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Case 4 - contraception Flashcards

1
Q

METHODS OF CONTRACEPTION

A

➢Natural family planning
➢Lactation Amenorrhoea Method
➢Barrier methods
➢Hormonal methods
➢Intra-uterine
➢Permanent methods
➢Emergency contraception

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2
Q

There are three main types of LARC provided in the UK, which are:

A
  • Intrauterine devices (IUD/IUS), last for between 5 and 10 years
  • Implants last for up to 3 years and
  • Injections (‘Depot’) last for up to 3 months
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3
Q

what are the barrier methods of contraception

A

Male condom

Female condom

Diaphragm/cap with spermicide

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4
Q

advantages of condoms

A

CAN HELP PROTECT FROM STI
Widely available
No serious side effects

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5
Q

Disadvantages of condoms

A

May slip off / split, Interrupts intimacy, Oil-based products can damage condoms, Requires negotiation

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6
Q

Advantages of diaphragm and cap

A

Can be put in up to 3 hours before sex
No serious side-effects

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7
Q

Disadvantages of diaphragm and cap

A

Extra spermicide needed for repeat intercourse
Some people may be sensitive to spermicide
Need to learn how to use correctly
Needs correctly sizing/fitting
Needs to be left in for 6 hours after sex

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8
Q

Tyes of combined hormonal contraceptives are:

A

➢COC

➢Patch

➢Ring

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9
Q

combined hormonal contraceptives work by:

A
  • Ovarian suppression
  • Cervical mucous effect
  • Endometrial effect
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10
Q

what about Combined Oral Contraception COC

A

Combined Oral Contraception COC - 21 pills in a pack, followed by hormone free interval traditional pills ethinylestradiol EE 20/30 microgram plus varied progesterones. (Oestradiol valerate is the only oestrogen alternative)

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11
Q

what about the patch - combined hormonal contraceptive

A

Patch- (33.9 μg EE and 203 μg norelgestromin) Change patch every week for 3 weeks, then it’s hormone free interval. Patch is less effective in women >90kg

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12
Q

what about the ring - combined hormonal contraceptive

A

➢Ring- (EE and etonogestrel at daily rates of 15 μg /120 μg) . place the Ring in the vagina for 3 weeks, then it’s hormone free interval. Better cycle control, lower dose hormones

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13
Q

Advantages of COMBINED HORMONAL CONTRACEPTION:

A

Doesn’t interrupt intercourse

Menstrual regularity

Helps PMS, PCOS, endometriosis, acne and peri menopause

Reduces certain cancer risk (Ovarian, endometrial, colon)

A combination of drugs (like a diuretic) or other medications don’t affect the patch and ring contraceptives

Don’t have to remember the patch and ring daily

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14
Q

Disadvantages of COMBINED HORMONAL CONTRACEPTION:

A

Side-effects (Breast tenderness, headache, mood changes, nausea, discharge, skin irritation with patch)

Breakthrough bleeding/spotting

Risk: VTE, MI, Stroke, Migraine

Increases certain cancer risk (Cervical and breast)

Ring: needs inserting vaginally

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15
Q

PROGESTERONE-ONLY PILLS examples

A

➢Traditional POP - Norithesterone, levonogestrel. These have a 3 hour window (take 3 hours to have an effect)

➢Desogestrel POP - 12 hour window (take 12 hours to have an effect)

➢Drospirenone POP - 24 hour window (take 24 hours to have an effect)

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16
Q

how to take PROGESTERONE-ONLY PILLS and their modes of actions

A

HOW TO TAKE
Take one pill daily, no breaks

MODE OF ACTION
* Thickens cervical mucous
* DSG (Desogestrel) and DRSP (Drospirenone) suppresses ovulation in 97% of cycles

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17
Q

advantages of PROGESTERONE ONLY PILLS

A

Easy pill-taking regime
May help with dysmennorhoea / PMS
Can be used if oestrogen is contra-indicated
(fewer restrictions)
Can induce amenorrhoea

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18
Q

disadvantages of PROGESTERONE ONLY PILLS

A

Bleeding irregularity
Progesterone side-effects
(acne, breast tenderness, headache, loss
of libido, weight change- no evidence)
A combination of drugs (like a diuretic) or other medications affect the pill effects, e,g GI absorption
Need to remember daily dose
Drug interactions - enzyme inducers
Ovarian cysts (UKMEC1 - no restriction to use this method)
Ectopic rate 10% (traditional POP)

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19
Q

what about the SUB-DERMAL IMPLANT

A

➢Flexible rod (40mm long by 2mm diameter)

➢Inserted subdermally – placed just beneath the skin in the hypodermis

➢Contains 68mg of etonogestrel, which is the active metabolite of desogestrel

➢The rate of diffusion is controlled by the external membrane.

