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Year 4 - Reproductive Health > 3.02 - Contraception > Flashcards

3.02 - Contraception Flashcards

1
Q

What are the UKMEC levels of risk for contraception?

A

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

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2
Q

What are the key risk factors to ask about in a contraception consultation?

A

Breast cancer - avoid hormonal contraception and opt for the copper coil or barrier methods.

Cervical or endometrial cancer - avoid the intrauterine system.

Wilson’s disease - avoid the copper coil.

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3
Q

What are the risk factors that should make you avoid the combined contraceptive pill (UKMEC 4)?

A
  • uncontrolled hypertension
  • migraine with aura
  • history of VTE
  • aged >35 years and smoking >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
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4
Q

In perimenopausal women, how long after the last period is contraception recommended?

A

2 years in women under 50.

1 year in women over 50.

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5
Q

Does HRT prevent pregnancy?

A

No - added contraception is required.

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6
Q

For amenorrhoeic women taking progesterone-only contraception, they should continue until:

A
  • FSH >30IU/L
  • 55 years of age
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7
Q

What are the options for contraception under the age of 20?

A
  • COCP (UKMEC1)
  • POP (UKMEC1)
  • progestogen implant (UKMEC1)
  • progestogen injection (UKMEC2)
  • IUD / IUS (UKMEC2)
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8
Q

What are the options for contraception after childbirth?

A

21 days postpartum, contraception is required.

Lactational amenorrhoea is >98% effective for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic.

POP and implant are considered safe in breastfeeding and can be started at any time after birth.

COCP should be avoided in breastfeeding until 6 weeks postpartum.

IUS or IUD can be inserted either within 48 hours of birth, or more than 4 weeks after birth.

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9
Q

What are the barrier methods of contraception?

A

Physical barrier to semen entering the uterus and causing pregnancy, also protecting against STIs.

  • condoms
  • diaphragms
  • cervical caps
  • dental dams
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10
Q

Condom effectiveness.

A

Perfect use: 98%

Typical use: 82%

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11
Q

What are diaphragms and cervical caps?

A

Silicone cups that fit over the cervix and prevent semen from entering the uterus.

They should be fitted before sex, and left in-situ for at least 6 hours after sex.

They can be used alongside spermicide gel to further reduce the risk of pregnancy.

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12
Q

Diaphragm and cervical caps effectiveness.

A

Perfect use: 95% effective

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13
Q

What are dental dams?

A

Used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus.

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14
Q

Which infections can be prevented using dental dams?

A

Prevents infection spread through oral sex:
- chlamydia
- gonorrhoea
- HSV-1 or HSV-2
- HPV
- E. coli
- public lice
- syphilis
- HIV

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15
Q

Effectiveness of COCP.

A

Perfect use: 99%

Typical use: 91%

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16
Q

MOA of COCP.

A

Oestrogen and progesterone have negative feedback effect on the HPG axis, suppressing the release of GnRH, LH and FSH. Without the effects of LH and FSH, ovulation is prevented.

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17
Q

What are the two types of COCP?

A

1) Monophasic pills (contain the same amount of hormones in each pill)

2) Multiphasic pills (contain varying hormones to match normal cyclical changes)

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18
Q

What are the different regimes used in COCP?

A
  • 21 days on and 7 days off
  • 63 days on and 7 days off
  • continuous use
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19
Q

Side effects of COCP.

A
  • unscheduled bleeding in the first three months
  • breast pain and tenderness
  • mood changes and depression
  • headaches
  • hypertension
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20
Q

Risks of COCP.

A
  • VTE (risk lower for the pill than pregnancy)
  • breast cancer
  • cervical cancer
  • myocardial infarction
  • stroke
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21
Q

Benefits of COCP.

A
  • effective
  • rapid return in fertility after stopping
  • improvement of PMS, menorrhagia and dysmenorrhoea
  • reduced risk of endometrial, ovarian and colon cancer
  • reduced risk of benign ovarian cysts
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22
Q

UKMEC4 risk factors for COCP.

A
  • uncontrolled hypertension
  • migraine with aura
  • history of VTE
  • 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
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23
Q

UKMEC3 risk factors for COCP.

A

BMI >35kg/m2

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24
Q

What advice should be given if a woman starts taking COCP on days 1-5 of the cycle?

A

No additional contraception required and protection is offered straight away.

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25
Q

What advice should be given if a woman starts taking COCP after day 5 of the cycle?

A

Additional contraception (i.e. condoms) required for the first 7 days of consistent pill use.

