11- Contraception Flashcards
methods of contraception
1) Short term contraception
- Combined pill
- Progesterone only pill
- Barrier methods
2) Long term contraception
- IUD
- IUS
- Implant
- Injection
- Surgery e,g. sterilisation
3) Emergency contraception
how % effectiveness works with contraception
What 99% effective means is that if an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
- depends on perfect use vs typical use
3 most effective forms of contraception
long term/permanent
- progesterone only implant
- coils
- surgery e.g. sterilisation
all >99% effective
risk factors to think about when offering contraception
- breast cancer
- cervical or endometrial cancer
- wilsons disease
which contraception to avoid if history of breask cacner
any hormonal contraception and go for the copper coil or barrier methods
which contraception to avoid if history of cervical or endometrial cancer
avoid the intrauterine system (i.e. Mirena coil)
which contraception to avoid if history of Wilsons disease
avoid copper coil
specific risk factors that should make you avoid the combined contraceptive pill
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
consideration of contraception in older women
- After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
- Hormone replacement therapy does not prevent pregnancy, and added contraception is required
- The combined contraceptive pill can be used up to age 50 years, and can treat perimenopausal symptoms
- The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of osteoporosis
fertility after childbirth is considered not to return until …. days after giving burth
21 days… no contraception required
contracpetion in women have have just giving birth
- lactational amenorrheoa
- progesterone only pill and implant
- copper coil or intrauterine system
Lactational amenorrhea
is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
when are the progestogen-only pill and implant considered safe after birth
me
any time
- will require protection for 2 days for POP
when is the COCP considered safe after birth
should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
when can a coil be inserted after birth
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1),** but not inserted between 48 hours and 4 weeks of birth **(UKMEC 3).
barrier method
provide a physical barrier to semen entering the uterus and causing pregnancy.
- They are the only method that helps protect against sexually transmitted infections (STIs).
- They are not 100% effective for contraception or preventing STIs.
example of barrier methods
- condoms
- diaphragms and cervical caps
- dental dams
effectiveness of condoms
perfect use: 98%
typical use : 82%
- using oil based lube can damage latex condom
diaphragms and cervical caps
Diaphragms and cervical caps are silicone cups that fit over the cervix and prevent semen from entering the uterus. The woman fits them before having sex, and leaves them in place for at least 6 hours after sex. They should be used with spermicide gel the further reduce the risk of pregnancy.
Dental Dams
are used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus. They are used to prevent infections that can be spread through oral sex, including:
- Chlamydia
- Gonorrhoea
- Herpes simplex 1 and 2
- HPV (human papillomavirus)
- E. coli
- Pubic lice
- Syphilis
- HIV
The combined pill
e.g. Microgynon and Yasmin MOA
Pill containing oestrogen and progestogen
3 MOA
- Stopping ovulation
- Making cervical mucus thicker
- Preventing thickening of the endometrium
how does the COCP affect the HPG axis
- Oestrogen and progesterone have a negative feedback effect on the hypothalamus and anterior pituitary, suppressing the release of
- GnRH, LH and FSH. Without the effects of LH and FSH, ovulation does not occur.
- Pregnancy cannot happen without ovulation.
2 types of COCPs
- Monophasic pills contain the same amount of hormone in each pill
- Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
which brands of COCP have a lower risk of VTE
Microgynon or Leostrin
which COCP for PMS
Yasmin (contains drospirenone - anti-mineralocorticoid and anti- androgen activity)
correct use of the COCP
- Take 1 every day for 21 days and then have a 7 day break (although can decide not to take a break)
- Take pill at around same time everyday
- When taken correctly 99% effective at preventing pregnancy
Starting this pill
- If you start the combined pill on the 1st day of your period ( day 1 of menstrual cycle) – protection from pregnancy starts straight away
- Starting after the 5th day of your cycle- need to take pill for 7 days
side effects of COCP
Side Effects and Risks
- Unscheduled bleeding is common in the first three months and should then settle with time
- Breast pain and tenderness
- Mood changes and depression
- Headaches
- Hypertension
- Venous thromboembolism (the risk is much lower for the pill than pregnancy)
- Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
- Small increased risk of myocardial infarction and stroke
benefits of COCP
- Effective contraception
- Rapid return of fertility after stopping
- Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
- Reduced risk of endometrial, ovarian and colon cancer
- Reduced risk of benign ovarian cysts
There are several things to check and discuss when prescribing the combined pill:
- Different contraceptive options, including long-acting reversible contraception (LARC)
- Contraindications
- Adverse effects
- Instructions for taking the pill, including missed pills
- Factors that will impact the efficacy (e.g. diarrhoea and vomiting)
- Sexually transmitted infections (this pill is not protective)
- Safeguarding concerns (particularly in those under 16)
Screen for contraindications by discussing and documenting:
- Age
- Weight and height (BMI)
- Blood pressure
- Smoker or non-smoker
- Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
- Family history (particularly VTE and breast cancer)
COCP: Missing one pill (less than 72 hours since the last pill was taken):
- Take the missed pill as soon as possible (even if this means taking two pills on the same day)
- No extra protection is required provided other pills before and after are taken correctly
COCP: Missing more than one pill (more than 72 hours since the last pill was taken)
Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day). Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight.
