BASIC - OBS & GYNAE Flashcards
What are the short acting methods of contraception?
Pill, patch, ring
What is in COCP?
Ethinyl Oestradiol + a progesterone
Give the types of progesterone possible?
2nd gen (norethisterone, levonorgestrel) 3rd gen (desogestrel, gestodene, norgestimate) Yasmin (contains drospirenone) Dianette (cyproteone acetate, used in acne)
Give brand names of different generations of COCP?
2nd Gen (microgynon, rigevidon) 3rd gen (Marvelon, Yasmin, Cilest) 4th gen (Glaira)
PEARL index in COCP?
0.3-4
How is COCP taken?
21 pills OD then 7 days off
Take at same time everyday
How does COCP work?
Stops ovulation by preventing FSH/LH release
Also thickens cervical mucus and thins endometrial lining
Common SE of COCP?
Breakthrough bleeding – 1st 3 months but then may become lighter
Weight gain, acne, mood changes, headache
Nausea, breast tenderness, tiredness, bloatedness
Increased risk of blood clots, breast/cervical cancer
Benefits of COCP?
Reduced menstrual blood loss and pain
Non-contraceptive benefits - acne, PCOS, PMS, endometriosis, irregular bleeding, menorrhagia
Decrease in PID, ovarian cysts, ovarian, uterine and colon
Risks of COCP?
Oestrogen thickens blood so VTE (x3-5), stroke (x2), MI, breast (returns to background risk after 10 years of stopping) and cervical cancers
P450 enzyme inducer interactions (reduce efficacy)
COCP- Affected by D&V and some Abx – use condoms from onset of Abx or D&V
Absolute CI of COCP?
<6 weeks post-partum & breastfeeding Smoking (>15/day) >35yrs (may use 1 year after stopping) BP >160/100 - PMH of: o Migraine with aura o Current or past VTE o CHD/CVA/IHD/AF o Current or history of Breast Ca (Oestrogen dependent tumours) o Decompensated liver cirrhosis
Relative CI of COCP?
- BMI>35
- Migraine > 35
- Adequately controlled hypertension
When do missed pill confer more risk? Missed pill rules of COCP?
Pills missed at beginning and end of pack confer more risk of pregnancy
If one pill missed (>24 hours and <48h) – take missed pill, even if means two at once, take rest of pack as usual
If two or more pills missed (>48h late) – last pill missed should be taken, leave earlier missed pills, take rest of pack as normal, condoms used for 7 days
If two or more COCP pills missed (>48h late) - what rules for each week are there?
- If in week 1 – emergency contraception needed
- If in week 2 – no need for EC, normal regimen
- If in week 3 – start next pack immediately
Rules for missed pills Qlaira COCP?
- If <12h late, pill taken immediately, take as usual
- If >12h late, read packaging
Rules for missed pills for Zoely COCP?
- If <12h late, pill taken immediately, take as usual
- If >12h late, read packaging
When are COCP effective postpartum?
Postpartum – start day 21 (not breastfeeding), 6 weeks (breastfeeding)
When are COCP effective according to menstrual cycle?
If started day 1-5 of cycle, effective immediately
After day 5- condoms for 1 week
When can COCP be started after EC and what else is needed for each type?
Started immediately after EC – use additional contraception for 7 days after levonorgestrel and 14 days after ulipristal acetate
What is in the combined patch? Brand name?
150mcg norelgestromin and 20mcg ethinyl oestradiolEvra
PEARL index of combined patch?
1.25
How is combined patch taken?
Change weekly, 1 patch-free week per month
How does combined patch work?
Synthetic oestrogen and progesterone prevent FSH/LH release, preventing follicular development and ovulation
Common SE of combined patch?
Local reaction
Patch detachment
Nausea, breast tenderness, headache, initial irregular bleeding, tiredness, mood swings, bloatedness, acne, weight gain
Benefits of combined patch?
Decrease in PID, ovarian cysts, ovarian, uterine and colon cancers, menstrual control, less benign breast disease
Risks of combined patch?