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26
Q

What advice should be given if a woman switches between COCPs?

A

Finish one pack, then immediately start the new pill pack without the pill-free period.

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27
Q

What advice should be given if a woman switches from traditional POP to COCP.

A

Additional contraception (i.e. condoms) required for the first 7 days of consistent pill use.

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28
Q

What advice should be given if a woman switches from desogestrel POP to COCP.

A

Switch immediately with no additional contraceptive requirements.

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29
Q

A COCP is classed as missed if it is:

A

More than 24 hours late

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30
Q

What advice should be given if a woman misses one COCP pill (less than 72 hours since the last pill was taken)?

A
  • take the missed pill as soon as possible
  • no extra protection in required
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31
Q

What advice should be given if a woman misses one COCP pill (more than 72 hours since the last pill was taken)?

A
  • take the most recent missed pill as soon as possible
  • additional contraception (i.e. condom) required for first 7 days of consistent pill use
  • emergency contraception if day 1-7 of the packet they had unprotected sex
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32
Q

Sick day rules for COCP.

A

A day of vomiting or diarrhoea is classed as a ‘missed pill’ day, as the illness may affect the absorption.

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33
Q

NICE (2019) recommend COCP is stopped how many weeks before a major operation?

A

4 weeks to reduce the risk of thrombosis.

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34
Q

Effectiveness of POP.

A

Perfect use: 99%

Typical use: 91%

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35
Q

Types of POP.

A
  • traditional POP
  • desogestrel-only pill
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36
Q

MOA of traditional POP.

A
  • thickening the cervical mucus
  • altering the endometrium and making it less accepting of implantation
  • reducing ciliary action in the fallopian tubes
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37
Q

MOA of desogestrel POP.

A
  • inhibiting ovulation
  • thickening the cervical mucus
  • altering the endometrium
  • reducing ciliary action
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38
Q

What advice should be given if a woman starts taking POP on days 1-5 of the cycle?

A

No additional contraception required as woman is protected immediately.

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39
Q

What advice should be given if a woman starts taking POP after day 5 of the cycle?

A

Additional contraception is required for 48 hours, to give time for the cervical mucus to thicken.

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40
Q

What advice should be given if a woman switches between POPs?

A

Switched immediately without any need for extra contraception.

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41
Q

What advice should be given if a woman switches from COCP to a POP.

A

They can start the POP immediately without additional contraception, if they:

  • have taken COCP consistently for more than 7 days
  • are on days 1-2 of the hormone-free period following a full pack of COCP
42
Q

What advice should be given if a woman switches from COCP to POP, when they are on day 3 of the hormone-free period.

A

No unprotected sex = start POP immediately, but additional contraception required for 48 hours.

Unprotected sex = take COCP for 7 days consecutively, then switch to POP.

43
Q

Side effects of POP.

A
  • unscheduled bleeding*
  • breast tenderness
  • headaches
  • acne

*a third have lughter, less regular or no bleeding; a third have normal bleeding; a third have unscheduled, heavier or more prolonged bleeding.

44
Q

A POP is classed as missed if it is:

A
  • more than 3 hours late for a traditional POP
  • more than 12 hours late for desogestrel-POP
45
Q

What are the missed pill rules for POP?

A

Take the missed pill as soon as possible, and use extra contraception for 48 hours after.

Emergency contraception required if they have unprotected sex since missing the pill or within 48 hours of restarting the regular pills.

46
Q

Sick day rules for POP.

A

Episodes of diarrhoea and vomiting are managed as ‘missed pills’ and extra contraception is required until 48 hours after the diarrhoea and vomiting settle.

47
Q

How often is the progesterone-only injection (DMPA) given?

A

12 to 13 week intervals as an IM or subcutaneous injection.

48
Q

DMPA effectiveness.

A

Perfect use: 99%

Typical use: 94%

49
Q

How long after stopping DMPA does fertility return?

A

Up to 12 months, making it less suitable for women who may wish to get pregnant in the near term.

50
Q

UKMEC4 contraindication to DMPA.

A
  • active breast cancer
51
Q

UKMEC3 contraindication to DMPA.

A
  • ischaemic heart disease and stroke
  • unexplained vaginal bleeding
  • severe liver cirrhosis
  • liver cancer
52
Q

MOA of DMPA.

A

Inhibits FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries and inhibiting ovulation.

53
Q

Timing advice of DMPA.

A

Starting on day 1-5 of the menstrual cycle offers immediate protection, and no extra contraception is required.