- If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
- If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
- If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
V and D and COCP
- If you vomit within 3 hours of taking combined pill- take another pill straight and away and the next pill at usual time. If you continue to vomit – use other contraception
- Very severe diarrhoea – use additional contraception when recovering
- If more than 24s hour missed, take 2 at a time
MOA of POP
only contains Progesterone
Traditional
- Thickening the cervical mucus
- Altering the endometrium and making it less accepting of implantation
- Reducing ciliary action in the fallopian tubes
Desogestrel
* Inhibiting ovulation
* Thickening the cervical mucus
* Altering the endometrium
* Reducing ciliary action in the fallopian tubes
correct use of the POP
- > 99% effective if taken properly
- Pill taken every day with no breaks between pills
- Should be taken at a similar time every day
Traditional POP- within 3 hours
**Desogestrel **– 12 hours late
- No breaks between packs
starting the POP
protection straight away if within 1- 5 days of menstrual cycle, otherwise take for 2 days withe xtra contraception
side effects of POP
- unscheduled bleeding (common in first 3 months)
- breast tenderness
- headaches
- acene
- ovarian cysts
- ectopic pregnnacy (with traditional)
- minimally increased risk of breast cancer
POP: missed pills
A pill is classed as “missed” if it is:
- More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
- More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use.
Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.
Episodes of diarrhoea or vomiting are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle.
Intrauterine contraception (IUC)
Two types
- IUD- Copper-bearing intrauterine device (Cu-IUD)
- IUS - Levonorgestrel- releasing intrauterine system (LNG- IUS)
contraindication to coil
- Pelvic inflammatory disease or infection
- Immunosuppression
- Pregnancy
- Unexplained bleeding
- Pelvic cancer
- Uterine cavity distortion (e.g. by fibroids)
insertion of the coil
In women at increased risk of sexually transmitted infections (e.g. under 25 years old), screening for chlamydia and gonorrhoea is performed before insertion of a coil.
Specific qualifications are required to insert the implant. A bimanual is performed before the procedure to check the position and size of the uterus. A speculum is inserted, and specialised equipment is used to fit the device. Forceps can be used to stabilise the cervix while the device is inserted. Blood pressure and heart rate are recorded before and after insertion.
There may be some temporary crampy period type pain after insertion. NSAIDs may be used to help with discomfort after the procedure. Women need to be seen 3 to 6 weeks after insertion to check the threads. They should be taught to feel the strings to ensure the coil remains in place.
