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Gynaecology > 1: Fertility Control - Contraception > Flashcards

1: Fertility Control - Contraception Flashcards

1
Q

What guidelines cover contraception in under 16’s

A

Fraser guidelines

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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

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3
Q

What age is a child considered unable to consent for sexual intercourse

A

under 13

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4
Q

What should happen someone under 13-years comes for contraception advice

A

child protection measures

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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

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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

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7
Q

What happens to cervical mucus around ovulation

A

Goes from being thin to becoming thick

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8
Q

What are the advantages of fertility awareness method

A
  • Can be used in developing countries

- Approved by catholic religion

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9
Q

What is the problem with fertility awareness

A
  • Heavily user dependent and often fails

- Cannot be used if irregular cycles

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10
Q

When do women usually need to start contraception after pregnancy

A

21 days

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11
Q

When is lactational amenorrhoea effective

A

If started less than 6 months, no supplementary formula is used and amenorrhoeic

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12
Q

When can POP be started post-partum

A

Immediately

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13
Q

If POP is started 21 days post-partum what should be done

A

Use additional contraception for two days

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14
Q

When is COCP absolutely CI

A

Breast feeding <6W post-birth

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15
Q

What is COCP not advised

A

Breast feeding 6W-6m

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16
Q

If COCP is started at 21d, what should be done

A

Use additional contraception for 7d

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17
Q

When should IUD be inserted

A

Within 48h of childbirth or after 4W

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18
Q

How does barrier contraception work

A

prevents sperm and ova meeting

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19
Q

What is the advantage of condoms

A

protects against STIs

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20
Q

What is a contraindication to condoms

A

latex allergy

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21
Q

What is the failure rate of condoms and what is the failure user rate

A

5% failure rate

15% user failure rate

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22
Q

What is the femidom

A

one end sits in the vagina and other just outside the vulva

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23
Q

What is the advantage of the femidom compared to the condom

A

less risk of tears

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24
Q

What does the femidom protect against

A

STIs

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25
Q

How long before sexual intercourse is the femidom inserted

A

8h

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26
Q

how effective is the femidom

A

95%

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27
Q

what is a diaphragm

A

a rubber cap that covers posterior fornix and anterior-inferior uterus - so covers the cervix

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28
Q

what is added with a diaphragm

A

spermicide

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29
Q

how long is a diaphragm inserted before intercourse

A

3h

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30
Q

what is the problem with diaphragms

A

requires fitting. If individual gains/looses weight or is pregnant, the femidom will not fit

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31
Q

what does diaphragms increase the risk of

A

UTI and STI

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32
Q

why do diaphragms increase risk of STIs

A

Diaphragm can irritate the vaginal mucosa increasing risk of STIs

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33
Q

what is the failure rate of diaphragms

A

6%

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34
Q

what is a cap

A

rubber cap that covers the cervix

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35
Q

what is given with a cap

A

spermicide

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36
Q

how long before intercourse is a cap inserted

A

2h

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37
Q

how long should a cap be kept in after

A

6h

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38
Q

what are two disadvantages of caps

A

Increase risk UTIs and STIs

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39
Q

why do caps increase risk of STIs

A

Due to causing inflammation of vagina

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40
Q

what is the failure rate of caps

A

9%

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41
Q

what are methods of hormonal contraception

A

Combined or Progesterone-only

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42
Q

what are the methods of combined contraception

A
  • Oral
  • Patch
  • Injection
  • Ring (IUD, IUS)
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43
Q

explain MOA of combined contraceptives

A

High doses of oestrogen and progesterone exert negative feedback on the HPA axis, thus preventing LH surge.

