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Chapter 7 - Genito-urinary system > 3. Contraception > Flashcards

3. Contraception Flashcards

1
Q

Fraser guidelines for prescribing contraceptives to under 16’s

A
  • She understands the doctor’s advice
  • She cannot be persuaded to inform her parents
  • She is very likely to continue having sex
  • Her mental and physical health will suffer without contraception
  • In her best interests to provide treatment
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2
Q

Types of combined -contraception

A

ORAL
* oestrogen (ethinylesteradiol, estradiol ect) AND progestogen (desogestrel, noresthisterone, levonorgestrel, nomegestrel)

TRANSDERMAL PATCH
* Evra patches (norelgestromin with ethinylestradiol)

VAGINAL RING
* Nuva ring (etongestrel with ethinylestradiol)

-strel = progestogen

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3
Q

Types of progestogren only contraceptives

A

ORAL
* desogestrel
* norethisterone
* levonorgestrel

PARENTERAL
* medroxyprogesterone (injection)
* Noresthisterone (injection)
* Etonogestrel (implant)

INTRAUTERINE DEVICE
* Levonorgestrel

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4
Q

Combined oral contraceptives mechansim of action

A

Inhibit ovulation

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5
Q

Combined oral contraceptives dosing and counselling

A

A menstrual bleed is caused by the shedding of the uterine lining as the uterine lining remains thin in females take COC, the patient’s menstrual period will not occur.

Take one tablet daily for 3 weeks + 1 week pill-free interval for withdrawal bleeding.
withdrawl bleeding is not a real period, the bleeding is induced by the drop in progestogen

Can begin anytime in menstrual cycle, if started on day 6 or after, use protection for 7 days.

Cannot be used by women older than 50 years, due to the increased risk of VTE.

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6
Q

Types of COC preparations

A
  1. Monophasic (fixed amount of oestrogen and progestogen)
  2. Phasic (varying amount of oestrogen and progestogen to mimic a normal menstrual cycle ). For women who do not have withdrawal bleeds or have breakthrough bleeds with monophasic preparations
  3. Every day prepation (pill-fre days replaced with inactive pills)

4.Low-stregnth oestrogen preparations (~20mg ethinylestradiol)
Used in women with a risk factor for circulatory disease, as they are at greater risk of VTE

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7
Q

COC risks

A

Risk of VTE
factors that increase risk further
* Obesity: BMI > 30
* Smoking
* Primary relative under 45 with VTE
* Immobilisation
* Age >35 years
* Type of progestofen: desogestrel, gestodene, drosperinone

Risk of arterial thromboembolism
factors that increase risk further
* diabetes mellitus
* hypertension
* migraine without aura

AVOID COC if 2 more mORE RISK FACTORS PRESENT

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8
Q

Combined oral contraceptives and surgery

A

Combined oral contraceptives should be stopped 4 weeks before major elective surgery.

For surgery to the legs or surgery that results in prolonged lower limb immobilisation:

  • can switch to progestogen-only contraceptives as it is the oestrogen content that increases risk of VTE
  • restart contraceptives on the first menses, at least 2 weeks following full mobilization

If surgery was not planned
- thromboprophylaxis with heparin and graduated compression hoisery can be used

These restrictions do not apply to minor surger with short duration anasthesia, e.g tooth extraction.
Also does not apply to women on oestrogen-free contraceptives

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9
Q

Combined oral contraceptives and travel

A

Can reduce risk of VTE with compression stocking and leg exercises

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10
Q

Signs of VTE

A
  • Sudden severe chest pain, breathlessness, cough with blood-stained sputum PULMONARY EMBOLISM
  • Unexplained swelling or severe pain in calf of one leg DEEP VEIN THROMBOSIS
  • Serious neurological effects such as severe polonged headache, slurred speech, dysphagia, motor disturbances STROKE

The oestrogen component of combined oral contraceptives is responsible f

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11
Q

Combined oral contraceptives and oestrogen containing HRT risks

A

COC’s and oestrogen containing HRT occasionally cause liver dysfunction (jaundice, hepatitis, liver enlargement)

COC’s and oestrogen containing HRT may also cause an increase in blood pressure. SHOULD BE STOPPED if systolic goes above 160mmHg or disastolic goes above 95mmHg