Oestrogen thickens blood so VTE (x3-5), stroke (x2), MI, breast and cervical cancersP450 enzyme inducer interactions
CI of combined patch?
<6 weeks post-partum & breastfeeding Smoking (>15/day) >35yrs (may use 1 year after stopping) BP >160/100 - PMH of: o Migraine with aura o Current or past VTE o CHD/CVA/IHD/AF o Current or history of Breast Ca (Oestrogen dependent tumours) o Decompensated liver cirrhosis
What happens if combined patch falls off?
Replace fallen patch with new
If off <48 hours – it will cover you for 9 days
If off >48 hours – may need EC and condoms
When is combined patch effective?
If started day 1-5 of cycle, effective immediately
After day 5- condoms for 1 week
What is in a Ring? Brand name?
15mcg ethinyl estradiol and 120ug etonogesterolNuvaRing
PEARL index of ring?
1.2
How is ring contraception taken?
Used for 21 days, then 1 week off
Inserted into vagina and not removed
How does ring work?
Synthetic oestrogen and progesterone prevent FSH/LH release, preventing follicular development and ovulation
Common SE of ring?
Vaginitis, vaginal discharge
Nausea, breast tenderness, headache, initial irregular bleeding, tiredness, mood swings, bloatedness, acne, weight gain
Pain during sex
Benefits of ring?
Decrease in PID, ovarian cysts, ovarian, uterine and colon cancers, menstrual control, less benign breast disease
Risks of ring?
Oestrogen thickens blood so VTE (x3-5), stroke (x2), MI, breast and cervical cancersP450 enzyme inducer interactions
CI of ring?
<6 weeks post-partum & breastfeeding Smoking (>15/day) >35yrs (may use 1 year after stopping) BP >160/100 - PMH of: o Migraine with aura o Current or past VTE o CHD/CVA/IHD/AF o Current or history of Breast Ca (Oestrogen dependent tumours) o Decompensated liver cirrhosis
What happens if ring comes out? Washing technique?
If out >3h or more than once per cycle- effect lost
Efficacy lost if ring free week extended
If comes out wash with tepid water and reinsert
When is ring effective?
If started day 1-5 of cycle, effective immediately
After day 5- condoms for 1 week
What is in the POP?
Contains either levonorgestrel, norethisterone or etynodiol acetate
Traditional or Cerazette (75mcg desogestrel)
PEARL index of POP?
0.4-5
How is POP taken? Rules for menstrual cycle, after miscarriage and pregnancy?
Taken every day, best at same time each day
If started on day 1, no extra contraception needed
If stated after day 5 – extra contraception used for 48h
After miscarriage – start on day
After pregnancy – starts on day 21
How does POP work?
Thickens cervical mucous
Desogestrel only pill prevents ovulation
Common SE of POP?
Irregular bleeds
Loss of libido
Ovarian cysts
Progesterone – headache, mood change, weight gain, acne, breast tenderness
Benefits of POP?
Can be used in breast feeding, older age
Can be used in sickle cell disease, SLE, other autoimmune diseases
Risks of POP?
Menstrual disturbance – regular, irregular or amenorrhoeic
Enzyme inducer interactions (increase metabolism of POP, reducing efficacy)
Remember to take at same time
CI of POP?
Pregnancy
Breast cancer in last 5 years
Current enzyme inducers
Decompensated liver disease
Missed pill rules of traditional POP? What happens if vomits?
Traditional – If >3h late – take missed pill ASAP, take subsequent pill at usual time and use extra contraception for next 48h
Consider EC if unprotected sex in 2-3 days prior, or since missed pill
If vomit within 2h of pill ingestion – take another pill now, use extra contraception for next 48h
Missed pill rules of Cerazette POP? What happens if vomits?
Cerazette – If >12h late – take missed pill ASAP, take subsequent pill at usual time and use extra contraception for next 48h
Consider EC if unprotected sex in 2-3 days prior, or since missed pill
If vomit within 2h of pill ingestion – take another pill now, use extra contraception for next 48h
When is POP effective?