Starting after day 5 of the menstrual cycle requires 7 days of extra contraception.

54
Q

Side effects of DMPA.

A
  • changes to bleeding schedule
  • weight gain*
  • osteoporosis*
  • acne
  • reduced libido
  • mood changes
  • headaches
  • alopecia
  • skin reactions at injection sites

*these adverse effects are not associated with any other forms of contraception.

55
Q

Which side effects are unique to DMPA contraception?

A

Weight gain and osteoporosis.

56
Q

Risks of DMPA.

A
  • osteoporosis
  • breast cancer
  • cervical cancer
57
Q

What changes to bleeding can occur when taking the DMPA?

A

In the first 6 months, irregular bleeding can occur but usually settles after this.

COCP can be taken in addition for three months, to help settle the bleeding.

58
Q

Benefits of DMPA.

A
  • improves dysmenorrhoea
  • improves endometriosis-related symptoms
  • reduces risk of ovarian and endometrial cancer
  • reduced the severity of sickle-cell crisis in patients with sickle-cell anaemia
59
Q

Effectiveness of progesterone-only implant.

A

Perfect use: 99%

Typical use: 99%

60
Q

MOA of progesterone-only implant.

A
  • inhibits ovulation
  • thickens cervical mucus
  • alters endometrium to make it less accepting of implantation
61
Q

How often should the progesterone-only implant be replaced?

A

Every three years to remain effective.

62
Q

What contraception advice should be given if inserting the implant on days 1 to 5 of the menstrual cycle?

A

Immediate protection provided so no additional contraception required.

63
Q

What contraception advice should be given if inserting the implant after day 5 of the menstrual cycle?

A

Additional contraception required for seven days after insertion.

64
Q

After removal of the implant, how long does the contraceptive mechanism last?

A

It doesn’t - additional contraception required immediately after removal.

65
Q

Benefits of the contraceptive implant.

A
  • effective and reliable
  • improves dysmenorrhoea
  • make periods lighter or stop altogether
  • no need to remember to take pills
  • does not cause weight gain
  • no effect on bone mineral density
  • no risk of thrombosis
  • no restrictions for use in obese patients
66
Q

Drawbacks of the contraceptive implant.

A
  • requires a minor operation for insertion and removal
  • worsening of acne
  • no protection against STIs
  • problematic bleeding
  • implants can be bent or fractured
67
Q

Why are women advised to palpate the implant occasionally?

A

The implant can become impalpable and deeply implanted.

If it is impalpable, extra contraception is required until it is located by ultrasound or xray.

68
Q

Bleeding pattern of the implant.

A
  • 1/3 have infrequent bleeding
  • 1/4 have frequent or prolonged bleeding
  • 1/5 have no bleeding
  • remainder have normal or regular bleeds

COCP can be used in the first three months until problematic bleeding settles.

69
Q

UKMEC4 contraindication for progesterone-only implant.

A

Breast cancer - otherwise very few contraindications and risks.

70
Q

Effectiveness of coils.

A

Perfect use: 99%

Typical use: 99%

71
Q

Contraindications of coils.

A
  • PID
  • immunosuppression
  • pregnancy
  • unexplained bleeding
  • pelvic cancer
  • uterine cavity distortion (e.g. by fibroids)
72
Q

How are the coils inserted?

A

Bimanual examination performed to check the position and size of the uterus.

A speculum is inserted, and specialised equipment is used to fit the device.

73
Q

Risks relating to the insertion of the coil.

A
  • bleeding
  • pain on insertion
  • vasovagal reaction
  • uterine perforation
  • PID
  • expulsion
74
Q

When is emergency contraception required following removal of the coil?

A

Fertility returns immediately, so use emergency contraception if unprotected sex in the last 7 days.

75
Q

What are the differentials for non-visible coil threads?

A

Women should be taught to feel the strings to ensure the coil remains in place. If they cannot be seen or palpated, three things need to be excluded:
- pregnancy
- expulsion
- uterine perforation

76
Q

How are non-visible coil threads managed?

A

Use additional contraception until the coil is located.

Locate using an ultrasound, xray, hysteroscopy or laparoscopic surgery.

77
Q

MOA of the copper coil (IUD)

A

Copper is toxic to the ovum and sperm.

78
Q

Benefits of the IUD.

A
  • reliable
  • insert at any time and immediately effective
  • no hormones, so safe for women at risk of VTE
  • reduced risk of endometrial and cervical cancer
79
Q

Drawbacks of the IUD.