➢Lasts 3 years

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20
Q

mode of action of SUB-DERMAL IMPLANT

A

MODE OF ACTION:
* Inhibits ovulation
* Thickens cervical mucous
* Thins endometrium

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21
Q

Advantages of SUB-DERMAL IMPLANT

A

The most effective contraceptive method

Covers for 3 years

Able to return to fertility upon removal of the implant

Indepent of intercourse

No GI absorption

No relevant effects on metabolism (lipids, clotting, blood pressure, so no increased risk of thrombotic events or decrease in bone mineral density)

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22
Q

Disadvantages of SUB-DERMAL IMPLANT

A

Bleeding pattern

Must learn the procedure to fit and remove

Drug interactions

Progesterone side-effects (acne(varies), breast tenderness, headache, changes in libido /mood, weight)

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23
Q

what about PROGESTERONE ONLY INJECTABLES?

A

Slow release of a synthetic progestogen over 12-14 weeks

DMPA: Depot medroxyprogesterone acetate given as deep IM (intramuscular) injection as
▪ Depo-Provera: 150mg in 1ml
or
▪Sayana Press: 104mg MPA (Medroxyprogesterone Acetate) in 0.65ml in a pre-filled injector (usually anterior thigh or abdomen) subcutaneously

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24
Q

how do you give PROGESTERONE ONLY INJECTABLES

A

➢Kept at room temperature
➢Given every 12 weeks
➢Can be given up to 14 weeks without the
loss of contraceptive cover

