1: Fertility Control - Contraception Flashcards
What guidelines cover contraception in under 16’s
Fraser guidelines
What do Fraser guidelines state
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
What age is a child considered unable to consent for sexual intercourse
under 13
What should happen someone under 13-years comes for contraception advice
child protection measures
What is the fertility awareness method
Individual has awareness of their menstrual cycles and uses this to plan when to have or avoid intercourse
If a person is using the fertility method and does not want to get pregnant when should they avoid sex
6d before and 2d after ovulation
What happens to cervical mucus around ovulation
Goes from being thin to becoming thick
What are the advantages of fertility awareness method
- Can be used in developing countries
- Approved by catholic religion
What is the problem with fertility awareness
- Heavily user dependent and often fails
- Cannot be used if irregular cycles
When do women usually need to start contraception after pregnancy
21 days
When is lactational amenorrhoea effective
If started less than 6 months, no supplementary formula is used and amenorrhoeic
When can POP be started post-partum
Immediately
If POP is started 21 days post-partum what should be done
Use additional contraception for two days
When is COCP absolutely CI
Breast feeding <6W post-birth
What is COCP not advised
Breast feeding 6W-6m
If COCP is started at 21d, what should be done
Use additional contraception for 7d
When should IUD be inserted
Within 48h of childbirth or after 4W
How does barrier contraception work
prevents sperm and ova meeting
What is the advantage of condoms
protects against STIs
What is a contraindication to condoms
latex allergy
What is the failure rate of condoms and what is the failure user rate
5% failure rate
15% user failure rate
What is the femidom
one end sits in the vagina and other just outside the vulva
What is the advantage of the femidom compared to the condom
less risk of tears
What does the femidom protect against
STIs
How long before sexual intercourse is the femidom inserted
8h
how effective is the femidom
95%
what is a diaphragm
a rubber cap that covers posterior fornix and anterior-inferior uterus - so covers the cervix
what is added with a diaphragm
spermicide
how long is a diaphragm inserted before intercourse
3h
what is the problem with diaphragms
requires fitting. If individual gains/looses weight or is pregnant, the femidom will not fit
what does diaphragms increase the risk of
UTI and STI
why do diaphragms increase risk of STIs
Diaphragm can irritate the vaginal mucosa increasing risk of STIs
what is the failure rate of diaphragms
6%
what is a cap
rubber cap that covers the cervix
what is given with a cap
spermicide
how long before intercourse is a cap inserted
2h
how long should a cap be kept in after
6h
what are two disadvantages of caps
Increase risk UTIs and STIs
why do caps increase risk of STIs
Due to causing inflammation of vagina
what is the failure rate of caps
9%
what are methods of hormonal contraception
Combined or Progesterone-only
what are the methods of combined contraception
- Oral
- Patch
- Injection
- Ring (IUD, IUS)
explain MOA of combined contraceptives
High doses of oestrogen and progesterone exert negative feedback on the HPA axis, thus preventing LH surge.
what is the role of progesterone on cervical mucus and progesterone
Progesterone thickens cervical mucus preventing passage of sperm. Inhibits endometrial proliferation
what happens in pill free interval
Drop in progesterone and oestrogen causes endometrium to shed
what is the oestrogen component of combined contraceptives
Ethinyloestradiol
what is the standard dose of ethinylestradiol in COCP
30-35ug
what is progesterone component of COCP
Norethisterone
Levonorgestrel
what does the combined contraceptive pill contain
Oestrogen and Progesterone
what are monophonic pills
Each pill contains same amount of oestrogen and progesterone
what are phasic pills
Oestrogen and progesterone levels vary between pills to replicate natural changes in cycle
what is most common COCP
Microgynon 30’
what does microgynon contain
35ug of ethinylestradiol and 150ug of levonorgestrel
explain taking microgynon
Microgynon is taken for 21d with a 7d pill-free interval
what is brevinor
35ug ethinylestradiol and 0.5ug levonorgestrel
how is brevinor taken
21d with 7d pill-free interval
What is the contraceptive transdermal patch
Oestrogen and progesterone patch put on the upper arm, abdomen or buttock to protect against pregnancy
What is ortho evra
It delivers 150ug norelgestromin and 25ug ethinyl estradiol
Explain ortho evra
Patch changed every 7d for a total of 3W. Then individual has a patch-free interval
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
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
