17. Contraception (28%)

Question 1

What populations should be advised about adequate contraception?

Answer 1

Tous les patients
particulièrement
* les adolescents
* les jeunes hommes
* les femmes en postpartum e
* les femmes en périménopause.

Question 2

Quels facteurs peuvent réduire l’efficacité de certaines méthodes contraceptives? (4)

Answer 2

• retard à débuter la méthode
• maladie
• médicaments
• lubrifiants spécifiques

Question 3

What should be assessed to ensure adequate contraception? (4)

Answer 3

• Risques (contre-indications relatives et absolues)
• Exposition aux maladies sexuellement transmissibles
• Obstacles à certaines méthodes (par exemple, coût, préoccupations culturelles)
• Efficacité et effets secondaires

Question 4

Que faut-il conseiller aux patientes utilisant des contraceptifs hormonaux? (3)

Answer 4

• Suivi adéquat des effets secondaires
• recommandez un essai d’une durée appropriée
• discutez des oestrogènes dans l’acétate de médroxyprogestérone [Depo-Provera]).

Question 5

Renseignez toutes les patientes sur la contraception post-coïtale, particulièrement qui ?

Answer 5

• celles qui utilisent des méthodes de barrière
• ou lorsque l’efficacité des méthodes hormonales est réduite.

Question 6

What are the typical use failure rates for barrier methods?

Answer 6

Barrier (Condom) - 18% failure rate

Question 7

What is the failure rate for the combined oral contraceptive pill?

Answer 7

9%

Question 8

What is the failure rate of Progestin-only pill (Micronor) ?

Answer 8

9%

Question 9

Name side effect of Progestin-only pill (Micronor)

Answer 9

Irregular bleeding

Question 10

What is the failure rate of combined transdermal patch ?

Answer 10

9%

Question 11

Describe : Combined transdermal patch (3)

Answer 11

• Evra 1 patch per week x 3 weeks, one week off)
  Stays on even in water, apply to dry clean area excluding breast
• 17% skin reaction

Question 12

What’s the failure rate of Combined vaginal ring ?

Answer 12

9%

Question 13

Describe : Combined vaginal ring

Answer 13

• NuvaRing x 3 weeks, one week off
• May remove for 3h (eg. during coitus)
• 5% vaginitis, leukorrhea

Question 14

What is the failure rate for the injectable progestins (DMPA, DMPA- Depo–Provera)?

Answer 14

6%

Question 15

Describe : DMPA- Depo–Provera (3)

Answer 15

• 150mg IM q12w
• Side effects: Irregular bleeding, weight gain, decrease bone density
• Consider supplemental low-dose estrogen to reduce irregular bleeding if persists past 3 cycles

Question 16

What are the failure rates for intrauterine devices?

Answer 16

<0.1%

Question 17

Describe : Intrauterine devices (3)

Answer 17

• LNG-IUD Mirena q7y, CU-IUD q10y
• 44% amenorrhea at 6 months
• Risk of expulsion/perforation postpartum until 6 weeks

Question 18

What’s the failure rates of Subdermal implant (Nexplanon - Etonogestrel)

Answer 18

very effective likely <0.1%

Question 19

Describe : Nexplanon - Etonogestrel

Answer 19

• Very rare risk of implant migration
• 15% bleeding irregularities
• Not studied in overweight >130% IBW

Question 20

What’s the failure rates of tubal ligation and vasectomy?

Answer 20

0.15%

Question 21

What should be done before starting contraception?

Answer 21

Start contraception if reasonably certain not pregnant

• Pregnancy test >2w after last episode of unprotected intercourse
• ≤7d after start of normal menses or spontaneous/induced abortion
• No sex since start of last normal menses
• Correctly, consistently using reliable contraception
• 4w postpartum
• Fully breastfeeding and <6 months postpartum
• Back-up contraception for 7d if >7d after menses started

Question 22

What contraceptive method is recommended for
* postpartum ?
* breastfeeding women ?
* smokers >35 years old ?

Answer 22

Consider progestin-only

Question 23

What contraceptions to consider for patients with multiple medical comorbidities ?

Answer 23

Long-acting reversible contraception (LARC)
* IUDs
* Implants

Question 24

What contraceptions to consider for patients > 50? (3)

Answer 24

• Consider progestin-only or non-hormonal method (consider avoiding estrogen)
• After amenorrhea x 12 months -> No need for contraception if using non-hormonal method and >50yo (if <50yo advised to wait 2 years)
• Consider FSH x 2 (>6 weeks apart) if >30IU/L then contraception required for another 12 months

Question 25

What contraceptions to consider for patients > 55?