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44
Q

what is the role of progesterone on cervical mucus and progesterone

A

Progesterone thickens cervical mucus preventing passage of sperm. Inhibits endometrial proliferation

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45
Q

what happens in pill free interval

A

Drop in progesterone and oestrogen causes endometrium to shed

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46
Q

what is the oestrogen component of combined contraceptives

A

Ethinyloestradiol

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47
Q

what is the standard dose of ethinylestradiol in COCP

A

30-35ug

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48
Q

what is progesterone component of COCP

A

Norethisterone

Levonorgestrel

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49
Q

what does the combined contraceptive pill contain

A

Oestrogen and Progesterone

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50
Q

what are monophonic pills

A

Each pill contains same amount of oestrogen and progesterone

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51
Q

what are phasic pills

A

Oestrogen and progesterone levels vary between pills to replicate natural changes in cycle

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52
Q

what is most common COCP

A

Microgynon 30’

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53
Q

what does microgynon contain

A

35ug of ethinylestradiol and 150ug of levonorgestrel

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54
Q

explain taking microgynon

A

Microgynon is taken for 21d with a 7d pill-free interval

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55
Q

what is brevinor

A

35ug ethinylestradiol and 0.5ug levonorgestrel

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56
Q

how is brevinor taken

A

21d with 7d pill-free interval

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57
Q

What is the contraceptive transdermal patch

A

Oestrogen and progesterone patch put on the upper arm, abdomen or buttock to protect against pregnancy

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58
Q

What is ortho evra

A

It delivers 150ug norelgestromin and 25ug ethinyl estradiol

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59
Q

Explain ortho evra

A

Patch changed every 7d for a total of 3W. Then individual has a patch-free interval

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60
Q

if a women is in week 1-2 and delays changing the patch less than 48h what should be done

A
  • Change patch as soon as possible

- No additional protection needed

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61
Q

If a women is week 1-2 and delays changing patch by 48h what should be done

A
  • Change patch as soon as possible

- Contraception for 7d

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62
Q

If a women has unprotected intercourse in week 1-2 and patch is delayed change what is required

A
  • Emergency contraception
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63
Q

explain what should happen if individual delays changing their patch in week 3

A

Take the patch free interval and apply patch at the start-date of the new cycle

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64
Q

explain what should happen if individual delays changing or applying patch in week 4 (patch free interval)

A
  • Use contraception for 7d
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65
Q

What is the nuvaring

A

Combined contraceptive ring that sits in the vagina

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66
Q

Explain the nuvaring

A

Inserted for 21d and then removes for 7d

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67
Q

When should women start the COCP

A

Day 1-5 of their cycle

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68
Q

If taken during which time period is the COCP immediately effective

A

Day 1-5

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69
Q

If COCP is started after day 5 what is required

A

Contraception for 7d

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70
Q

Explain taking the COCP

A

Take the pill for 21d with 7d pill-free interval

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71
Q

How is the COCP taken

A

Same-time everyday

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72
Q

If individual has vomiting or diarrhoea on the COCP what should they do

A

Use additional contraception for 7d from onset of illness

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73
Q

How long should COCP be started post-partum

A

21-days

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74
Q

How long should COCP be started post-termination

A

7-days

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75
Q

If individual has missed one COCP pill what should be done

A
  • Take pill as soon as possible
  • Continue pack as normal
  • No additional contraception
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76
Q

If individual has missed two or more pills what should she do about taking that pill

A
  • Take pill as soon as possible. Even if that means two pills in one day
  • Leave any earlier missed pills
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77
Q

If women missed >2 pills in day 1-7 and had sex what should be done

A

Emergency contraception required

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78
Q

If women missed >2 pills in day 8-14 and had sex what should be done

A

No need for emergency contraception

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79
Q

If women missed >2 pills in day 15-21 and had sex what should be done

A

Omit pill free interval

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80
Q

What is the principle of taking the COCP

A

Women needs to take the pill for 7 continuous days for it to be effective

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81
Q

What governs contraindications of contraceptives

A

UK medical eligibility criteria

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82
Q

What is UKMEC category 1

A

No restrictions

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83
Q

What is UKMEC category 2

A

Benefits > Risks

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84
Q

What is UKMEC Category 3

A

Risks > Benefits

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85
Q

If wanting to prescribe method with UKMEC category 3 guidance what is required

A

Referral to specialist contraceptive provider

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86
Q

What is UKMEC category 4

A

Harmful to prescribe this method

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87
Q

For the COCP what are 8 UKMEC 3 contraindications

A

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

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88
Q

For COCP what are 10 UKMEC 4 contraindications

A

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
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89
Q