If a women has unprotected intercourse in week 1-2 and patch is delayed change what is required
- Emergency contraception
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
explain what should happen if individual delays changing or applying patch in week 4 (patch free interval)
- Use contraception for 7d
What is the nuvaring
Combined contraceptive ring that sits in the vagina
Explain the nuvaring
Inserted for 21d and then removes for 7d
When should women start the COCP
Day 1-5 of their cycle
If taken during which time period is the COCP immediately effective
Day 1-5
If COCP is started after day 5 what is required
Contraception for 7d
Explain taking the COCP
Take the pill for 21d with 7d pill-free interval
How is the COCP taken
Same-time everyday
If individual has vomiting or diarrhoea on the COCP what should they do
Use additional contraception for 7d from onset of illness
How long should COCP be started post-partum
21-days
How long should COCP be started post-termination
7-days
If individual has missed one COCP pill what should be done
- Take pill as soon as possible
- Continue pack as normal
- No additional contraception
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
If women missed >2 pills in day 1-7 and had sex what should be done
Emergency contraception required
If women missed >2 pills in day 8-14 and had sex what should be done
No need for emergency contraception
If women missed >2 pills in day 15-21 and had sex what should be done
Omit pill free interval
What is the principle of taking the COCP
Women needs to take the pill for 7 continuous days for it to be effective
What governs contraindications of contraceptives
UK medical eligibility criteria
What is UKMEC category 1
No restrictions
What is UKMEC category 2
Benefits > Risks
What is UKMEC Category 3
Risks > Benefits
If wanting to prescribe method with UKMEC category 3 guidance what is required
Referral to specialist contraceptive provider
What is UKMEC category 4
Harmful to prescribe this method
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
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
If on what medication should patients NOT be given COCP
Lamotrigine
Why should patients on lamotrigine not be given the COCP
COCP reduces concentration of lamotrigine increasing seizure frequency
What other class of drugs does COCP interact with
CYP450 Inducers = reduce concentration COCP
If on CYP450 inducers, what should happen
Give a higher dose of ethinylestradiol (50ug)
Or reduce pill-free interval to 4d
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
What are 3 side effects of COCP
Weight gain
Spotting
Headaches
What does COCP immediately increase risk of
VTE
What two cancers does COCP DEcreasee risk of
Colorectal cancer
Ovarian cancer
Explain COCP reduction in ovarian cancer
Reduces risk of ovarian cancer during its use and up to 15-years afterwards
What does the COCP increase the risk of
VTE Stroke CVD Breast cancer Cervical cancer
What two cancers does COCP increase risk of
Breast and Cervical Cancer
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
What is the background use of VTE for women
5 in 100,000
What is risk of VTE on COCP
10 in 100,000
What is a women-year
One year in the reproductive life of a sexually active women that represents 12m risk exposure to pregnancy
What is failure rate of COCP
0.2-0.3 per 100 women years
What can be used to describe rate efficacy of contraceptive methods
Pearl index
What does pearl index describe
Describes efficacy of contraceptive methods if one hundred women were to take that method for one year
What 3 cancers does COCP decrease risk of
Endometrial
Ovarian
Colorectal
Explain COCP and surgery
Stop 4W before major surgery to upper and lower limbs
What are 3 methods of progesterone-only contraception
Implant
Injectable
Oral (POP)
How many POPs are licensed in the UK
5
What is femulen
Etynodiol dicacetate
What is norgeston
Levonorgestrel
What is noriday
Norethisterone
What is micronor
Norethisterone
What is cerazette
Desogestrel
What is the window to take the pill if it contains etynodiol, levonorgestrel or northisterone
3h
What is the window to take the pill if it contains desogestrel
12h
What pill has a 12h window
Cerazette
What are the 3 mechanisms of action of progesterone as a contraceptive
- High doses of progesterone suppress HPA axis
- Thickens cervical mucus
- Endometrial thinning
When should the POP be started
Day 1-5 of the cycle
If started after day-5 how long should contraception be used for
If started after day 5 take other contraception for 48h
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
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
After TOP when should POP be stated
Same-day
Explain missed pill for POP
Take pill as soon as possible and subsequent pills. Use additional contraception for 48h.