Also increase the risk of breast and cervical cancer. BUT decrease risk of ovarian, colorectal and endometrial cancer.
Also reduce dysmennorrhea, menorrhagia, symptomatic fibroids and cysts

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12
Q

Combined oral contraceptives contraindications

A

Combined oral contraceptives should be stopped if a patient has a risk factor that contraindicates treatment:

  • Smoking > 40 cigarettes
  • History of arterial or venous thrombus
  • Migraine/severe migraine lasting >72 hrs, migraine treated with ergot derivatives
  • Diabetes mellitus with complications
  • BMI >35
  • Over 50 years
  • Transient iscaemic attack
  • Hypertension; systolic >160mmHg and diastolic >95mmHg
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13
Q

Progestogen-only pill (POP) mechanism of action

A

Prevents pregnancy by thickening the mucus in the cervix to stop sperm reaching an egg

Menstrual irregularities, heavy or light periods is common

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14
Q

Progestogen-only pill (POP) dosing regimen

A

One tablet is taken daily on a continuous basis, starting on day 1 and taken at the same time each day .

If the regimen is started after day 5 of the menstrual cycle, additional precuation must be used for 2 days, such as a condom

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15
Q

Progestogen-only pill (POP) risks

A

Increase the risk of breast cancer

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16
Q

Missed pill rules (COC)

A

If pill is missed for ≥ 24 hours
(Zoely/Qlaira ≥ 12 hours)

If its only 1 pill:
Take the missed pill AND take the next one at normal time even if it means taking two together. No more precautions needed for this.

If its 2 or more pissed pills:
Take one pill ASAP + condom for 7 days
(condom for 9 days if Zoely/Qlaira)

Miss out-pill free interval, if a pill is missed in the last 7 days of the cycle

If the pill is missed in the first 7 days and unprotected sex has occured - get EMERGENCY HORMONAL CONTRACEPTION

17
Q

Progestogen-only pill (POP) missed pill rules

A

If pill is missed for > 3 hours
(Desogestrel > 12 hours)

Take ASAP + use condom for 2 days

If a woman has missed 1 or more pills and has had unprotected sex, before 2 pills are taken correctly = Obatin emergency hormonal contraception

18
Q

Combined oral contraceptives (COC) - vomiting/diarrhoea

A

If vomiting/diarrhoea occurs less than 2 hours of taking it - TAKE ANOTHER ONE

In more serious cases of vomiting/diarrhoea lasting >24 hours - additional protection must be used during and 7 days (9 days if Qlaira) after recovery. Pill can then be resumed.

If vomiting/diarrhoea occurs in the last 7 days - pill-free interval must be missed out

19
Q

Progestogen-only pill (POP) - vomiting/diarrhoea rules

A

If vomiting/diarrhoea occurs less than 2 hours of taking it - TAKE ANOTHER ONE

If vomiting/diarrhoea is severe or pill is not taken within 3 hours of normal times (12 hours if desogestrel) - additional protection must be used during and 2 days after recovery and pill is resumed

20
Q

Transdermal patch (Evra) application/dosing

A

1 weekly patch is applied for 3 weeks, then 1 week is patch freee

If a patch is detached for less than 24 hours
* it can be attached or replaced immediately. No additional protection is needed.

If a patch is detached for >24 hours or application is delayed at the start of the cycle:
* the current contraceptive cycle should be stopped and a new patch should be applied + condom should be used for 7 days

If a women forgets to apply her patch in the middle of the cycle (beginning of week 2 or week 3)/day 8 or 15:
* If it has been ≤48 hours - a new patch can be applied immediately and can be continued as normal.
* If it has been > 48 hours - a new contraceptive cycle must be started + condom for 7 days

21
Q

Contraceptives interactions

A

Exceptions to these contraceptive interactions include IUD’s and progestogen only injections BUT include emergency hormonal contraceptives

The effecriveness of contraceptives can be reduced by hepatic enzyme inducing drugs
* CRAPGPSSS

Alterntaively, if contraception cannot be changed or stopped
* IUD OR Progestogen-only injections can be used

Emergency contraception alternative methods
Ulipristal efficacy is reduced by drugs that increase gastric PH, like antacids, H2 receptor antagonists, PPI’s
* copper IUD
* 3mg dose of levorgestrel (unlicensed)