If on what medication should patients NOT be given COCP

A

Lamotrigine

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90
Q

Why should patients on lamotrigine not be given the COCP

A

COCP reduces concentration of lamotrigine increasing seizure frequency

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91
Q

What other class of drugs does COCP interact with

A

CYP450 Inducers = reduce concentration COCP

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92
Q

If on CYP450 inducers, what should happen

A

Give a higher dose of ethinylestradiol (50ug)

Or reduce pill-free interval to 4d

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93
Q

What is a side effect of COCP and how can this be reduced

A

Spotting for first 3-4m.

Reduce by taking the pill at the same time every day

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94
Q

What are 3 side effects of COCP

A

Weight gain
Spotting
Headaches

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95
Q

What does COCP immediately increase risk of

A

VTE

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96
Q

What two cancers does COCP DEcreasee risk of

A

Colorectal cancer

Ovarian cancer

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97
Q

Explain COCP reduction in ovarian cancer

A

Reduces risk of ovarian cancer during its use and up to 15-years afterwards

98
Q

What does the COCP increase the risk of

A 
VTE
Stroke 
CVD 
Breast cancer
Cervical cancer
99
Q

What two cancers does COCP increase risk of

A

Breast and Cervical Cancer

100
Q

Explain COCP and risk of breast cancer

A

COCP increases risk of breast cancer during use. This risk returns to baseline 10-years after ceasing use

101
Q

What is the background use of VTE for women

A

5 in 100,000

102
Q

What is risk of VTE on COCP

A

10 in 100,000

103
Q

What is a women-year

A

One year in the reproductive life of a sexually active women that represents 12m risk exposure to pregnancy

104
Q

What is failure rate of COCP

A

0.2-0.3 per 100 women years

105
Q

What can be used to describe rate efficacy of contraceptive methods

A

Pearl index

106
Q

What does pearl index describe

A

Describes efficacy of contraceptive methods if one hundred women were to take that method for one year

107
Q

What 3 cancers does COCP decrease risk of

A

Endometrial
Ovarian
Colorectal

108
Q

Explain COCP and surgery

A

Stop 4W before major surgery to upper and lower limbs

109
Q

What are 3 methods of progesterone-only contraception

A

Implant
Injectable
Oral (POP)

110
Q

How many POPs are licensed in the UK

111
Q

What is femulen

A

Etynodiol dicacetate

112
Q

What is norgeston

A

Levonorgestrel

113
Q

What is noriday

A

Norethisterone

114
Q

What is micronor

A

Norethisterone

115
Q

What is cerazette

A

Desogestrel

116
Q

What is the window to take the pill if it contains etynodiol, levonorgestrel or northisterone

117
Q

What is the window to take the pill if it contains desogestrel

118
Q

What pill has a 12h window

119
Q

What are the 3 mechanisms of action of progesterone as a contraceptive

A
  1. High doses of progesterone suppress HPA axis
  2. Thickens cervical mucus
  3. Endometrial thinning
120
Q

When should the POP be started

A

Day 1-5 of the cycle

121
Q

If started after day-5 how long should contraception be used for

A

If started after day 5 take other contraception for 48h

122
Q

Explain taking the POP

A

POP should be taken at the same time every-day. If containing levongestrel or northisterone take 3h. If desoestrogel take 12h

123
Q

After pregnancy when should POP be started

A

POP can be started at anytime postpartum and is hence the preferred method.

If started after day 21 - need two days barrier contraception

124
Q

After TOP when should POP be stated

125
Q

Explain missed pill for POP

A

Take pill as soon as possible and subsequent pills. Use additional contraception for 48h.