Answer 25

>55 years old can discontinue contraception (even if menstrual cycles continue, spontaneous conception very unlikely)

Question 26

Name emergency contraceptions (4)

Answer 26

* Copper IUD Hormonal/oral : * Ulipristal acetate (Ella) * Levonorgestrel (Plan B) * Combined OCP (Yuzpe) + Levonorgestrel (5 pills of Alesse)

Question 27

Describe : Copper IUD (2)

Answer 27

* failure rate of <1% (>95% effective) * Effective up to 5 days (limited evidence up to 7 days) after unprotected intercourse, provided pregnancy ruled out

Question 28

Name populations that Hormonal/oral emergency contrapception are less effective in (2)

Answer 28

less effective if BMI>30 or weight ≥80kg

Question 29

Describe : Ulipristal acetate (Emergency contraception)

Answer 29

* Effective up to 5 days * Hormonal contraception can be initiated up to 5 days after unprotected sex with backup for first 14d

Question 30

Describe : Levonorgestrel (Emergency contraception)

Answer 30

* Effective up to 72h (proven efficacy up to 96h, limited efficacy up to 120h) * Hormonal contraception can be initiated the day of (or after) with backup for first 7d

Question 31

Name C-I Emergency contraception (2)

Answer 31

* Pregnancy * and active pelvic infection/cervicitis for IUD

Question 32

Name examples of Estrogen OCP (6)

Answer 32

* Monophasie : Alesse, Marvelon, Yasmin, Yaz * Biphasique : Lolo, Synphasic * Triphasic * Longue durée * IUD : NuvaRing * Timbre transdermique : Evra

Question 33

Name examples of Progestin-only OCP (3)

Answer 33

* PO : Micronoc, Slynd * IM : Depo-Provera * Implant S/C : Nexplanon * IUD : Kyleena, Mirena

Question 34

Name Contraindications to Estrogen

Answer 34

* Migraine with aura (≥5 min reversible visual/sensory/speech/motor symptom that is accompanied within 60 mins by a headache) * Smoker age ≥35 years and smoking ≥15 cigarettes per day * Uncontrolled hypertension (>160/100) * Acute DVT/PE * History of DVT/PE, not on anticogulation, with risk factor (history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including antiphospholipid syndrome/SLE, active cancer with the exception of non-melanoma skin cancer, history of recurrent DVT/PE) * Current or history of vascular disease, ischemic heart disease, stroke, complicated valvular disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis) * Liver disease (severe cirrhosis, hepatocellular adenoma, malignant hepatoma) * <4 weeks postpartum or peripartum cardiomyopathy * Major surgery with prolonged immobilization * Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy) * Active breast cancer

Question 35

Name C-I : Progestin-only pills (2)

Answer 35

* current breast cancer * relative contraindications include liver disease

Question 36

Combined-COC has less effectiveness with what other medications? (3)

Answer 36

* anticonvulsants (phenytoin, phenobarbitol) * antiretrovirals * rifampin (not other antibiotics)

Question 37

Name side-effects of Combined COC ()

Answer 37

Common in first three months, tend to improve with time * Nausea - Take pill at bedtime or with meal (consider lower estrogen) * Breast tenderness (consider lower estrogen) * Headache * Breakthrough bleeding (r/o smoking, noncompliance, cervical/uterine disease, pregnancy, consider increase estrogen) * No evidence of weight gain

Question 38

Name Non-Contraceptive Benefits of Combined COC (6)

Answer 38

* Cycle regulation, predictable bleeds * Decreased menstrual flow, anemia * Decreased acne, hirsutism * Decreased dysmenorrhea, premenstrual symptoms * Decreased perimenopausal symptoms * Decreased risk of fibroids, ovarian cyst

Question 39

Name Non-Contraceptive Risks of Combined COC (6)

Answer 39

* TVP (10 / 10,000 woman-years (COC users) vs. 4-5 / 10,000 woman-years (non-users) * UNCLEAR risk of gallbladder disease, possible increase in symptomatic gallstones when used for 15 years

Question 40

Describe risk of Combined-COC and cancer (4)

Answer 40

* Decreased ovarian, endometrial, colorectal cancer * Possible association with cervical cancer (causation not demonstrated) * Decreased risk of benign breast disease * Possible increase in breast cancer in current/recent COC users (5 / 1000 COC-users vs. 4 / 1000 non-users will be diagnosed with breast cancer before 39 years-old)

Question 41

Describe follow-up in COC (4)

Answer 41

* Weight (BMI), BP * Contraindications (Smoking, Migraines, Liver disease, Thromboembolic disease, Cardiovascular risk factors, Cancer). * Stop OCP at age 50yo, consider taper or switch to HRT if vasomotor symptoms * STI screen

Question 42

What to do if missed combined OCP : If missed pill <24h in any week

Answer 42

Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack

Question 43

What to do if missed combined OCP :If missed pills in first week

Answer 43

* Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack * Back up x 7d*

Question 44

What to do if missed combined OCP : If missed pills during second or third week

Answer 44

* Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack and start new cycle of OCP without a hormone-free interval * Back-up contraception if 3 or more consecutive doses/days of OCP missed

Question 45

If unprotected intercourse in last ____ days and not on active hormone x ____ days, there is a risk of ovulation and unintended pregnancy consider emergency contraception

Answer 45

if unprotected intercourse in last 5 days and not on active hormone x 7 consecutive days, there is a risk of ovulation and unintended pregnancy consider emergency contraception

Question 46

What to do with Missed Progestin only pills (3)

Answer 46

>3h delay * Take most recent pill ASAP and continue taking remaining pills until end of pack * Back-up x 48h * If unprotected intercourse in last 5 days, EC recommended