missed two or more pills what should she do about taking that pill
- Take pill as soon as possible. Even if that means two pills in one day
- Leave any earlier missed pills
77
If women missed >2 pills in day 1-7 and had sex what should be done
Emergency contraception required
78
If women missed >2 pills in day 8-14 and had sex what should be done
No need for emergency contraception
79
If women missed >2 pills in day 15-21 and had sex what should be done
Omit pill free interval
80
What is the principle of taking the COCP
Women needs to take the pill for 7 continuous days for it to be effective
81
What governs contraindications of contraceptives
UK medical eligibility criteria
82
What is UKMEC category 1
No restrictions
83
What is UKMEC category 2
Benefits > Risks
84
What is UKMEC Category 3
Risks > Benefits
85
If wanting to prescribe method with UKMEC category 3 guidance what is required
Referral to specialist contraceptive provider
86
What is UKMEC category 4
Harmful to prescribe this method
87
For the COCP what are 8 UKMEC 3 contraindications
BIG-DOGS PB:
BP: HTN Controlled
Immobile - Wheelchair Bound
Gall bladder disease at present
Diabetes >20-years
Obese: BMI >35
Genes: BRCA I or 2
PE or DVT in First-Degree relative under 45
Breast Feeding: 6-months
Smokes <15d and >35 years-old
88
For COCP what are 10 UKMEC 4 contraindications
BIB's Mad Ship:
```
Breast cancer
Immobility due to major surgery
Breast feeding 6W
Smoke >15d and <35
Migraine with aura
Antiphospholipid Syndrome
Diabetes over 20-years ago
Stroke previously
HTN uncontrolled
IHD previously
PE or DVT previously. Or, thrombophillia
```
89
If on what medication should patients NOT be given COCP
Lamotrigine
90
Why should patients on lamotrigine not be given the COCP
COCP reduces concentration of lamotrigine increasing seizure frequency
91
What other class of drugs does COCP interact with
CYP450 Inducers = reduce concentration COCP
92
If on CYP450 inducers, what should happen
Give a higher dose of ethinylestradiol (50ug)
| Or reduce pill-free interval to 4d
93
What is a side effect of COCP and how can this be reduced
Spotting for first 3-4m.
| Reduce by taking the pill at the same time every day
94
What are 3 side effects of COCP
Weight gain
Spotting
Headaches
95
What does COCP immediately increase risk of
VTE
96
What two cancers does COCP DEcreasee risk of
Colorectal cancer
| Ovarian cancer
97
Explain COCP reduction in ovarian cancer
Reduces risk of ovarian cancer during its use and up to 15-years afterwards
98
What does the COCP increase the risk of
```
VTE
Stroke
CVD
Breast cancer
Cervical cancer
```
99
What two cancers does COCP increase risk of
Breast and Cervical Cancer
100
Explain COCP and risk of breast cancer
COCP increases risk of breast cancer during use. This risk returns to baseline 10-years after ceasing use
101
What is the background use of VTE for women
5 in 100,000
102
What is risk of VTE on COCP
10 in 100,000
103
What is a women-year
One year in the reproductive life of a sexually active women that represents 12m risk exposure to pregnancy
104
What is failure rate of COCP
0.2-0.3 per 100 women years
105
What can be used to describe rate efficacy of contraceptive methods
Pearl index
106
What does pearl index describe
Describes efficacy of contraceptive methods if one hundred women were to take that method for one year
107
What 3 cancers does COCP decrease risk of
Endometrial
Ovarian
Colorectal
108
Explain COCP and surgery
Stop 4W before major surgery to upper and lower limbs
109
What are 3 methods of progesterone-only contraception
Implant
Injectable
Oral (POP)
110
How many POPs are licensed in the UK
5
111
What is femulen
Etynodiol dicacetate
112
What is norgeston
Levonorgestrel
113
What is noriday
Norethisterone
114
What is micronor
Norethisterone
115
What is cerazette
Desogestrel
116
What is the window to take the pill if it contains etynodiol, levonorgestrel or northisterone
3h
117
What is the window to take the pill if it contains desogestrel
12h
118
What pill has a 12h window
Cerazette
119
What are the 3 mechanisms of action of progesterone as a contraceptive
1. High doses of progesterone suppress HPA axis
2. Thickens cervical mucus
3. Endometrial thinning
120
When should the POP be started
Day 1-5 of the cycle
121
If started after day-5 how long should contraception be used for
If started after day 5 take other contraception for 48h
122
Explain taking the POP
POP should be taken at the same time every-day. If containing levongestrel or northisterone take 3h. If desoestrogel take 12h
123
After pregnancy when should POP be started
POP can be started at anytime postpartum and is hence the preferred method.
