14 - Contraception Flashcards
What are the following for the contraceptive implant:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: Progestrogen only (etonogestrel). Inhibits ovulation and thickens cervical mucus.
Indications: contraception, may help dysmenorrhoea
Contraindications: pregnancy, St John’s Wort, Enzyme inducing drugs (e.g carbamazepine/griseofulvin/TB), history of breast cancer/heart disease/liver disease/unexplained pV bleeding
Correct Use: Lasts 3 years. Need to use condoms for 7 days after implantation
Benefits: no effect on bone mineral density, may be protective of endometrial cancer, can be used breastfeeding, can be used in all BMIs, little risk of VTE, 99% effective, fertility returns straight away
Side effects: doesn’t prevent STIs, changes/irregularity in menstrual bleeding rule of thirds
What are the following for the IUD:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: thickens cervical mucus, toxic to sperm/doesn’t allow capacitation, changes endometrial lining stopping implantation
Indications: long lasting birth control, emergency contraception up to 5 days after unprotected sex
Contraindications: history of PID, recent STI exposure, current pregnancy/4 weeks post partum, uterine structural abnormalities, current gynae malignancy, allergy to copper, history of DVT/liver disease/breast cancer
Correct Use: immediate contraceptive after insertion, needs to be replaced after 5-10 years. 6 week check up and then pt needs to check strings every 1/12
Benefits/Side effects: heavier longer periods, uterine perforation, ectopics,
return of fertility immediately, see image for more
What are the main contraindications for progesterone only contraceptives?
What are the following for the IUS:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: progestogen thins endometrium preventing implantation also thickened cervical mucus. Stops ovulation
Indications: first line therapy for menorraghia as often causes amenorrhea, second line for dysmenorrhea, contraception
Contraindications: see image
Correct Use: effective immediately if inserted first 7 days of cycle, otherwise use condoms for 7 days. Lasts for 3-5 years. check for pregnancy and STIs before insertion
Benefits: good if forget to take pills, lighter periods/amenorrhea, fertility returns immediately, can be used if COCP contraindicated
Side effects: spotting/irregular bleeding for first 6/12, risk of perforation, risk of STIs/PID, ectopic risk, body my expel it
What are the following for the Depo Provera (medroxyprogesterone acetate) injection:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: supresses LH and FSH so no ovulation, thickens cervical mucus so barrier to sperm entry, thins endometrium
Indications: long term contraception
Contraindications: current breast cancer, Severe arterial disease, Pregnancy, Vascular disease, People who want to return to fertility in the near future
Correct Use: deep IM every 12 weeks (14 weeks max if 12weeks+5 check not pregnant and advise condoms for 7 days).
If day 1-5 of cycle effective immediately, otherwise condoms for 7 days. 94-99% effective
Benefits: very effective, can be used when breastfeeding/migraines, may lighten bleeding/pms, no known interactions with any drugs, reduce risk of ovarian/endometrial cancer, can be used in all BMIs
Side Effects: can take a year for fertility to return, unscheduled bleeding, weight gain, loss of bone mineral density if using over a year so review every 2 years for osteoporosis, increased risk of breast cancer, need to stop over age 50
What are the following for the combined contraceptive patch Evra:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: preventing ovulation, thinning the endometrial lining and thickening cervical mucus
Indications: contraception and menstrual symptoms
Contraindications: breast feeding, up to 6 weeks post partum, current breast cancer, over 35, smoking over 15/day, see image
Correct use: apply to upper arm, abdomen, buttock or back for 7 days for three weeks then a week off. 91-99% effective.
Use barrier method when starting unless starting on day 1-5 of cycle. N+V/Diarrhoea do not affect. Detached patch >48 hours may need emergency contraception if not used for 7 days before
Benefits: as effective as COCP, not affected by vomiting
Side effects: delay in fertility return by few months, skin irritation, increased risk of VTE, breast discomfort, dysmenorrhea, n+v, liver inducing enzymes may decrease effectiveness
What are the following for the latex free combined NuvaRing:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: prevents ovulation, thins the endometrial lining and thickens cervical mucus
Indications: contraception
Contraindications: see image
Correct use: place in for 21 days then remove for 7. can be removed for up to 3 hours if uncomfortable in sex. if 8 or more days since ring removed consider emergency contraception
Benefits: not effected by vomiting and diarrhoea, effective as the pill
Side effects: foreign body sensation, vaginal infections, headaches, delay in fertility return for few months, can be broken or expelled during use, blood pressure increase, risk of VTE
What are the following for the COCP:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: preventing ovulation, thinning the endometrial lining and thickening cervical mucus. can be monophasic or phasic
Indications: acne, contraception, symptom control of endometriosis, hyperadrogenism (PCOS), menstrual disorders like menorraghia/dysmennorhea
Contraindications: over 35, history of DVT/VTEs, migraines with aura, breastfeeding, BMI>35, smoker, HTN, breast cancer, liver tumour
Benefits: lighter less painful menses, reduced acne, protective of certain cancers, normal fertility returns straight away
Side effects: less effective than long acting methods, breast pain/tenderness, N+V, abdominal pain, headache, mood changes, risk of VTE, risk of breast/cervical cancer
What are the rules for missed pills when on the COCP?