126
Q

What are 5 side-effects of the POP

A 
Breast tenderness 
Appetite stimulant - weight gain 
Mood changes
Abdominal Bloating 
Headaches 
Menstrual irregularity
127
Q

What is a UKMEC category 4 contraindication of POP

A

Current breast cancer

128
Q

What are 4 UKMEC category 3 contraindications for POP

A
  1. IHD on POP (stop POP)
  2. Decompensated liver cirrhosis or hepatocellular carcinoma
  3. Previous breast cancer
  4. Unexplained vaginal bleeding
129
Q

What drugs does POP interact with

A

CYP450 Inducers decrease efficacy of POP

130
Q

What cancer does POP decrease incidence of

A

Endometrial

131
Q

What condition does POP decrease incidence of

132
Q

What cancer does POP increase incidence of

133
Q

What condition does POP increase risk of

A

Ovarian cysts

134
Q

Explain efficacy of POP related to BMI

A

> 70Kg: has a very limited efficacy

135
Q

What is the failure rate of POP

A

4% in 100 women-years

136
Q

What is the only progesterone implant licensed in the UK called

137
Q

What is nexaplanon

A

Small flexible tube inserted sub-dermally into the upper arm

138
Q

What does nexplanon contain

A

68mg etonorgestrel

139
Q

How long is nexplanon effective

140
Q

What is the predominant mechanism of nexplanon

A

High-dose inhibits HPA axis

141
Q

Aside from inhibiting ovulation, how else may progesterone prevent fertilisation

A
  • Thickens cervical mucus

- Thins endometrium

142
Q

When should progesterone-implant be inserted

143
Q

If implant is inserted after day-5 cycle what is required

A

Additional barrier contraception

144
Q

What is the main side-effect of the implant

A

Erratic bleeding

145
Q

What is UKMEC Category 4 for implant

A

Breast Cancer

146
Q

What are 4 UKMEC Category 3’s for the implant

A

Decompensated Cirrhosis
Hepatocellular carcinoma
IHD on implant
Unexplained vaginal bleeding

147
Q

What happens to fertility on removal of implant

A

Fertility returns immediately

148
Q

What cancer does implant reduce incidence of

A

Endometrial

149
Q

What cancer does implant increase risk of

150
Q

What is failure rate of implant

A

<0.1 per 100-women years

151
Q

Explain progesterone-only injectable

A

Long-term contraception. Where individuals receives IM or injectable progesterone

152
Q

What are the three types of injectable progesterone in the UK

A

Depo-provea
Noristerat
Sayan Press

153
Q

What is Depo-Provera Injection

A

Medroxyprogesterone acetate 150mg

154
Q

How is depo-provea given

A

IM-injection every 12W

155
Q

What cancer does depo-provea reduce incidence of

A

Endometrial

156
Q

What is the main complication of depo-provea

A
  • Delayed Fertility after cessation
  • Weight gain 2-3Kg per-year
  • Erratic bleeding
157
Q

When may depo-provea not be suitable

A

Sub-fertile individuals. Eg. PCOS, as delayed return to fertility further decreases their chances

158
Q

What is main side effect whilst on depo provea

A

Erratic bleeding

Weight Gain

159
Q

Explain weight changes on depo provea

A

2-3Kg weight gain per year

160
Q

What cancer does depo provea increase risk of

A

Breast cancer

161
Q

If used for more than one year, what does depo provea increase risk of

A

Decreases bone mineral density - can lead to osteoporosis

162
Q

Give 4 side effects of depo-provea

A
  • Irregular bleeding
  • Delayed return to fertility of 6-12m
  • Appetite stimulate causing weight gain
  • Decreases bone mineral density
163
Q

What is a UKMEC 4 contraindication of injectable progesterone

A

Current breast cancer

164
Q

What are 5 UKMEC 3 contraindications for injectable progesterone

A
  1. Several CVD risk factors
  2. Peripheral vascular disease
  3. History TIA or Stroke
  4. Previous breast cancer
    .5 Cirrhosis or hepatocellular carcinoma
  5. Unexplained vaginal bleeding
165
Q

What do intrauterine systems contain

A

Levonorgestrel

166
Q

What are the two types of levonorgestrel releasing system

A

Jaydess

Mirena

167
Q

How long does jaydess last

168
Q

How long does the mirena coil last

169
Q

What is the MOA of the IUS

A

Releases levonorgestrel daily. This thickens cervical mucus preventing sperm entry. And, thins the endometrium.

