7.3. Contraception Flashcards
A 19-year-old female starts Microgynon 30 (combined oral contraceptive pill) on day 8 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Immediately
2 days
5 days
7 days
Until first day of next period
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Counselling of COC
Combined oral contraceptive pill: counselling
Women who are considering taking the combined oral contraceptive pill (COC) should be counselled in a number of areas:
Potential harms and benefits, including
the COC is > 99% effective if taken correctly
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
Advice on taking the pill, including
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
should be taken at the same time every day
the COCP is conventionally taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation. However, there was a major change following the 2019 guidelines. ‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break
advice that intercourse during the pill-free period is only safe if the next pack is started on time
Discussion on situations where efficacy may be reduced*
if vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
if taking liver enzyme-inducing drugs
Other information
discussion on STIs
*Concurrent antibiotic use
for many years doctors in the UK have advised that the concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra-precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
no such precautions are taken in the US or the majority of mainland Europe
in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
precautions should still be taken with enzyme inducing antibiotics such as rifampicin
A 37-year-old woman presents to her local surgery requesting to start ‘the Pill’. On further discussion you find she is keen on using a combined oral contraceptive pill and is not interested in using a long-acting reversible method. She has no significant medical history of note and no family history of thromboembolism or cancer.
Select the two most relevant further actions before deciding on whether to prescribe a combined oral contraceptive pill.
- A.Breast examination
- B.Blood pressure
- C.Vaginal examination
- D.Ask about smoking status
- E.Ask about alcohol intake
Correct answer: B D
- Blood pressure should be checked before starting the combined oral contraceptive pill (COCP) and at least annually. Not only does hypertension increase the risk of cardiovascular events but a small number of women using the COCP develop high blood pressure as a side-effect.
- Her smoking status is important as being older than 35 years and smoking more than 15 cigs/day is an absolute contraindication to the COCP.
- Both a breast and vaginal examination are unnecessary unless the woman reports symptoms.
- Alcohol intake is of course an important general health question but it is not as relevant as smoking status when prescribing the COCP.
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
- UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
- UKMEC 2: advantages generally outweigh the disadvantages
- UKMEC 3: disadvantages generally outweigh the advantages
- UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
Examples of UKMEC 4 conditions include
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Changes in 2016
- breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2
A 24-year-old-woman is considering starting the combined oral contraceptive pill (COC).
Which of the following pieces of information or advice is most appropriate to give to this woman?
Select one:
A. Additional contraceptive precautions are required when antibiotics, such as amoxicillin, are used concurrently
B. For women who are having natural menstrual cycles, the COC pill can be started up to and including day 5 of the menstrual cycle without the need for additional contraceptive protection Correct
C. The 21 day regimen (21 days active tablets followed by 7 days hormone free interval) is safer than continuous or extended regimens
D. The COC pill is associated with a reduced risk of breast cancer and venous thrombosis
E. With perfect use, the COC pill is 100% effective at preventing pregnancy, which drops to 97% with typical use
For women who are having natural menstrual cycles, the COC pill can be started up to and including day 5 of the menstrual cycle
There is a possible small increase in risk of developing breast cancer, which returns to no increased risk within 10 years after stopping the COC. The estimated failure rate for typical use of COCs is 9% at 1 year. Additional contraceptive precautions are not required when antibiotics that do not induce enzymes are used in conjunction with CHCs.
The correct answer is: For women who are having natural menstrual cycles, the COC pill can be started up to and including day 5 of the menstrual cycle without the need for additional contraceptive protection
A 34-year-old woman walks into your pharmacy and requests the supply of ellaOne® (ulipristal acetate). She has read that it is an emergency contraception, which can be taken after unprotected sexual intercourse.
Use the information provided about ellaOne® in the resource pack.
Which ONE of the following statements regarding ellaOne® is CORRECT?
Select one:
A. ellaOne® can be recommended to be taken in pregnancy or suspected pregnancy
B. ellaOne® must be taken within 72 hours of unprotected sex
C. If hormonal contraception is continued after administering ellaOne®, barrier contraception does not need to be used until the next period or withdrawal bleed
D. One ellaOne® tablet contains 150 micrograms of ulipristal acetate
E. The primary mechanism of action for ellaOne® is inhibition or delay of ovulation Correct
ellaOne consists of 30mg of ulipristal acetate. It is not recommended to be used more than once per cycle. ellaOne is not intended for use during pregnancy and should not be taken by any woman suspected or known to be pregnant
The correct answer is: The primary mechanism of action for ellaOne® is inhibition or delay of ovulation
A 23-year-old female patient has been taking an oral contraceptive pill (containing ethinylestradiol and levonorgestrel) for the past 4 years. She is not taking any other medicines and has no significant past medical history. She is due a review with the prescriber. Identify the parameter which should be measured before prescribing a repeat prescription.
Select one:
A. Blood pressure Correct
B. Chest X-ray
C. Electrocardiogram (ECG)
D. Fasting blood glucose
E. Heart rate
F. Plasma urea
G. Serum alanine transaminase (ALT)
H. Urinalysis
Blood pressure should be measured as hypertension is a known risk factor that increases the risk of arterial disease associated with oral contraceptives.
