20 - Contraception Flashcards
What are some contraindications for COCP?
Absolute Contraindication (UKMEC 4)
- Known or suspected pregnancy
- Smoker >35 who smokes >15 cigarettes
- Obesity
- Breast feeding <6 weeks post partum
- FHx of thrombosis before 45 years old
- Breast cancer or BRCA genes
Disadvantages outweigh advantages (UKMEC 3)
- Previous arterial or venous clots
- Migraines with aura
- Active disease of liver or gallbladder
What are the Fraser Guidelines?
Set of criteria that must be met for a health professional to give advice to a child <16 regarding contraception and sexual health without breaking confidentiality
What is included in the Fraser Guidelines?
- He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
- He/she cannot be persuaded to tell her parents or to allow the doctor to tell them
- He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
- His/her physical or mental health is likely to suffer unless he/she received the advice or treatment
- The advice or treatment is in the young person’s best interests.
If all of the above are met, the child is ‘Fraser competent’ and can therefore receive advice without breaking confidentiality
When counselling a patient on different methods of contraception, what are some important points to cover?
- Different options
- Suitability (including assessing contraindications and risks)
- Effectiveness
- Mechanism of action
- Instruction on use
What are the different types of contraception?
- Natural family planning (“rhythm method”)
- Barrier methods (i.e. condoms)
- Combined contraceptive pills
- Progesterone only pills
- Coils (i.e. copper coil or Mirena)
- Progesterone injection
- Progesterone implant
- Surgery (i.e. sterilisation or vasectomy)
What do each of the UKMEC categories mean?
- UKMEC 1: No restriction in use (minimal risk)
- UKMEC 2: Benefits generally outweigh the risks
- UKMEC 3: Risks generally outweigh the benefits
- UKMEC 4: Unacceptable risk (the method is contraindicated)
The COCP pill is 99% effective if taken perfectly. What does this actually mean?
If the average person used this contraception correctly with a regular partner for 1 year there is a 1% chance of pregnancy
What is the typical and perfect use for the following contraceptive methods?
What type of contraception is contraindicated in the following scenarios?
- Breast cancer
- Wilson’s disease
- Cervical or Endometrial Cancer
- Avoid any hormonal contraception. Copper coil or Barrier methods only
- Avoid copper coil
- Avoid IUS/Mirena
What factors of UKMEC4 for the COCP?
- Migraines with aura
- >35 smoking over 15 a day
- BMI>30
- History of VTE
- Breast cancer or FHx of Breast cancer
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Major surgery with prolonged immobility
- Vascular disease or stroke
- IHD, cardiomyopathy or atrial fibrillation
- Liver cirrhosis and liver tumours
- SLE and antiphospholipid syndrome
What contraception is UKMEC2 for women under the age of 20?
- Coils: Higher risk of expulsion
- Depo-Provera: Can reduced bone mineral density
If an older woman is on progesterone only contraception and is amenorrhoeic, how do you know if she has gone through the menopause and can stop contraception?
- FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
- 55 years of age
At what age do women have to stop using hormone contraception?
- COCP: Can use up to age 50 and can help perimenopausal symptoms
- Depo Injection: Stop before 50 due to risk of osteoporosis
What is the most to least effective methods of contraception?
What contraception can be used after childbirth and at what point?
Not considered fertile until 21 days post birth
Lactational amenorrhea: 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods)
POP and Implant: safe in breastfeeding and can be started at any time after birth.
COCP: avoid in breastfeeding for 6/52 (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks)
Copper coil or IUS (e.g. Mirena): can be inserted either within 48 hours of birth or more than 4 weeks after birth
What are barrier methods of contraception and how effective are they?
Only method that provides protection from STIs!!
- Condoms: 98% perfect, 82% typical (oil based lube can damage latex condoms, polyurethane can be used for latex allergy)
- Diaphragms and Cervical Caps: 95% perfect. Do not protect against STIs. Need to stay in for at least 6 hours after sex and use spermicide gel
- Dental Dams: for oral sex, protection against STIs
What is the effectiveness of the COCP and what is the mechanism of action?
Perfect Use 99%, Typical Use 91%
- Prevents ovulation (primary MOA)
- Progesterone thickens cervical mucus
- Progesterone prevents endometrium thickening so less chance of implantation
Will have withdrawal bleed and breakthrough bleeding if no pill free break taken
What hormones are used in the COCP?
Ethinylestradiol + A progesterone
Can be monophonic or multiphasic to mimic normal hormonal changes
Recommended to have the progesterone levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin) as lower risk of VTE
What type of COCP is used for PMS and acne?
PMS
Yasmin: and other COCPs containing drospirenone as reduces bloating and mood changes
Acne and Hirsutism
Dianette: and other COCPs containing cyproterone acetate (i.e. co-cyprindiol). Usually stopped after having acne under control for 3/12 as high risk of VTE due to high oestrogen effects
What are the pros and cons of the COCP?