What are 5 side-effects of the POP
Breast tenderness Appetite stimulant - weight gain Mood changes Abdominal Bloating Headaches Menstrual irregularity
What is a UKMEC category 4 contraindication of POP
Current breast cancer
What are 4 UKMEC category 3 contraindications for POP
- IHD on POP (stop POP)
- Decompensated liver cirrhosis or hepatocellular carcinoma
- Previous breast cancer
- Unexplained vaginal bleeding
What drugs does POP interact with
CYP450 Inducers decrease efficacy of POP
What cancer does POP decrease incidence of
Endometrial
What condition does POP decrease incidence of
PID
What cancer does POP increase incidence of
Breast
What condition does POP increase risk of
Ovarian cysts
Explain efficacy of POP related to BMI
> 70Kg: has a very limited efficacy
What is the failure rate of POP
4% in 100 women-years
What is the only progesterone implant licensed in the UK called
Nexplenon
What is nexaplanon
Small flexible tube inserted sub-dermally into the upper arm
What does nexplanon contain
68mg etonorgestrel
How long is nexplanon effective
3-years
What is the predominant mechanism of nexplanon
High-dose inhibits HPA axis
Aside from inhibiting ovulation, how else may progesterone prevent fertilisation
- Thickens cervical mucus
- Thins endometrium
When should progesterone-implant be inserted
Day 1-5
If implant is inserted after day-5 cycle what is required
Additional barrier contraception
What is the main side-effect of the implant
Erratic bleeding
What is UKMEC Category 4 for implant
Breast Cancer
What are 4 UKMEC Category 3’s for the implant
Decompensated Cirrhosis
Hepatocellular carcinoma
IHD on implant
Unexplained vaginal bleeding
What happens to fertility on removal of implant
Fertility returns immediately
What cancer does implant reduce incidence of
Endometrial
What cancer does implant increase risk of
Breast
What is failure rate of implant
<0.1 per 100-women years
Explain progesterone-only injectable
Long-term contraception. Where individuals receives IM or injectable progesterone
What are the three types of injectable progesterone in the UK
Depo-provea
Noristerat
Sayan Press
What is Depo-Provera Injection
Medroxyprogesterone acetate 150mg
How is depo-provea given
IM-injection every 12W
What cancer does depo-provea reduce incidence of
Endometrial
What is the main complication of depo-provea
- Delayed Fertility after cessation
- Weight gain 2-3Kg per-year
- Erratic bleeding
When may depo-provea not be suitable
Sub-fertile individuals. Eg. PCOS, as delayed return to fertility further decreases their chances
What is main side effect whilst on depo provea
Erratic bleeding
Weight Gain
Explain weight changes on depo provea
2-3Kg weight gain per year
What cancer does depo provea increase risk of
Breast cancer
If used for more than one year, what does depo provea increase risk of
Decreases bone mineral density - can lead to osteoporosis
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
What is a UKMEC 4 contraindication of injectable progesterone
Current breast cancer
What are 5 UKMEC 3 contraindications for injectable progesterone
- Several CVD risk factors
- Peripheral vascular disease
- History TIA or Stroke
- Previous breast cancer
.5 Cirrhosis or hepatocellular carcinoma - Unexplained vaginal bleeding
What do intrauterine systems contain
Levonorgestrel
What are the two types of levonorgestrel releasing system
Jaydess
Mirena
How long does jaydess last
3-years
How long does the mirena coil last
5-years
What is the MOA of the IUS
Releases levonorgestrel daily. This thickens cervical mucus preventing sperm entry. And, thins the endometrium.
What is a common side effect of IUS
Irregular bleeding in first 3-4 months
What are 3 UKMEC 3 contraindications of IUS
- Fibroids
- Hepatocellular carcinoma
- Long QT
What are 6 UKMEC4 contraindications of IUS
- Unexplained PV Bleed
- PID
- Gonorrhoea
- Chlamydia
- Endometrial cancer
- Cervical cancer
- Raised hCG
What is the IUD
Copper coil
What is the advantage of the IUD
Can be used for emergency contraception
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
What are the two types of IUD
5-year
10-year
What needs to be checked prior to inserting IUD
STI screen
If need to insert same-day, cover with 1g azithromycin
When should IUD be inserted
Can be inserted any-time during the cycle
When can IUD be inserted following birth
4W
What are two risks of inserting IUD
Cervical shock
Perforation
What is cervical shock
Hypotension and tachycardia due to increased vagal tone
When does expulsion of IUD occur
First 3 months
When should individual with IUD be followed up
Follow up after first period to ensure still in place
What should happen prior to removing IUD
Cover with another form of contraception. if not, abstain for 7d
If a women is over-50 and has not had periods for one year, how long should they keep IUD in
1-year
If a women is under-50 and has not had periods for one year, how long should they keep IUD in
2-years
What does IUD increase risk of immediately following insertion
For first 21-days after insertion, IUD increases risk of PID
How long does IUD increase risk of PID
21-days
What are 2 side effects of IUD
Menorrhagia
Dysmenorrhoea
What is the problem if someone becomes pregnant with IUD
1:20 chance it is ectopic
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.