A
  • procedure required to insert and remove the coil
  • HMB
  • pelvic pain
  • no protection against STIs
  • increased risk of ectopic pregnancy
  • expulsion
80
Q

Contraindications of the copper coil.

A

Wilson’s disease - copper coil can worsen the excessive accumulation of copper in the body and tissues.

81
Q

How long is the Mirena IUS effective for?

A

5 years for contraception and menorrhagia.

4 years for HRT.

82
Q

MOA of IUS.

A
  • thickening cervical mucus
  • alter the endometrium to make it less accepting of implantation
  • inhibits ovulation
83
Q

What advice should be given if inserting the IUS between days 1 to 7 of the menstrual cycle?

A

No need for additional contraception.

84
Q

What advice should be given if inserting the IUS after day 7 of the menstrual cycle?

A

Pregnancy needs to be excluded (pregnancy test), and extra contraception is required for 7 days.

85
Q

Benefits of the IUS.

A
  • make periods lighter or stop altogether
  • improve dysmenorrhoea
  • no effect on BMD
  • no risk of thrombosis
  • no restrictions for use in obese patients
  • useful for HRT and menorrhagia
86
Q

Drawbacks of IUS.

A
  • procedure required for insertion and removal
  • spotting or irregular bleeding
  • pelvic pain
  • no STI protection
  • increased risk of ectopic pregnancy
  • increased risk of ovarian cysts
  • acne, headaches or breast tenderness
  • expulsion
87
Q

If problematic bleeding occurs following IUS insertion, what is the management?

A

COCOP in addition to IUS for three months, to help settle the bleeding.

If this continues, offer:
- sexual health screen
- pregnancy test
- cervical screening

88
Q

What are the sterilisation options?

A

M: Vasectomy

F: Tubal occlusion

89
Q

MOA of tubal occlusion.

A

Prevents the ovum from travelling from the ovary to the uterus, meaning pregnancy cannot occur.

Alternative contraception required until the next menstrual period, as the ovum may have already reached the uterus during that cycle.

90
Q

MOA of vasectomy.

A

Cutting the Vas deferens so prevents semen entering the sperm.

Alternative contraception is required for two months after the procedure, with semen analysis carried out to confirm the absence of sperm.

91
Q

What are the options for emergency contraception?

A
  • Levonorgestrel
  • Ulipristal
  • IUD
92
Q

What is the most effective emergency contraceptive?

A

IUD - not effected by BMI, enzyme-inducing drugs or malabsorption.

93
Q

Outline the use of IUD as an emergency contracetion.

A

Can be used up to 5 days after unprotected intercourse, or within 5 days of the earliest estimated date of ovulation.

First line emergency contraceptive.

94
Q

Outline the use of levnorgestrel as an emergency contraceptive.

A

Prevents or delays ovulation, and licensed for use up to 72 hours post intercourse.

95
Q

Common side effects of Levnorgestrel.

A

Nausea and vomiting - if occurs within 3 hours, repeat the dose.

Other side effects include:
- spotting
- diarrhoea
- breast tenderness
- dizziness
- depressed mood

96
Q

Outline the use of Ulipristal as an emergency contraceptive.

A

Selective progesterone receptor modulator (SERM) working by delaying ovulation.

Licensed for use up to 5 days after intercourse.

97
Q

Common side effects of Ulipristal.

A

Nausea and vomiting - if vomiting occurs within 3 hours taking the pill, the dose should be repeated.

Other side effects include:
- spotting
- abdominal or pelvic pain
- mood changes
- headache
- dizziness
- breast tenderness

98
Q

Restrictions with ulipristal.

A
  • breastfeeding avoided for 1 week after taking ulipristal
  • avoid in patients with severe asthma
99
Q

What is Gillick Competence?

A

Refers to a judgement about whether the intelligence of the child is sufficient to consider treatment.

Consent needs to be given voluntarily, and it is important to assess for coercion or pressure.

100
Q

What are the Frazer guidelines?

A

Guidelines for providing contraception to patients under 16 years without having parental input and consent.

  1. They are mature and intelligent enough to understand the treatment (Gillick competency).
  2. They can’t be persuaded to discuss it with their parents, or let the healthcare professional discuss it.
  3. They are likely to have intercourse regardless of treatment.
  4. Their physical or mental health is likely to suffer without treatment.
  5. Treatment is in their best interest.
101
Q

When does contraception consultations raise safeguarding concerns?

A
  • disclosure of sexual assault or coercion
  • children <13 years
  • children <16 years without Gillick competency

Year 4 - Reproductive Health (12 decks)

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