If started after day 21 - need two days barrier contraception
124
After TOP when should POP be stated
Same-day
125
Explain missed pill for POP
Take pill as soon as possible and subsequent pills. Use additional contraception for 48h.
126
What are 5 side-effects of the POP
```
Breast tenderness
Appetite stimulant - weight gain
Mood changes
Abdominal Bloating
Headaches
Menstrual irregularity
```
127
What is a UKMEC category 4 contraindication of POP
Current breast cancer
128
What are 4 UKMEC category 3 contraindications for POP
1. IHD on POP (stop POP)
2. Decompensated liver cirrhosis or hepatocellular carcinoma
3. Previous breast cancer
4. Unexplained vaginal bleeding
129
What drugs does POP interact with
CYP450 Inducers decrease efficacy of POP
130
What cancer does POP decrease incidence of
Endometrial
131
What condition does POP decrease incidence of
PID
132
What cancer does POP increase incidence of
Breast
133
What condition does POP increase risk of
Ovarian cysts
134
Explain efficacy of POP related to BMI
>70Kg: has a very limited efficacy
135
What is the failure rate of POP
4% in 100 women-years
136
What is the only progesterone implant licensed in the UK called
Nexplenon
137
What is nexaplanon
Small flexible tube inserted sub-dermally into the upper arm
138
What does nexplanon contain
68mg etonorgestrel
139
How long is nexplanon effective
3-years
140
What is the predominant mechanism of nexplanon
High-dose inhibits HPA axis
141
Aside from inhibiting ovulation, how else may progesterone prevent fertilisation
- Thickens cervical mucus
| - Thins endometrium
142
When should progesterone-implant be inserted
Day 1-5
143
If implant is inserted after day-5 cycle what is required
Additional barrier contraception
144
What is the main side-effect of the implant
Erratic bleeding
145
What is UKMEC Category 4 for implant
Breast Cancer
146
What are 4 UKMEC Category 3's for the implant
Decompensated Cirrhosis
Hepatocellular carcinoma
IHD on implant
Unexplained vaginal bleeding
147
What happens to fertility on removal of implant
Fertility returns immediately
148
What cancer does implant reduce incidence of
Endometrial
149
What cancer does implant increase risk of
Breast
150
What is failure rate of implant
<0.1 per 100-women years
151
Explain progesterone-only injectable
Long-term contraception. Where individuals receives IM or injectable progesterone
152
What are the three types of injectable progesterone in the UK
Depo-provea
Noristerat
Sayan Press
153
What is Depo-Provera Injection
Medroxyprogesterone acetate 150mg
154
How is depo-provea given
IM-injection every 12W
155
What cancer does depo-provea reduce incidence of
Endometrial
156
What is the main complication of depo-provea
- Delayed Fertility after cessation
- Weight gain 2-3Kg per-year
- Erratic bleeding
157
When may depo-provea not be suitable
Sub-fertile individuals. Eg. PCOS, as delayed return to fertility further decreases their chances
158
What is main side effect whilst on depo provea
Erratic bleeding
| Weight Gain
159
Explain weight changes on depo provea
2-3Kg weight gain per year
160
What cancer does depo provea increase risk of
Breast cancer
161
If used for more than one year, what does depo provea increase risk of
Decreases bone mineral density - can lead to osteoporosis
162
Give 4 side effects of depo-provea
- Irregular bleeding
- Delayed return to fertility of 6-12m
- Appetite stimulate causing weight gain
- Decreases bone mineral density
163
What is a UKMEC 4 contraindication of injectable progesterone
Current breast cancer
164
What are 5 UKMEC 3 contraindications for injectable progesterone
1. Several CVD risk factors
2. Peripheral vascular disease
3. History TIA or Stroke
4. Previous breast cancer
.5 Cirrhosis or hepatocellular carcinoma
6. Unexplained vaginal bleeding
165
What do intrauterine systems contain
Levonorgestrel
166
What are the two types of levonorgestrel releasing system
Jaydess
| Mirena
167
How long does jaydess last
3-years
168
How long does the mirena coil last
5-years
169
What is the MOA of the IUS
Releases levonorgestrel daily. This thickens cervical mucus preventing sperm entry. And, thins the endometrium.