C CARBAMAZEPINES
R RIFAMPICIN
A ALCOHOL
P PHENYTOIN
G GRISEOFULVIN
P PHE

22
Q

Emergency contraceptive options

A

1st line: Copper IUD
Most effective
Inserted up to 5 days after unprotected intercourse or up to 5 days after the earliest calculated ovulation

Intrauterine devices are unsutiable for women <35 years as they are at increased risk of pelvic inflammatory disease

2nd line: hormonal methods
Oral EHC: levonorgestrel or ulipristal (more effective)

If BMI>26kg/m2 or >70kg: ulipristal or double dose of levonorgestrel

23
Q

Levonorgestrel mechanism of action and dose

A

Mechanism of action:
prevents ovulation and fertilisation

Dose:
1500mg < 72 hours (3 days) of unprotected sex
If vomiting occurs within 3 hours of taking the dose, must have a replacement dose.

Caution:
* Crohn’s disease
* Past ectopic pregnancy
* Ciclosporin (due to toxicity)

24
Q

Ulipristal mechanism of action, dose, cautions and contra-indications

A

mechanism of action: progestogen receptor modulator inhibits or delays ovulation

dose: 30mg must be given within 120 hours (5 days) of unprotected sex.
If vomiting occurs less than 3 hours of taking dose, provide replacement dose

caution:
* severe asthma treated by oral corticosteroids
* severe liver impairement (AVOIDED)

contraindications:
- repeated use within same menstrual cycle (only levonorgestrel can be used repeatedly within the same menstrual cycle)

25
Q

Emergency contraceptives and regular contraceptives timing

A

Ulipristal reduces effectiveness of regular contraception, use barrier protection :
- combined contraceptives: for 14 days (16 days if Qlaira)
- progestogen-only: for 9 days (14 days if parenteral)

Levonorgestrel also reduces effectiveness of regular contraceptives:
- wait 5 days before using regular contraceptives. Use condoms/abstain duirng this period

26
Q

Emergency hormonal contraceptives side effects

A

side effects:
- irregular menstrual cycle

counselling
* Next period may be early or late
* Use barrier protected until next period
* If lower abdominal pain must see GP to rule out ectopic pregnancy
* If periods are abnormal, light, heavy, brief or absent must take a pregnancy test (at least 3 weeks after unprotected sex)

27
Q

Types of IUD contraceptives

A

1. Copper IUD’s

2. Levonorgestre-releasing IUD’s
adv: reduced bleeding, period pain, lower risk of pelvic inflammatory disease

Must be prescribed by brand:
- Mirena = 5 years
- Levosert = 3 years
- Jaydess = 3 years

28
Q

IUD side effects

A
  • common: prolonged menstrual bleeding/spotting
  • Pain and bleeding on insertion
  • Uterine perfortation, risk if increased if given before 36 weeks postpartum or women breastfeeding.
    Patients must report signs of: severe pelvic pain after insertion, pain during sex, pain or increased bleeding for more than a few weeks, unable to feel threads (patients must be taught on how to feel threads)
  • Risk of infection (risk increased after first 20 days of insertion) and related to existing STI’s. Pre-insertion chlamydia screening must be conducted for high risk groups (under 25/new partner/multiple partners/history of STI)

Patients taking it for emergency contraception must be given antibiotic prophylaxis.

29
Q

IUD removal

A
  • Must not be removed mid cycle UNLESS additional contraceptives are used for 7 days
  • If removal is needed, and unprotected sex occurs, offer EHC
  • If pregnant, MUST be removed in 1st trimester
30
Q

Parenteral contraceptives

A

Medroxyprogesterone injection: lasts 2 years
BUT may result in
delayed fertility
menstrual irregualirities
risk of osteoperosis

Noresthisterone injection: lasts 8 weeks
used as a short term interim

Etonogestrel implant: lasts 3 years
A rod that is inserted into the upper arm.
However have been reports of the rod reaching the lungs via pulmonary artery therefore must be able to locate the implant under the arm. If it cannot be locared, REMOVE ASAP (use chest imaging if necessary)

31
Q

Spermicidal contraceptives

A

They kill sperm and prevent them from reaching the egg to fertilise it.

They come in different forms: gels, films, suppositories.

Should not be used alone as they are not very effective

Chapter 7 - Genito-urinary system (7 decks)

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