Pros
- Contraception
- Rapid return of fertility after stopping
- Improvement in premenstrual symptoms, menorrhagia and dysmenorrhoea
- Reduced risk of endometrial, ovarian and colon cancer
- Reduced risk of benign ovarian cysts
Cons
- Unscheduled bleeding common in first three months
- Breast pain and tenderness
- Mood changes and depression
- Headaches
- Hypertension
- VTE (lower than risk in pregnancy)
- Small increase risk of breast and cervical cancer, returning to normal ten years after stopping
- Small increased risk of myocardial infarction and stroke
What are some contraindications to the COCP? (UKMEC4)
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Migraine with aura (risk of stroke)
- History of VTE
- Aged over 35 and 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
- SLE and antiphospholipid syndrome
- BMI>35 (UKMEC3)
What information do you need to give a woman when starting on the COCP?
- Starting Pill: Ensure not pregnant. If start on day 1-5 of cycle no contraception needed. If over day 5, need 7 days worth of contraception e.g condoms. If switching from POP will also need 7 days of condoms
- Factors that will impact the efficacy (e.g. diarrhoea and vomiting, St John’s Wort, Rifampicin)
- Side effects and CI
- Information on missed pills
- No protection against STIs
- Investigate safeguarding concerns if <16
When do you need to stop the COCP for surgery?
4 weeks if surgery needed that lasts longer than 30 minutes or requires immobilisation of legs
What information should you give a woman who has ‘missed a pill’? (COCP)
More than 24 hours late (48 hours since the last pill was taken), Vomited within 2 hours or Diarrhoea
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
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)
- Condoms until they have taken the pill regularly for 7 days straight
- If day 1 – 7 of packet need emergency contraception if 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
What is the mechanism of action of the POP and how effective is it?
Perfect 99%, Typical 91%
- Progesterone thickens cervical mucus
- Progesterone prevents endometrium growing
- Progesterone reduces cilia action in fallopian tubes
Taken continuously
When is a POP classified as a missed pill?
Traditional: If 3 hours or more late
Desogestrel: If 12 hours or more late
Need to take as soon as notice even if means taking 2 pills in same day. Use condoms for 48 hours and take emergency contraception if had unprotected sex since missed pills
What advice can you give a woman on starting the POP?
- Starting day 1 to 5 means woman is protected immediately
- Can be started at other times of the cycle provided pregnancy can be excluded, even though no harm in pregnancy. Additional contraception is required for 48 hours to allow mucus to thicken.
What are the contraindications to POP?
Only UKMEC4 is breast cancer
What are the side effects and risks with the POP?
Unscheduled bleeding common in first 3/12. If longer than this other causes need to be excluded (e.g. STIs, pregnancy or cancer)
- Breast tenderness
- Headaches
- Acne
- Ovarian cysts
- Small risk of ectopic pregnancy with traditional POPs (not desogestrel)
- Minimal increased risk of breast cancer, returning to normal ten years after stopping
What are the hormones used in the progesterone only injection and how effective is this contraception?
Depot medroxyprogesterone acetate (DMPA) SC or IM
Given at 12 to 13 week intervals
Perfect Use 99%, Typical Use 94% as women may forget to book in for an injection every 12 to 13 weeks
What are the contraindications to the progesterone implant?
UK MEC 4
- Active breast cancer
UK MEC 3
- IHD and stroke
- Unexplained vaginal bleeding
- Severe liver cirrhosis
- Liver cancer
Can cause osteoporosis so consider in older women and patients on steroids for asthma or inflammatory conditions. It is UK MEC 2 in women over 45 years, and women should generally switch to an alternative by age 50 years.
What is the mechanism of action of the Depo Provera?
Main Action: inhibit ovulation by inhibiting FSH secretion, preventing the development of follicles in the ovaries.
Additionally, the depot injection works by:
- Thickening cervical mucus
- Altering the endometrium and making it less accepting of implantation
How long after the Depo injection are you protected from pregnancy?
Day 1 to 5: immediate protection, and no extra contraception is required.
After Day 5: requires seven days of extra contraception (e.g. condoms)
Delaying past 13 weeks creates a risk of pregnancy.
Can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary
What are the benefits with the Depo Injection?
- Improves dysmenorrhoea
- 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
What are the side effects and risks with the Depo?
(NB)
- Weight gain
- Osteoporosis
- Irregular heavier longer bleeding but after 1 year mostly amenorrhoeic
- 12 months for return of fertility
- Acne
- Reduced libido
- Mood changes
- Headaches
- Flushes
- Hair loss (alopecia)
- Skin reactions at injection sites
The depot injection may be associated with a very small increased risk of breast and cervical cancer
Why does the Depo increase risk of osteoporosis?