170
What is a common side effect of IUS
Irregular bleeding in first 3-4 months
171
What are 3 UKMEC 3 contraindications of IUS
1. Fibroids
2. Hepatocellular carcinoma
3. Long QT
172
What are 6 UKMEC4 contraindications of IUS
1. Unexplained PV Bleed
2. PID
3. Gonorrhoea
4. Chlamydia
5. Endometrial cancer
6. Cervical cancer
7. Raised hCG
173
What is the IUD
Copper coil
174
What is the advantage of the IUD
Can be used for emergency contraception
175
Explain MOA of IUD
- Copper is spermatotoxic
| - It also causes an inflammatory reaction of the endometrium, meaning if fertilised it will be unable to implant
176
What are the two types of IUD
5-year
| 10-year
177
What needs to be checked prior to inserting IUD
STI screen
| If need to insert same-day, cover with 1g azithromycin
178
When should IUD be inserted
Can be inserted any-time during the cycle
179
When can IUD be inserted following birth
4W
180
What are two risks of inserting IUD
Cervical shock
| Perforation
181
What is cervical shock
Hypotension and tachycardia due to increased vagal tone
182
When does expulsion of IUD occur
First 3 months
183
When should individual with IUD be followed up
Follow up after first period to ensure still in place
184
What should happen prior to removing IUD
Cover with another form of contraception. if not, abstain for 7d
185
If a women is over-50 and has not had periods for one year, how long should they keep IUD in
1-year
186
If a women is under-50 and has not had periods for one year, how long should they keep IUD in
2-years
187
What does IUD increase risk of immediately following insertion
For first 21-days after insertion, IUD increases risk of PID
188
How long does IUD increase risk of PID
21-days
189
What are 2 side effects of IUD
Menorrhagia
| Dysmenorrhoea
190
What is the problem if someone becomes pregnant with IUD
1:20 chance it is ectopic
191
With an IUD, what should a women check after each period
That they can feel the threats. If unpalatable, US uterus to find coil. If still not found, x-ray.
192
If individual has an STI with an IUD what should be done
Keep IUD in and treat infection
193
If individual removes IUD due to STI what should be done about re-inserting
Do not re-insert for 3-months
194
If person finds out they are pregnant with IUD what should be done
Remove IUD as soon as possible.