- If one pill missed take pill ASAP and do not need emergency contraception as long as the HFI was 7 days and all pills taken normal before break. No condoms needed
- If 2 or more missed in week 1 need to take last missed pill ASAP. Need to consider emergency contraception and use condoms for next 7 days
- If 2 or more missed in week 2 or 3 same as above but don’t need emergency contraception if 7 days before correct pill taking
- If less than 7 days left of pills skip break!!
- Consider follow up pregnancy tests after emergency contraception
What are the following for the POP:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: primarly thickens cervical mucus, only stops ovulation in 60%, thin endometrium, reduced activity of cilia in tubes
Indications: contraceptive for when oestrogen is Cx
Contraindications: breast cancer (only UKMEC 4), cirrhosis, liver tumours, stroke, SLE, enzyme inducing drugs
Correct use: need to use contraception for 48 hours if starting after day 1-5 of cycle. need to take at same time everyday within 3 hour frame, no break between packs
Benefits: reduces risk of endometrial cancer, desogesterel can manage dysmenorrhea, immediate return of fertility, good if oestrogen Cx
Side effects: breast tenderness, unscheduled bleeding, headaches, acne, risk of ectopics, risk of breast cancer, increased risk of ovarian cysts
How does vomiting and diarrhoea affect the COCP/POP?
- If vomit within 2 hours of taking pill need to take another one
- If more than 6-8 watery stools a day need to use other methods of contraception. If IBD not suitable to use COCP for contraception
What should you do when missing a POP?
- Missed pill if over 3 hours late (or 12 hours with desogesterol)
- Take pill ASAP and use condoms for next 48 hours
- Consider emergency contraception if unprotected sex occured between missed pill and 48 hours in taking next pill
What are the following for the diaphragm/cap with spermicide (barrier contraception like condoms):
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: they cover the cervix to stop sperm entry. Caps are used with spermicide which is extra efficacy
Indications: contraception
Contraindications: toxic shock syndrome, vaginal prolapse, latex allergy, cervical cancer, high risk of HIV, less than 6 weeks post partum
Correct Use: check for holes before insertion, apply spermicide (no oil-based), place in vagina up to 3 hours before intercourse and leave in for a minimum of 6 hours after. Needs to be removed 30-48 hours after
Assess after 1-2 weeks by doctor to see if correct fit
Benefits: allows spontaneity, no interactions with any other drugs, little adverse effects
Side effects: STI, need training to fit, weight gain >3kg or pregnancy will need refitting, higher risk of UTIs, low efficacy around 88% typical use, allergies to cap/spermicide
What are the following for female internal condoms:
- MOA
- Indications and contraindications
- Correct use
- Benefits/Side effects
MOA: barrier to sperm
Indications: contraception
Contraindications: latex allergy
Correct use: can be applied up to 8 hours before intercourse
Side effects: penis may end up between condom and vaginal wall so perfect use hard, 95% effective, may be noisy, not widely available
How do fertility awareness methods work and who is not suitable to use this method?
- Need to record body temperature, menstrual cycle length and cervical mucus changes. Can take 3-6 cycles to learn the method. When highly fertile use barrier methods
- Conditions that affect cervical mucus: menstrual irregularities first 4 weeks post-partum, recent use of hormonal contraception, drugs like cold remedies, analgesics, tetracyclines
- Also cannot be used in patients who “cannot” get pregnant e.g on teratogenic drugs, Eisenmenger syndrome
What are the different options for emergency contraception?
- Levonelle
- EllaOne
- Copper IUD
The hormonal pills do not stop implantation, only ovulation!!
How does Levonorgesterel 1.5mg tablet work as an emergency contraceptive and what are the benefits and side effects?
- Synthetic progesterone that can delay ovulation for 5 to 7 days, after which any sperm will have become non-viable
- Up to 72 hours after unprotected sex
- Not as effective if diseases of malabsorption e.g Crohn’s, or taking enzyme inducing drugs e.g rifampacin (take 3mg)
- If vomit up to 3 hours after taking need another dose.
- Take pregnancy test after 2 weeks
- Can take more than once in a cycle but not recommended as disturbs menses. Can have UPS up to 12 hours after taking
How does Ulipristal Acetate 30mg tablet work as an emergency contraceptive and what are the benefits and side effects?