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
Some women experience problematic irregular bleeding with the Depo in the first 6 months. How is this resolved?
- Reassure settles with time and the longer she is on it the more chance she will be amenorrhoeic
- Alternative causes need to be excluded where problematic bleeding continues, including a sexual health screen, pregnancy test and ensuring cervical screening is up to date
- Take COCP in addition to the injection for three months when problematic bleeding occurs, to help settle the bleeding. Another option is a short course (5 days) of mefenamic acid to halt the bleeding
What is the mechanism of action of the implant, how effective is it and how long does it last for?
99% effective with perfect and typical use
Effective for 3 years, containing 68mg of etonogestrel
How long after the implant is put in is it effective as a contraceptive?
Day 1-5: immediate protection
After day 5: seven days of extra contraception (e.g. condoms)
Inserted one-third the way up the upper arm, on the medial side. Local anaesthetic (lidocaine) is used prior to inserting the implant. Place on top of subcut fat and should be able to feel after insertion
Contraception is required immediately after it has been removed (but not immediately before)
What are contraindications to the progesterone implant?
Active Breast Cancer
What are the pros and cons of the implant?
Benefits
- Effective and reliable contraception
- Can improve dysmenorrhoea
- It can make periods lighter or stop all together
- No need to remember to take pills
- It does not cause weight gain
- No effect on bone mineral density
- No increase in thrombosis risk (unlike the COCP)
- No restrictions for use in obese patients (unlike the COCP)
Drawbacks
- Requires minor operation with local anaesthetic to insert and remove
- Can worsen acne
- No STI protection
- It can cause problematic bleeding
- Implants can be bent or fractured
- Implants can become impalpable or deeply implanted
What investigations need to be done if an implant becomes impalpable?
- Extra contraception is required until it is located
- Ultrasound or xray to locate. The manufacturer of Nexplanon adds barium sulphate to make it radio-opaque so that it can be seen on xrays.
- If the implant cannot be located even after an ultrasound scan, a chest xray may be considered to identify an implant in a pulmonary artery.
How is problematic bleeding with the implant dealt with?
Cannot predict what bleeding pattern someone is going to have
Add COCP in addition to the implant for three months to help settle the bleeding (provided there are no contraindications).
What are the different types of coil, what is their mechanism of action, how long do they last for and how effective are they?
Typical and Perfect Use is 99%
Cu-IUD: Copper is toxic to egg and sperm and creates hostile environment in uterus so cannot implant. Lasts 5-10 years. Can also be used as emergency contraception up to 5 days after unprotected sex
LNG-IUS: Thickens cervical mucus, alters endometrium so cannot implant, does not stop ovulation. Lasts 5 years, 4 years if for HRT. Used for contraception, menorraghia or endometrial protection.
What are the contraindications for a coil?
- Pelvic inflammatory disease or infection
- Immunosuppression
- Pregnancy
- Unexplained bleeding
- Pelvic cancer
- Uterine cavity distortion (e.g. by fibroids)
- Wilson’s Disease (IUD)
How is the coil inserted and what are the risks with insertion?
- If <25 need STI screening before insertion
- Bimanual Exam to examine size/position of uterus
- Speculum inserted and device fitted, forceps can be used to stabilise the cervix while the device is inserted.
- Blood pressure and heart rate are recorded before and after insertion.
Period cramps after insertion, take NSAIDs
Women need to be seen 3 to 6 weeks after insertion to check the threads and be taught how to check them
When a coil is removed, how long does it take for fertility to return?
Immediately, need to abstain from sex or use condoms for 7 days if want it to be removed
Pull slowly on strings to remove
If the coil threads are not visible/cannot be palpated, what needs to be done?
Need to exclude:
- Expulsion
- Pregnancy
- Uterine perforation
Use contraception until it is found. Send for US. May need AXR/Pelvic X-ray if uterine perforation. Last line is hysteroscopy or laparascopy
What are the pros and cons of the copper coil?
Benefits
- Reliable contraception
- Effective immediately
- It contains no hormones, so safe for women at risk of VTE or with a history of hormone-related cancers
- It may reduce the risk of endometrial and cervical cancer
Drawbacks
- Procedured required
- It can cause heavy or intermenstrual bleeding
- Pelvic pain
- No protection for STIs
- Increased risk of ectopic pregnancies
- Intrauterine devices can occasionally fall out (around 5%)
When does the LNG-IUS become effective as a contraception after insertion?
- Day 1-7: effective immediately
- Over Day 7: Need to rule out pregnancy and use condoms for 7 days
What are the pros and cons of the IUS?