If started on day 1-5, effective immediately
After day 5 – condoms for 48h
What are the types of long-acting contraception?
Injectable, implant, Intrauterine Contraception
What is the implant?
Nexplanon (etonogestrel)
PEARL index of implant?
0.05
How is implant taken?
Single sub-dermal implant lasting 3 years
Requires a small procedure under LA
Inserted into upper part of arm (between biceps and triceps)
How does implant work?
Inhibits ovulation
Thickens cervical mucous
Common SE of implant?
Irregular bleeds
Progesterone – headache, mood change, weight gain, acne, breast tenderness
Insertion bruising, infection, scarring, expulsion
Benefits of implant?
As effective as sterilisation, quick return to fertility once removed
Can forget about it
Risks of implants?
Irregular bleeding in 80%
20% amenorrhoeic
CI of implants?
Breast cancer in last 5 years, current enzyme inducers, CVA, severe liver disease
When is implant effective?
If started day 1-5 of cycle, effective immediately
After day 5- condoms for 1 week
What is in injection?
DepoProvera (medroxyprogesterone acetate)
Noristerat (norethisterone)
PEARL index of injection?
0.4
How is injection taken?What if late?
IM injection into buttocks
Depo – 12 weeks
Noristerat – 8 weeks
If start/late (>14w) then condoms for 7 days
How does injection work?
Slow-release progesterone, bypasses circulation
Inhibits ovulation
Thickens cervical mucus
Common SE of injection?
Irregular bleeds
Progesterone – headache, mood change, weight gain, acne, breast tenderness
Benefits of injection?
No drug interactions
Amenorrhoea in 70%
Good for those with heavy/painful periods
Risks of injection?
Proven weight gain (3kg in 2 years)
Decrease in bone mineral density (>5 years stop)
Fertility delay (6-12 months after stopping)
Once given, cannot remove so SE can last 3 months
CI of injections?
Breast cancer in last 5 years, current enzyme inducers, CVA, severe liver disease
What is the IUS?
Levonorgesttrel-releasing system (daily dose 20mcg)
Mirena
PEARL index of IUS?
0.2
How is IUS taken?
Inserted into uterus lasting 3-5 years
STI check before insertion
Nurse/Doctor will put speculum into vagina and special inserter puts IUD through opening of cervix into uterus (<5 minutes)
Need to check strings monthly
How does IUS work?
Prevents endometrial proliferation
Thickens cervical mucus
Common SE of IUS?
Irregular bleeds – for 6 months then have shorter/lighter periods
Progesterone – headache, mood change, weight gain, acne, breast tenderness
Benefits of IUS?
Useful in menorrhagia and HRT
Can forget about it
Risks of IUS?
Small risk of perforation on insertion (1 in 1000) and expulsion (5%) can occur
Increased risk of ectopic if IUS fails
May continue to have unpredictable spotting
CI of IUS?
Breast cancer in last 5 years, current enzyme inducers, CVA, severe liver disease
Unexplained vaginal bleeding
Cervical/Endometrial cancer
Uterine abnormalities, current chlamydia/gonorrhoea, PID <3 months ago
Postpartum sepsis
Missed pill rules of IUS?
If expelled, then efficacy lost
Strings must be checked regularly
When is IUS effective?
Exclude possible pregnancy
Menstruating, no sex since menstruation, no sex in last 3 weeks + negative pregnancy test or using other forms of reliable contraception (not condoms)
What is IUCD?
Copper ions
ParaGard
PEARL index IUCD?
0.6-0.8
How is the IUCD taken?
Inserted into uterus lasting 5-10 years
Nurse/Doctor will put speculum into vagina and special inserter puts IUD through opening of cervix into uterus (<5 minutes)
How does IUCD work?
Copper ions inhibit sperm motility and survival
Common SE of IUCD?
Heavy bleeding, irregular in first 3-6 months
Dysmenorrhoea
Benefits of IUCD?
No hormones, long-lasting method
Effective instantly
If fitted >40, can stay til no longer required