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25
mode of action of PROGESTERONE ONLY INJECTABLES
MODE OF ACTION *Inhibiting ovulation *Thickens cervical mucus
26
Advantages of PROGESTERONE INJECTABLES
Lasts 3 months Not affected by other medications 70% amenorrhoeic at 1 year Possible reduction in some cancers (endometrial, ovarian) Improvement of endometriosis Reduction in menorrhagia / dysmenorrhoea
27
disadvantages of PROGESTERONE INJECTABLES
Progesterone side effects (hair loss, acne, decreased libido, mood change, headache, hot flushes & vaginitis) Altered menstrual bleeding Weight gain (adolescents BMI >30, women with >5% gain first 6 months) Slight increase risk in breast cancer & cervical cancer Can’t be removed once given Bone mineral density loss Delayed return to fertility – 9 months+ Injection site reactions (induration, scarring, atrophy)
28
copper IUDs - Primary effect is through copper ions:
Direct effect on the sperm and ova (female sex cells, or eggs, produced in the ovaries and released during ovulation) Decreased sperm motility (movement) Decreased sperm survival
29
copper IUDs - Secondary effect on the endometrium:
Sperm phagocytosis Impeded/delayed implantation
30
Advantages of Copper IUDs
Immediately effective Non – hormonal, no systemic effects No drug interactions Independent of intercourse Easily reversible Inexpensive Can be used as emergency contraception
31
Disadvantages of Copper IUDs
Longer painful periods Periods up to 50% heavier Procedure (invasive, discomfort, infection, perforation) Expulsion – where the IUD can partially or completely come out of the uterus Ectopic pregnancy - No overall increased risk of this
32
IUS - Primary effect of IUS is hormonal:
Prevention of endometrial proliferation Cervical mucus thickening, thus inhibiting the passage of sperm Prevention of ovulation in a small percentage of cycles
33
Advantages of IUS
Up to 8 years of cover Periods lighter, shorter, less painful (Mirena reduces menstrual loss by 90%) Dysmenorrhoea, HMB, Endometriosis, adenomyosis Easily reversible No drug interactions Endometrial protection in HRT (hormonal replacement therapy) for 5 years Independent of intercourse Little or no increased risk of VTE or MI
34
disadvantages of IUS
Irregular spotting Progesterone side-effects Functional ovarian cysts Procedure (invasive, discomfort, infection, perforation) Expulsion Independent of intercourse Ectopic pregnancy - No overall increased risk of this
35
what are the 2 types of emergency contraception
2 main types ➢Copper IUD ➢ORAL emergency contraception
36
what is the sperm survival?
sperm can survive in the female reproductive tract for up to 5 days
37
how long does the ovulated egg remain viable for?
24 hours
38
how many days is the fertile window
6 days
39
UKMEC category 1
a condition for which there's no restriction for the use of the method
40
UKMEC category 2
a condition where the advantages of using the method generally outweigh the theoretical or proven risks
41
UKMEC category 3
a condition where the theoretical or proven risks usually outweigh the advantages of using the [contraceptive] method. the provision of the method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method isn't usually recommended unless more appropriate methods aren't available or aren't acceptable
42
UKMEC category 4
a condition which represents an unacceptable health risk if the method is used
43
what are fertility awareness methods
Fertility awareness methods (sometimes known as "natural family planning") take a few different forms, but all involve a woman knowing when she's ovulating and planning sex around that to avoid unintended pregnancy.
44
give examples of fertility awareness methods
the calendar method - charting your menstrual cycle using an app or diary, so you can recognise patterns in your menstrual cycle and predict when ovulation is likely to take place, down to the day The sympto-thermal method - which looks at not just cervical mucus, but also at basal body temperature. In other words: You have to take your temperature every morning and keep track of when it rises. The Billings ovulation method - involves tracking just your cervical mucus, which is wet and slippery when you're at your most fertile
45
advantages of fertility awareness method
No hormonal side effects No health risks Greater awareness of body/cycles Can be used to PLAN pregnancy
46
disadvantges of fertility awareness method
Less effective than other methods (76% typical) Daily record keeping : BBT (basal body temperature) and mucous Relies on abstinence / barrier methods at fertile times Takes 3-6 cycles to learn effectively No protection against STI
47
1st line of combined hormonal contraceptives prescribing
Ist line is: 2nd generation, monophasic, norethisterone or levonorgestrel containing, ≤30mcg EE pill eg microgynon 30 Rationale: simple to take, lowest VTE risk,
48
2nd line of combined hormonal contraceptives prescribing
2nd line is: 3rd generation pills, Newer progesterones Fewer side effects but higher VTE risk - gestodene (femodene) desogestrel (marvelon), norgestimate (cilest)
49
3rd line of combined hormonal contraceptives prescribing
3rd line: are Phasic pills - Good for cycle control Every daypills - 21 active and 7 dummy pills Qlaira / zoely - Alternative oestrogen for different side effects - Oestradiol valerate 20mcg version of 30mcg pills – logynon 20 / eloine
50
ADVANTAGES of off licence regimes of combined hormonal contraceptives
Infrequent bleeds Efficacy , compliance and safety similar Satisfaction better with extended regimens No evidence to suggest superiority Newer pills have 4 daybreak
51
standard regimen of combined hormonal contraceptives
21 days (21 active pills or 1 ring, or 3 patches) HFI (hormone free interval) - 7 days
52
UKMEC4 for the subdermal implant
▪Current breast cancer
53
UKMEC3 for the subdermal implant
▪Current ischaemic heart disease ▪Stroke ▪Unexplained vaginal bleeding ▪Past history of breast cancer ▪Cirrhosis (severe decompensated) ▪Liver tumours
54
PROGESTERONE INJECTABLES UKMEC 3
▪Multiple risk factors for cardiovascular disease ▪Vascular disease, Stroke/ TIA ▪Current and history of ischaemic heart disease ▪Past history of breast cancer ▪Cirrhosis - severe (decompensated) ▪Liver tumour malignant or hepatoma/ adenoma ▪Unexplained vaginal bleeding ▪Hypertensive retinopathy
55
PROGESTERONE INJECTABLES UKMEC 4
▪Current breast cancer ▪Pregnancy
56
Copper IUD UKMEC4
Current pregnancy Persistent raised βHCG post molar pregnancy Post abortion / postpartum sepsis Unexplained vaginal bleeding Chlamydia/ Gonorrhoea infection or PID Current pelvic tuberculosis Endometrial cancer (initiation) Cervical cancer awaiting treatment (Initiation)
57
Copper IUD UKMEC3
< 4 weeks post partum Structural abnormality uterus (fibroids/ other) Radical Trachelectomy HIV CD4<200 (initiation) Complications post organ transplant (initiation) Known long QT syndrome (initiation)
58
INTER UTERINE SYSTEM IUS UKMEC4
Breast cancer Current pregnancy Puerperal sepsis Recent septic abortion Unexplained vaginal bleeding Cervical cancer Current Chlamydia infection or PID Persistent raised βHCG post molar pregnancy
59
INTER UTERINE SYSTEM IUS UKMEC3
Severe decompensated cirrhosis Structural abnormality of the uterine cavity Liver tumours (adenoma, hepatoma) History of breast cancer over 5 years ago < 4 weeks post partum SLE - positive anti-phospholipid antibodies Endometrial or ovarian cancer
60
advantages of sterilisation
Don’t have to think about contraception again Non-hormonal
61
disadvantages of sterilisation
Not easily reversed Can take up to 3 months to be effective Procedure (bleeding, swelling, infection, pain) Ectopic pregnancy 0.7%
62
when is the Cu-IUD effective after ovulation?
the Cu-IUD is effective until 5 days after ovulation

Case 4 (8 decks)

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