Benefits
- Can make periods lighter or stop altogether
- It may improve dysmenorrhoea or pelvic pain related to endometriosis
- No effect on bone mineral density
- No increase in thrombosis risk
- No restrictions for use in obese patients
- The Mirena has additional uses (i.e. HRT and menorrhagia)
Drawbacks
- Procedure required
- It can cause spotting or irregular bleeding
- Pelvic pain
- No STI protection
- Increased risk of ectopic pregnancies
- Increased incidence of ovarian cysts
- There can be systemic absorption causing side effects of acne, headaches, or breast tenderness
- Intrauterine devices can occasionally fall out (around 5%)
How is problematic bleeding with the coil dealt with?
Irregular bleeding can occur for first 6/12
Alternative causes need to be excluded where problematic bleeding continues, including a sexual health screen, pregnancy test and ensuring cervical screening is up to date.
Take COCP for three months with LNG-IUS to see if settles
What is often found on smear tests when a woman has an IUD coil?
Actinomyces-like organisms
Does not need treatment if asymptomatic. If symptomatic may need to remove coil
What are the three different types of emergency contraception and how long after unprotected sex can they be taken?
- Levonorgestrel within 72 hours of UPSI
- Ulipristal Acetate within 120 hours of UPSI
- Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
What is the most effective emergency contraception?
Copper Coil
Not effected by BMI, malabsorption or enzyme-inducing drugs
If ovulation has already occurred oral emergency contraception is not likely to work!!!
Needs to be kept in until at least the next period before removal or can keep as LTC
How does Levonorgestrel work as an emergency contraception?
Type of progestogen that delays ovulation, not harmful to pregnancy
Need to taken within 72 hours of intercourse, more effective the earlier taken
N+V is common, if within 3 hours then need to repeat dose
Can start COCP or POP immediately after taking
What are the side effects of Levonorgestrel?
- N+V
- Spotting and changes to the next menstrual period
- Diarrhoea
- Breast tenderness
- Dizziness
- Depressed mood
Avoid breastfeeding for 8 hours after taking
How does Ulipristal Acetate (EllaOne) work as an emergency contraception?
Selective progesterone receptor modulator (SERM) that works by delaying ovulation
Taken within 120 hours of UPSI
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal
Nausea and vomiting are common side effects, if within 3 hours of taking the pill, the dose should be repeated
What are the side effects and contraindications of Ulipristal Acetate for emergency contraception?
- Spotting and changes to the next menstrual period
- Abdominal or pelvic pain
- Back pain
- Mood changes
- Headache
- Dizziness
- Breast tenderness
Avoid in asthmatics
Do not breastfeed for 1 week after taking, express and discard
What are the methods for female sterilisation?
Tubal Occlusion: performed by laparoscopy under general anaesthesia using Filshie clips
Tube ligation or removal: done electively or during C-section
What is the failure rate with female sterilisation and when is it effective as a contraception?
1 in 200
Need to use contraception up to day of surgery and until next menstrual period
Need pregnancy test before operation as any pregnancy likely to become ectopic
What criteria needs to be met for a GP to refer a woman to a gynaecologist for sterilisation?
- Explore other long term contraceptive options as they are as effective and reversible
- Counselling
- Usually have to be over 30 and have children
- Partner usually needs to be in agreement
- Explain cannot get reversal on NHS it is permanent
What are the methods for male sterilisation?
Vasectomy
Cutting of the vas deferens done under local anaesthetic in 15-20 minutes. Less invasive so better option for couples that are considering permanent means of contraception
What is the failure rate with a Vasectomy and how long does it take to become effective as a contraceptive?
1 in 2000
At least 2 months need to use other contraception
Need to wait for semen analysis at 12 weeks to check azoospermia before fully effective
What are the complications that can occur with male and female sterilisation?
Male
- Bruising
- Bleeding
- Infection
- Chronic Post Vasectomy Pain
Female
- Internal bleeding
- Damage to organs
- Failure
- Infection
- Ectopic
Can people under the age of 18 make decisions about their healthcare treatment?
Yes - 16 and 17 years old can make decisions but if they refuse treatment this can be overruled by parents or by the court
If under 16 can make decisions if they have Gilick Competence
What is Gillick competence and how is it proven?
Help to assess whether a child under 16 has the maturity to make their own decisions and to understand the implications of those decision
Must make sure child is not being coerced or pressured
The same child may be considered Gillick competent to make one decision but not competent to make a different decision.
What are Fraser Guidelines?
Apply specifically to advice and treatment about contraception and sexual health (STI screen and TOP)
Children under the age of 16 (not below 13) are only allowed confidential treatment and advice if they fulfil Fraser Guidelines
When should you be concerned if a child under 16 presents for sexual health advice?
- Anyone under the age of 13 needs child protection referral
- Repeated STIs and TOPs could indicate sexual abuse
Always ask about the age of their partner!!!!