risks associated with the coil insertion
Bleeding
Pain on insertion
Vasovagal reactions (dizziness, bradycardia and arrhythmias)
Uterine perforation (1 in 1000, higher in breastfeeding women)
Pelvic inflammatory disease (particularly in the first 20 days)
The expulsion rate is highest in the first three months
Removal of the coil
Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy. The strings are located and slowly pulled to remove the device
Non-Visible Threads
When the coil threads cannot be seen or palpated, three things need to be excluded:
- Expulsion
- Pregnancy
- Uterine perforation
Investigation
- US
- x-ray
MOA of IUD (Copper coil)
o Releases copper into the womb
o Alters cervical mucus
o Spermicide
o Stops implantation
IUD: Indications and contraindications
Most people with a womb can use an IUD
Contraindications
- If you think you may be pregnant
- STI
- Unexplained bleeding between periods or after sex
- menorrhagia
side effects of IUD
- Periods can be heavier, longer and more painful in first 3-6 months
- Small risk of infection e.g. PID in first 20 days
- Small risk of rejection or rupture
- Does not protect against STI
- Ectopic pregnancy
benefits of IUD
o For women who can remember to take the pill
o Works straight away
o No hormonal side effects
o Doesn’t effect fertility
o Doesn’t increase risk of cervical, uterine or ovarian cancer
MOA of IUS
o Levonorgestrel- releasing intrauterine system (LNG- IUS)
Releases progestogen into the womb
o Thickens cervical mucus
o Thins lining of the womb
o Can prevent ovulation
IUS: Indications and contraindications
Indication
- Can be used in those who cannot take COCP
- Menorrhagia
Contraindication
- Current or past breast cancer
- Cervical cancer
- Untreated STI
IUS and extra protection after insertion
The LNG-IUS can be inserted up to day 7 of the menstrual cycle without any need for additional contraception. If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.
IUS side effects
o Mood swings
o Skin problems
o Breast tenderness
o Risk of infection
o Ectopic pregnancy
o Doesn’t protect against STI
IUS benefits
- It can make periods lighter or stop altogether
- It may improve dysmenorrhoea or pelvic pain related to endometriosis
- No effect on bone mineral density (unlike the depo injection)
- No increase in thrombosis risk (unlike the COCP)
- No restrictions for use in obese patients (unlike the COCP)
- The Mirena has additional uses (i.e. HRT and menorrhagia)
Coils and Actinomyces-Like Organisms (ALO) on Smears
Actinomyces-like organisms are often discovered incidentally during smear tests in women with an intrauterine device (coil). These do not require treatment unless they are symptomatic. Where the woman is symptomatic (e.g. pelvic pain or abnormal bleeding), removal of the intrauterine device may be considered.
the injection MOA
Depo-provera most given in the UK
**Mode of action **
- Progestogen is steadily released into bloodstream and prevents ovulation
- Also thickens cervical mucus and thins endometrium
types of injection
There are two versions commonly used in the UK, all containing medroxyprogesterone acetate:
Depo-Provera: given by intramuscular injection
Sayana Press: a subcutaneous injection device that can be self-injected by the patient
The injection: Indications and contraindications
Indication
Can be used in women cant use contraception that contains oestrogen
Contraindication
- If pregnant
- Active breast cancer
- If you don’t want periods to change
- Want to have a baby in the next year
- Unexplained bleeding
- Risk of osteoporosis -due to suppression of oestrogen
- ischaemic heart disease
- severe liver cirrhosis/ cancer
how often does the injection have to occur
every 12 to 13 weeks
- Starting on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required.
- Starting after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms) before the injection becomes reliably effective.
the injection side effects
o Weight gain
o Headaches
o Mood swings
o Breast tenderness
o Irregular bleeding
o Hair loss
o Decreased sex drive
o Can take up to a year for fertility to return to normal after injection wears off
o Doesn’t protect against STI
the injection and osteoporosis
Reduced bone mineral density (osteoporosis) is an important side effect of the depot injection. Oestrogen helps maintain bone mineral density in women, and is mainly produced by the follicles in the ovaries. Suppressing the development of follicles reduces the amount of oestrogen produced, and this can lead to decreased bone mineral density.
The depot injection may be associated with a very small increased risk of breast and cervical cancer.
benefits of the injection
- Improves dysmenorrhoea (painful periods)
- Improves endometriosis-related symptoms
- Reduces the risk of ovarian and endometrial cancer
- Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
*
progestogen only implant implantation
- The progestogen-only implant is a small (4cm) flexible plastic rod that is placed in the upper arm, beneath the skin and above the subcutaneous fat.