195
What are 4 UKMEC 3 CI to IUD
Fibroids
Long QT
48h - 4W post-partum
HIV CD4 <200
196
What are 6 UKMEC 4 CI to IUD
1. Unexplained PV Bleed
2. PID
3. Gonorrhoea
4. Chlamydia
5. Pelvic TB
6. Copper allergy
7. Post-partum sepsis or post-abortion sepsis
8. Raised bHCG
9. Endometrial cancer
10. Cervical cancer
197
What is sterilisation
Permanent irreversible contraception
198
What is a pre-requisite for sterilisation
Both partners should be seen to:
- Acting under their own free will
- Considered other methods
199
Who is required to consent for sterilisation
Only patient themselves
200
If patient does not have capacity, who can consent for sterilisation
High Court Judgement decision
201
Explain reversing sterilisation
50% successful
| Not funded on NHS
202
What contraceptive method is more effective than sterilisation in females
Mirena coil is more effective than sterilisation
203
What is most common form of sterilisation in women >40
Tubal occlusion with fishy clips
204
What is lifetime risk of failure for sterilisation
1:200
205
What is increases risk in sterilisation
If women becomes pregnancy, likely to be ectopic
206
What do RCOG recommend about sterilisation
Do not offer to women under-30 due to high-risk of regret
207
What is first-line for sterilisation for women
Tubal occlusion with fishy clips
208
If post-partum or C section what may be used for sterilisation
Pomeroy procedure (mini-laparotomy)
209
What is the main side-effect of sterilisation
Menorrhagia
210
What is offered in male sterilisation
Vasectomy
211
When is reversal of vasectomy most-successful
In 10-years following procedure
212
How long does it take before sperm-stores are used up
3-months
213
What must be checked following vasectomy before stopping other methods of contraception
Must have two ejaculates, negative for sperm and 8W and 12W before stopping other methods of contraception.
214
What is emergency contraception
Contraception given following unprotected sexual intercourse - it is not intended for regular use
215
What are two indications for emergency contraception
- Unprotected intercourse
| - Failure of contraceptive method
216
What are the two types of emergency contraception in the UK
1. Morning-after pill
| 2. IUD
217
What are the two morning-after pills in the UK
Levonelle One-Step
| Ella-One
218
What does levonelle one step contain
Levonorgestrel 1.5mg
219
What is the MOA of levonorgestrel
Delays ovulation by 5-7d (Which is the lifetime of sperm)
220
When does levonorgestrel NOT work and why
It does not work if given after ovulation its mechanism of action is to delay ovulation to prevent sperm and egg meeting
221
What time frame of UPSI does levonorgestrel have to be given
3-days of UPSI
222
When may levonorgestrel be less effective
CYP450 inducers
Crohn's disease
>70 Kg
223
If individual is >70Kg or using CYP450-Inducers what dose of levonorgestrel should they receive
Double-dose of levonorgestrel to 3mg
224
what is the effectiveness of levonorgestrel
95% effective if taken within 3d of unprotected sex
225
what is contained in EllaOne
Ulipristil acetate
226
What is ullipristal acetate
Selective progesterone receptor modulator (SPRM)
227
What is the MOA of EllaOne
Selective progesterone receptor modulator
228
When is EllaOne not effective and why
Taken prior to ovulation. As its mechanism of action is to delay ovulation by 5-7 days
229
What respiratory condition is EllaOne contraindicated
Asthma insufficiently controlled by corticosteroids
230
What GI Conditions is EllaOne CI in
Malabsorption
Drugs than increase gastric pH (PPI, Ranitidine)
Severe Hepatic Dysfunction
231
What medications are an absolute CI of EllaOne
CYP450 inducers
232
Explain breast feeding and EllaOne
Contraindicated in breast feeding.
| Mother should not breast feed for 7d after
233
What is the time-frame of EllaOne
Take within 5d
234
What is the efficacy of EllaOne
99% effective
235
Which is better EllaOne or Levonelle One Step
EllaOne
236
What should happen if someone vomits after taking Ella One or Levonelle One Step
Seek medical help
237
What is follow-up of morning-after pill
Pregnancy Test After 3W
238
Explain IUD as form of emergency contraception
IUD is effective immediately. Can be inserted anytime during the cycle. Effective up to 5d after UPSI
239
Explain MOA of IUD as emergency contraception
Causes inflammation endometrium , preventing implantation
240
What are 3 CI to IUD
1. Fibroids
2. PID
3. STI
241
What is the efficacy of IUD for emergency contraception
99%
242
What is there an increased risk of IUD
Ectopic pregnancy. Be aware if bleeding delayed by 5d