Selective progesterone receptor modulator that can be taken up to 120hours/5 days after UPS. Inhibits or delays ovulation
Cx: diseases of malabsorption, enzyme inducing drugs, severe hepatic dysfunction, asthma not controlled by corticosteroids, drugs increasing gastric pH e.g PPIs,breastfeeding cannot occur for 7 days after taking
If vomit within 3 hours need another pill
Take pregnancy test if period more than seven days late as hormonal emergency contraception ineffective after ovulation
How does the IUD work as an emergency contraceptive and what are the benefits and side effects?
Insertion up to 5 days after UPS. Toxic to sperm and causes inflammatory response in endometrium so implantation cannot occur. Lasts up to 5-10 years after
Cx: suspected STI, documented PID, uterine fibroids or structural abnormality
Increased risk of ectopic pregnancy so be aware of late periods and abdominal pain
s/e: pelvic infections, pain, irregular/heavier bleeding, expulsion of IUD, risk of perforation
What are a male’s options for sterilisation and what are some of the complications procedure?
Vasectomy: done under local anaesthetic to cut the vas deferens. Scrotal exam before to check for any potential problems e.g varicocele may make vas def hard to get tp
- Failure rate of 1 in 2000
- Check patients capacity and level of understanding
Issues: need contraception until azoospermia confirmed at 12 weeks sperm analysis, haematoma, reversal not offered on NHS, post scrotal vasectomy pain CPVP, small link with prostate cancer
What aftercare advice is given to a man after a vasectomy?
- Take NSAIDs for pain
- Abstain from sexual activity for 2-7 days
- Wear supportive pants or athletic underwear to support the scrotum for the first 48 hours even at night
- No strenuous activity until pain has gone
- Seek advice if persistent bleeding, pain, infection, one sided growing haematoma
What options are available for female sterilisation and what are some complications of these?
- Tubal occlusion by blocking with rings (Essure hysteroscopic) or cutting fallopian tubes (laparascopic). Under general
Perform a bimanual and pregnancy test before
- Failure rate 1 in 200, lower if Essure
- Need to use contraception for 4 weeks after (3 months with Essure)
- Complications: no effect on menstruation but seems heavier as stop other contraception, risk of ectopics if fall pregnant, injury to bowel/bladder
What do doctors need to inform patients of when they request sterilisation?
Doctor needs to assess which partner would be more suited to having the sterilisation, mostly a lot easier to do in men
What aftercare advice should we give after female sterilisation?
- Keep incision clean and dry for 1-2 days
- Avoid rigorous physical activity for one week
- Avoid sex for at least one week
- If hysteroscopic sterilisation need to use contraception untl confirmed in place after 3 months
- Laparoscopic sterilisation should continue hormonal contraceptives for at least 7 days after, skipping break if less than 7 days left
What are the UKMEC criteria?
Offers guidance as to if a patient can use a contraceptive safely
What are some websites you can signpost patients to when they are looking at contraception options?
- Family Planning Association (FPA) leaflets
- NHS:Your Contraceptive guide
- Sexwise
- SH24
What is Gillick competency and Fraser guidelines?
Gillick Competence
- Decision about whether a child under 16 is allowed to consent to their own medical treatment without parent’s knowledge/permission
- Determining a child’s capacity to consent
- Could be Gillick competent to make one decision but not another
Fraser Guidelines
- Used to allow under 16s to consent to contraceptive or sexual health advice and treatment (e.g termination) without parent’s knowledge
- See first image for guidelines
How should a doctor approach a patient learning disabilities who is requesting contraception?
- Allowed to make her own choice, not the choice of the carers
- Think about LARC over the pill as LD may not reliably take the pill but don’t rule it out
- Provide information aimed at them as the FPA leaflets require a reading age of 13. This could mean booking into a special contraceptive clinic for those with LDs or choice support
What are the laws around underage sex and when does a patient need to be referred to safeguarding?
- Age of consentl/legal age is 16. e.g a 15 year old and 18 year old is statutory rape even if both consented
- Completely illegal if under the age of 13. Anyone under 13 cannot consent and is illegal under all circumstances
- Illegal for anyone over 18 in position of power to have sex with anyone under 18 e.g teacher
- Need to refer to safeguarding if young person presenting with STIs, pregnancy, any age differences that are illegal, having sex under 16
What monitoring is required with the COCP and POP?
- Need to do 3 month BP check and weight check with COCP as risk of HTN when first prescribed
- Ask about headaches, migraines and aura at COCP check
- 12 month check from then on
What is an IMCA?
Independent Mental Capacity Advocate
For people who lack the capacity to make their own decision but noone independent of the doctors are available e.g family who are unsuitable to make decisions