- It slowly releases progestogen into the systemic circulation. It lasts for three years and then needs replacing.
implant: contraindication
active breast cancer
MOA of the implant
- Inhibiting ovulation
- Thickening cervical mucus
- Altering the endometrium and making it less accepting of implantation
how long does the implant last for
o Last for 3 years
o If fitted within first 5 days of menstrual cycle- protected immediately
how long does the implant last for
o Last for 3 years
o If fitted within first 5 days of menstrual cycle- protected immediately
side effects of the implant
o Bruising and swelling when first implanted
o Headaches, nausea, breast tenderness and mood swings for first few months
o Acne
o Doesn’t protect against STI
benefits of the implant
- Effective and reliable contraception
- It can improve dysmenorrhoea (painful menstruation)
- It can make periods lighter or stop all together
- No need to remember to take pills (just remember to change the device every three years)
- It does not cause weight gain (unlike the depo injection)
- No effect on bone mineral density (unlike the depo injection)
- No increase in thrombosis risk (unlike the COCP)
- No restrictions for use in obese patients (unlike the COCP)
using contraception to manage menorrhagia
- First line (NICE): IUS i.e. mirena coil
- ``in practice this is often not offered first line esp in younger women
- Combined contraceptive pill or POP (if COCP contraindicated)
- Medication to stop the bleeding i.e. tranexamic acid
- NSAIDS e.g. mefenamic acid or naproxen
- Treatment for iron deficiency anaemia
Post- coital contraception
Two types of emergency contraception
- Emergency contraceptive pill – levonelle or ellaOne
- The IUD
MOA of levonelle
within 3 days (72hours) of unprotected sex
- Contains levonorgestrel a synthetic version of progesterone
- Stops or delays ovulation
MOA of ellaOne
within 5 days (120 hours)
- contains ulipristal acetate- stops progesterone working normally
- stops or delays ovulation
emergency contraception: indication and contraindication
o most women can take it (levonelle is even safe to take whilst breast feeling)
o contraindications
e.g. medicine for epilepsy, HIV or TB
side effects of emergency contraception
o Headache
o Tummy pain
o Change to next period
o Feeing or being sick (get medical attention if you’re sick within 2hours of taking levonelle or 3 hours of taking ellaOne
emergency contraception: the coil
The IUD
- Can be fitted up to 5 days after unprotected sex or up to 5 days after the earliest time you could have ovulated
- More effective than the pill
Vasectomy
Is a surgical procedure to cut or seal the tubes that carry a man’s sperm to permanently prevent pregnancy.
- > 99% effective
- Permanent- very difficult to reverse and not on the NHS
- Doesn’t affect sex drive
- Counselling before operation
- Safer and simpler to female sterilisation
- Often only done in those >30
how does a vasectomy work
- Stopping sperm getting into semen by cutting the vas deferens (removing a small section and then the ends are closed by tying them or sealing them using heat
- 2 types of vasectomy
o Scalpel (surgical)- conventional
o Non-scalpel - Need to use contraception for 8-12 weeks after operation because sperm will still be in the tubes
- Up to 2 semen test done after operation to make sperm have gone
- At 12 weeks sample of semen tested for sperm
sterilisation
Female sterilisation is an operation to permanently prevent pregnancy. The fallopian tubes are blocked or sealed to prevent the eggs reaching the sperm and becoming fertilised.
- >99% effective
- Does not affect hormone levels and you still have periods
- Reversal is not available on the NHS
- Counselling before operation
how does sterilisation work
- Fallopian tubes sealed preventing eggs travelling down to be fertilised
- Eggs will still be released from the ovaries as normal, but they’ll be absorbed naturally into the woman’s body.
- Methods:
o Applying clips
o Applying rings
o Tying, cutting and removing - If blocking tubes hasn’t work, tubes can be removed- salpingectomy
- Often done under general anaesthetic
how long to wait till unprotected sex with sterillisation
- If you have had tubal occlusion, use additional contraception until first period to protect yourself from pregnancy
how long to wait till unprotected sex with sterillisation
- If you have had tubal occlusion, use additional contraception until first period to protect yourself from pregnancy
RF with sterilisation
- Internal bleeding
- Infection
- Damage to other organs
- May not work and increased risk of ectopic pregnancy
- Non reversible
- Doesn’t protect against STI
fertility awareness method summary
Fertility awareness method
Involves monitoring and recording fertility indicators throughout the cycle
e.g. cervical secretions, changes in your cervix, basal body temp
**
When you are most fertile: **
- cervical secretions are wetter, transparent, slippery and most stretchy
- basal body temp increases slightly after ovulation (36.1 to 36.4 whereas after ovulation it rises between 36.4 – 37)
Advantage
- no hormones involves
- can be up 99% effective if followed very carefully
Disadvantages
- time consuming, unreliable, no STI protection