The correct answer is: Blood pressure
Which ONE of the following is NOT a reason to STOP the combined oral contraceptive pill?
Sudden breathlessness
Severe stomach pains
Hypertension - 150/90 mmHg
Jaundice
Unexplained swelling of the calf of one leg
The correct answer was Hypertension - 150/90 mmHg
Only blood pressure above systolic 160 mmHg or diastolic 100 mmHg is a reason to stop the combined oral contraceptive pill.
In which one of the following patients should combined oral contraceptives be avoided due to arterial disease risk factors?
A patient who smokes 30 cigarettes a day
A patient with a blood pressure of 150/90
A 45-year-old patient
A patient with a BMI of 33kg/m2
A patient with severe migraines with aura
The correct answer was A patient with severe migraines with aura
Under risk factors for arterial disease - only migraine as described is an avoid criteria. Patients with migraine with aura are at an increased risk of stroke and should not take combined contraceptives because of the increased risk of stroke. The other options are use with caution criteria unless they are combined and a patient has two or more factors.
There are several drugs which may interact with the oral contraceptive Yasmin.
Which of the following drugs reduces the effectiveness of Yasmin?
Naloxone
Paracetamol
Ranolazine
Rifabutin
Selegiline
The correct answer was Rifabutin
Rifabutin is predicted to decrease the efficacy of combined oral contraceptives.
Miss RG asks your advice on taking her combined oral contraceptive as she is 5 hours late in taking her next tablet. She is at the middle of her cycle.
Which of the following would be the correct advice?
Take two tablets now and no further action is required
Take the missed tablet straight away and no further action is required
Take the missed tablet straight away and use another form of contraception for 7 days
Take the missed tablet straight away and use another form of contraception for 14 days
Stop the present cycle of the pill and start a new cycle in 7 days time
The correct answer was Take the missed tablet straight away and no further action is required
A ‘missed pill’ is one that is 24 hours late. Therefore, the missed pill is not classed as ‘late’ and can be taken immediately and the cycle continued
A 22-year-old female comes into your pharmacy for advice about contraceptive effectiveness. She has been taking a progesterone-only contraceptive pill (Cerazette®) regularly for the past 12 months. She took her pill this morning at 7 am but started to feel unwell and vomited at 9.15 am. She is concerned about contraceptive failure.
Which of the following is the most appropriate advice for this lady?
- Emergency hormonal contraception is required
- No further action required
- Recommence Cerazette® when she feels better
- Take another Cerazette® as soon as possible
- Use barrier contraception for the next 7 days
The correct answer was Take another Cerazette® as soon as possible
A 24-year-old female comes into your pharmacy to ask for a hormonal emergency contraceptive pill. After asking her all of the relevant questions you supply ulipristal and counsel her. She is not currently taking the oral contraceptive pill, she is not taking any other medicines, has no medical conditions and no allergies.
Which one of the following counselling points is the LEAST suitable to tell the patient?
- You should use a barrier method of contraception until your next period
- Your next period may be earlier or later than usual
- If you are sick within the first 3 hours of taking this medicine you should come back for a replacement dose.
- You may experience lower abdominal pain as a side effect of this medication
- If the next menstrual period is more than 7 days late a pregnancy test should be performed
Lower abdominal pain may be indicative of an ectopic pregnancy and medical attention should be sought.
- The correct answer was You may experience lower abdominal pain as a side effect of this medication
You are the pharmacist on duty in a community pharmacy that offers emergency contraception. Miss CJ presents to your pharmacy for emergency contraception. She is 18 years old and would like advice on the most effective form of contraception going forward.
What is the most appropriate answer?
- Combined hormonal oral contraceptive
- Diaphragm
- IUD
- Male condom
- Natural family planning
The correct answer was IUD
An Intrauterine device is more than 99% effective. With typical use the combined oral contraceptive is around 91% effective. With typical use male condoms are around 82% effective. With typical use diaphragms are around 71-88% effective, the natural family planning method is around 76% effective.
You offer a patient group direction (PGD) for emergency contraception in your pharmacy. The PGD allows for supply to those under 16 years of age.
Under what age are children too young to legally consent to sexual activity and consideration should be given to raising the issue with social services?
- 10 years
- 12 years
- 13 years
- 16 years
- 18 years
The correct answer was 13 years
Children under the age of 13 are legally too young to consent to sexual activity and consideration should be given to reporting to Social Services. Sexual activity with children under the age of 16 is an offence but may be consensual.
Oral contraception is a very commonly used reversible method of contraception, Many women rely on the pill to help prevent unwanted pregnancy. One of the commonly prescribed pills in the UK is Yasmin.
Which of the following is UNTRUE regarding Yasmin?
- It can cause vaginal discharge
- It contains drospirenone 3 mg
- It contains ethinylestradiol 30 mcg
- It is a monophasic 28-day preparation
- It may cause sexual dysfunction
The correct answer was It is a monophasic 28-day preparation
Yasmin is a monophasic 21-day preparation.