170
Q

What is a common side effect of IUS

A

Irregular bleeding in first 3-4 months

171
Q

What are 3 UKMEC 3 contraindications of IUS

A
  1. Fibroids
  2. Hepatocellular carcinoma
  3. Long QT
172
Q

What are 6 UKMEC4 contraindications of IUS

A
  1. Unexplained PV Bleed
  2. PID
  3. Gonorrhoea
  4. Chlamydia
  5. Endometrial cancer
  6. Cervical cancer
  7. Raised hCG
173
Q

What is the IUD

A

Copper coil

174
Q

What is the advantage of the IUD

A

Can be used for emergency contraception

175
Q

Explain MOA of IUD

A
  • Copper is spermatotoxic

- It also causes an inflammatory reaction of the endometrium, meaning if fertilised it will be unable to implant

176
Q

What are the two types of IUD

A

5-year

10-year

177
Q

What needs to be checked prior to inserting IUD

A

STI screen

If need to insert same-day, cover with 1g azithromycin

178
Q

When should IUD be inserted

A

Can be inserted any-time during the cycle

179
Q

When can IUD be inserted following birth

180
Q

What are two risks of inserting IUD

A

Cervical shock

Perforation

181
Q

What is cervical shock

A

Hypotension and tachycardia due to increased vagal tone

182
Q

When does expulsion of IUD occur

A

First 3 months

183
Q

When should individual with IUD be followed up

A

Follow up after first period to ensure still in place

184
Q

What should happen prior to removing IUD

A

Cover with another form of contraception. if not, abstain for 7d

185
Q

If a women is over-50 and has not had periods for one year, how long should they keep IUD in

186
Q

If a women is under-50 and has not had periods for one year, how long should they keep IUD in

187
Q

What does IUD increase risk of immediately following insertion

A

For first 21-days after insertion, IUD increases risk of PID

188
Q

How long does IUD increase risk of PID

189
Q

What are 2 side effects of IUD

A

Menorrhagia

Dysmenorrhoea

190
Q

What is the problem if someone becomes pregnant with IUD

A

1:20 chance it is ectopic

191
Q

With an IUD, what should a women check after each period

A

That they can feel the threats. If unpalatable, US uterus to find coil. If still not found, x-ray.

192
Q

If individual has an STI with an IUD what should be done

A

Keep IUD in and treat infection

193
Q

If individual removes IUD due to STI what should be done about re-inserting

A

Do not re-insert for 3-months

194
Q

If person finds out they are pregnant with IUD what should be done

A

Remove IUD as soon as possible.

195
Q

What are 4 UKMEC 3 CI to IUD

A

Fibroids
Long QT
48h - 4W post-partum
HIV CD4 <200

196
Q

What are 6 UKMEC 4 CI to IUD

A
  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
Q

What is sterilisation

A

Permanent irreversible contraception

198
Q

What is a pre-requisite for sterilisation

A

Both partners should be seen to:

  • Acting under their own free will
  • Considered other methods
199
Q

Who is required to consent for sterilisation

A

Only patient themselves

200
Q

If patient does not have capacity, who can consent for sterilisation

A

High Court Judgement decision

201
Q

Explain reversing sterilisation

A

50% successful

Not funded on NHS

202
Q

What contraceptive method is more effective than sterilisation in females

A

Mirena coil is more effective than sterilisation

203
Q

What is most common form of sterilisation in women >40

A

Tubal occlusion with fishy clips

204
Q

What is lifetime risk of failure for sterilisation

205
Q

What is increases risk in sterilisation

A

If women becomes pregnancy, likely to be ectopic

206
Q

What do RCOG recommend about sterilisation

A

Do not offer to women under-30 due to high-risk of regret

207
Q

What is first-line for sterilisation for women

A

Tubal occlusion with fishy clips

208
Q

If post-partum or C section what may be used for sterilisation

A

Pomeroy procedure (mini-laparotomy)