If individual has an STI with an IUD what should be done
Keep IUD in and treat infection
If individual removes IUD due to STI what should be done about re-inserting
Do not re-insert for 3-months
If person finds out they are pregnant with IUD what should be done
Remove IUD as soon as possible.
What are 4 UKMEC 3 CI to IUD
Fibroids
Long QT
48h - 4W post-partum
HIV CD4 <200
What are 6 UKMEC 4 CI to IUD
- Unexplained PV Bleed
- PID
- Gonorrhoea
- Chlamydia
- Pelvic TB
- Copper allergy
- Post-partum sepsis or post-abortion sepsis
- Raised bHCG
- Endometrial cancer
- Cervical cancer
What is sterilisation
Permanent irreversible contraception
What is a pre-requisite for sterilisation
Both partners should be seen to:
- Acting under their own free will
- Considered other methods
Who is required to consent for sterilisation
Only patient themselves
If patient does not have capacity, who can consent for sterilisation
High Court Judgement decision
Explain reversing sterilisation
50% successful
Not funded on NHS
What contraceptive method is more effective than sterilisation in females
Mirena coil is more effective than sterilisation
What is most common form of sterilisation in women >40
Tubal occlusion with fishy clips
What is lifetime risk of failure for sterilisation
1:200
What is increases risk in sterilisation
If women becomes pregnancy, likely to be ectopic
What do RCOG recommend about sterilisation
Do not offer to women under-30 due to high-risk of regret
What is first-line for sterilisation for women
Tubal occlusion with fishy clips
If post-partum or C section what may be used for sterilisation
Pomeroy procedure (mini-laparotomy)
What is the main side-effect of sterilisation
Menorrhagia
What is offered in male sterilisation
Vasectomy
When is reversal of vasectomy most-successful
In 10-years following procedure
How long does it take before sperm-stores are used up
3-months
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.
What is emergency contraception
Contraception given following unprotected sexual intercourse - it is not intended for regular use
What are two indications for emergency contraception
- Unprotected intercourse
- Failure of contraceptive method
What are the two types of emergency contraception in the UK
- Morning-after pill
2. IUD
What are the two morning-after pills in the UK
Levonelle One-Step
Ella-One
What does levonelle one step contain
Levonorgestrel 1.5mg
What is the MOA of levonorgestrel
Delays ovulation by 5-7d (Which is the lifetime of sperm)
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
What time frame of UPSI does levonorgestrel have to be given
3-days of UPSI
When may levonorgestrel be less effective
CYP450 inducers
Crohn’s disease
>70 Kg
If individual is >70Kg or using CYP450-Inducers what dose of levonorgestrel should they receive
Double-dose of levonorgestrel to 3mg
what is the effectiveness of levonorgestrel
95% effective if taken within 3d of unprotected sex
what is contained in EllaOne
Ulipristil acetate
What is ullipristal acetate
Selective progesterone receptor modulator (SPRM)
What is the MOA of EllaOne
Selective progesterone receptor modulator
When is EllaOne not effective and why
Taken prior to ovulation. As its mechanism of action is to delay ovulation by 5-7 days
What respiratory condition is EllaOne contraindicated
Asthma insufficiently controlled by corticosteroids
What GI Conditions is EllaOne CI in
Malabsorption
Drugs than increase gastric pH (PPI, Ranitidine)
Severe Hepatic Dysfunction
What medications are an absolute CI of EllaOne
CYP450 inducers
Explain breast feeding and EllaOne
Contraindicated in breast feeding.
Mother should not breast feed for 7d after
What is the time-frame of EllaOne
Take within 5d
What is the efficacy of EllaOne
99% effective
Which is better EllaOne or Levonelle One Step
EllaOne
What should happen if someone vomits after taking Ella One or Levonelle One Step
Seek medical help
What is follow-up of morning-after pill
Pregnancy Test After 3W
Explain IUD as form of emergency contraception
IUD is effective immediately. Can be inserted anytime during the cycle. Effective up to 5d after UPSI
Explain MOA of IUD as emergency contraception
Causes inflammation endometrium , preventing implantation
What are 3 CI to IUD
- Fibroids
- PID
- STI
What is the efficacy of IUD for emergency contraception
99%
What is there an increased risk of IUD
Ectopic pregnancy. Be aware if bleeding delayed by 5d