209
Q

What is the main side-effect of sterilisation

A

Menorrhagia

210
Q

What is offered in male sterilisation

211
Q

When is reversal of vasectomy most-successful

A

In 10-years following procedure

212
Q

How long does it take before sperm-stores are used up

213
Q

What must be checked following vasectomy before stopping other methods of contraception

A

Must have two ejaculates, negative for sperm and 8W and 12W before stopping other methods of contraception.

214
Q

What is emergency contraception

A

Contraception given following unprotected sexual intercourse - it is not intended for regular use

215
Q

What are two indications for emergency contraception

A
  • Unprotected intercourse

- Failure of contraceptive method

216
Q

What are the two types of emergency contraception in the UK

A
  1. Morning-after pill

2. IUD

217
Q

What are the two morning-after pills in the UK

A

Levonelle One-Step

Ella-One

218
Q

What does levonelle one step contain

A

Levonorgestrel 1.5mg

219
Q

What is the MOA of levonorgestrel

A

Delays ovulation by 5-7d (Which is the lifetime of sperm)

220
Q

When does levonorgestrel NOT work and why

A

It does not work if given after ovulation its mechanism of action is to delay ovulation to prevent sperm and egg meeting

221
Q

What time frame of UPSI does levonorgestrel have to be given

A

3-days of UPSI

222
Q

When may levonorgestrel be less effective

A

CYP450 inducers
Crohn’s disease
>70 Kg

223
Q

If individual is >70Kg or using CYP450-Inducers what dose of levonorgestrel should they receive

A

Double-dose of levonorgestrel to 3mg

224
Q

what is the effectiveness of levonorgestrel

A

95% effective if taken within 3d of unprotected sex

225
Q

what is contained in EllaOne

A

Ulipristil acetate

226
Q

What is ullipristal acetate

A

Selective progesterone receptor modulator (SPRM)

227
Q

What is the MOA of EllaOne

A

Selective progesterone receptor modulator

228
Q

When is EllaOne not effective and why

A

Taken prior to ovulation. As its mechanism of action is to delay ovulation by 5-7 days

229
Q

What respiratory condition is EllaOne contraindicated

A

Asthma insufficiently controlled by corticosteroids

230
Q

What GI Conditions is EllaOne CI in

A

Malabsorption
Drugs than increase gastric pH (PPI, Ranitidine)
Severe Hepatic Dysfunction

231
Q

What medications are an absolute CI of EllaOne

A

CYP450 inducers

232
Q

Explain breast feeding and EllaOne

A

Contraindicated in breast feeding.

Mother should not breast feed for 7d after

233
Q

What is the time-frame of EllaOne

A

Take within 5d

234
Q

What is the efficacy of EllaOne

A

99% effective

235
Q

Which is better EllaOne or Levonelle One Step

236
Q

What should happen if someone vomits after taking Ella One or Levonelle One Step

A

Seek medical help

237
Q

What is follow-up of morning-after pill

A

Pregnancy Test After 3W

238
Q

Explain IUD as form of emergency contraception

A

IUD is effective immediately. Can be inserted anytime during the cycle. Effective up to 5d after UPSI

239
Q

Explain MOA of IUD as emergency contraception

A

Causes inflammation endometrium , preventing implantation

240
Q

What are 3 CI to IUD

A
  1. Fibroids
  2. PID
  3. STI
241
Q

What is the efficacy of IUD for emergency contraception

242
Q

What is there an increased risk of IUD

A

Ectopic pregnancy. Be aware if bleeding delayed by 5d

Gynaecology (22 decks)

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