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Contraception > COCP > Flashcards

COCP Flashcards

1
Q

16-66 (40) pages long and has quiz at end of document

A
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2
Q

What synthetic oestrogen is used in CHC

A

Ethinylestradiol (EE)

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3
Q

What types of CHC are available

A

Pill (COC)
Vaginal ring (CVR)
Transdermal patch (CTP)

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4
Q

Health risks and give figures

A

Increased risk of serious health events including:
1. Venous and arterial thromboembolism (minimised by using <30micrograms of ethinylestradiol) - PE/DVT / stroke/MI
- use of COC is assoc with x3 increased risk. NB- absolute risk of VTE in CHC women = 5-12 per 10’000/ year (with 1% mortality) compared to 2 per 10’000/ year non-CHC users. VTE risk is lower during CHC than during pregnancy. Risk highest in months starting, reduces after.

  1. Breast cancer- small increased risk (RR 1.19 for current users vs never-users), reduces with time after stopping [same as normal after 10y]
  2. Cervical cancer - current COC use >5y, doubles risk. Returns to normal after 10y (and prob 5y). No evidence with patch or ring.
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5
Q

Health benefits

A

Reduced risk of the following cancers:
1. Endometrial cancer*
2. Ovarian cancer*
3. Colorectal cancer

  • significant reduction in risk that increases with duration of use and persists for many years after stopping CHC

Other benefits:
1. Predictable bleeding patterns
2. Reduction in heavy menstrual bleeding and pain
3. Management of symptoms of PCOS (acne, hirsutism, menstrual irregularities)
4. Reduce risk of endometriosis recurrence after surgical management [continuous regimen]
5. Improve PMS symptoms
6. Improve acne

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6
Q

Side effects + important things to explain in consult

A
  • Mood change [mixed evidence]
  • Headache
  • Unscheduled bleeding [assoc with lower levels of oestrogen], likely to improve within 3-4 months

Other associated - nausea, dizziness, br tenderness - often assoc with HFI so advise this if experiencing.

Explain:
- Missed pills advice
- COC effectiveness could be reduced by vomiting or severe diarrhoea. Follow advice for missed pills if vomitting occurs within 3h of taking COC or if severe diarrhoea occurs for >24h

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7
Q

CHC regimens - any benefit in difference?

A

Traditional 21/7 with monthly withdrawal bleed confers no health benefit over other patterns. HFI risks escape ovulation particularly with lower dose EE and if use is not perfect. Tailor to patient.

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8
Q

Drug interactions

A
  • Hepatic enzyme-inducing drugs could reduce the contraceptive effectiveness of all CHC methods
  • CHC can affect serum levels of drugs such as lamotrigine with potential significant SE’s
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9
Q

How much can supply at once?
How regularly follow ups?

A

Up to a years supply at first consultation (although only 3mo of vaginal ring can be supplied at one time). Annual f/u with r/v of medical eligibility, drug interactions, compliance and consideration of alternative contraception incl LARC is recommended as routine.

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10
Q

Fertility issues?

A

CHC not assoc with a delay in return to fertility after stopping

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11
Q

Maximum period of CHC use / maximum age?

A

No arbitrary maximum period of CHC use. Repeated stopping and starting should be discouraged because of thrombotic risk. Can use up to age 50 for contraception / menopausal symptoms and maintenance of BMD.

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12
Q

The majority of CHC contain how much synthetic oestrogen?

A

Between 20 micrograms and 35 micrograms.
This ‘low-dose’ was developed to reduce the health risks assoc with high oestrogen content of COC available in 1960s/70s.

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13
Q

Benefits of progestogens in CHC

A

Progestogens are synthetic steroids
- convenient dosing intervals
- potent suppression of ovulation
- prevents over-proliferation of the endometrium in response to oestrogen

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14
Q

1st, 2nd, 3rd, newer generation progestogens

A

First: norethisterone
Second: levonorgestrel
Third: desogestrel, gestodene, norgestimate
Newer: drospirenone, dienogest, nomegestrol acetate

Norelgestromin (used in patch) is a metabolite of norgestimate
Etonogestrel (used in vaginal ring) is the active metabolite of desogestrel

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15
Q

Combined transdermal patch releases how much EE and progestogen per day?

A

EE - 33.9 micrograms
Norelgestromin - 200microgram

per 24h

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16
Q

Combined vaginal ring releases how much EE and progestogen per day?

A

EE - 15 microgram
Etonogestrel - 120microgram

per 24h

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17
Q

How does CHC work?

A
  • Primary mechanism is by prevention of ovulation
  • CHC acts on the hypothalamo-pituitary-ovarian axis to suppress LH and FSH and thus inhibit ovulation
  • Cervical mucus, endometrium and tubal motility that result from progestogen exposure may also contribute to the contraceptive effect.
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18
Q

You can take CHC in a number of ways. Traditionally with a HFI of 7 days. Tell me the drawbacks of this.

A

21/7 cycles were designed to mimick natural cycles with a bleed however there is no health benefit to this and the 7d HFI has drawbacks:
- bleeding may be heavy/ painful/ unwanted
- may get headaches and mood change
- ovarian suppression is reduced and follicular development occurs in the HFI. Errors in pill taking / patch / ring use could result in extension of the HFI = risk of ovulation= risk of pregnancy

Using tailored use (no break, multiple packs and then a break, a shorter break) is off license but supported by FSRH

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19
Q

Describe the standard CHC regimens (with pill / patch / ring)

A

Pill - 21 days of pill, 7d break. First 7 pills inhibit ovulation, remaining 14 maintain anovulation.

Patch - as above but a patch lasts 7d. Use 3. Then patch free week.

Ring - leave vaginal ring in for 21d, then 7d ring free period.

During HFI withdrawal bleed due to endometrial shedding. Be clear this is not physiological menstruation and has no health benefit.

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20
Q

Give e.g.s of tailored regimens
Drawbacks of these

A

-4d HFI
- Tricycling - 3x 21 active pills / 3 rings / 9 patches consecutively then 4 or 7d break
- Flexible extended use - continuous use until breakthrough bleed then have a 4d break
- Continuous use with no breaks

Drawbacks of continued use is that you are more likely to get breakthrough/ unscheduled bleeding
In theory it reduces the risk of escape ovulation which is good

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21
Q

When can you start CHC

A
  1. Up to and including day 5 of a natural menstrual cycle without the need for additional protection
  2. At any other time in the cycle with additional contraception for 7 days PROVIDING THAT:
    - it is reasonably certain a woman is not pregnant
    - a high sensitivity urine preg test is negative (even if risk from past 21d). f/u PT required after 21d from UPSI.

Almost all of the available evidence suggests no adverse impact of fetal exposure to contraceptive hormones on pregnancy outcomes or risk of fetal abnormality. Note that starting CHC should be delayed for 5d after ulpristal acetate EC.

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22
Q

EC - levenogestrel, advice for starting COC vs.
ulpristal acectate EC

A

levenogestrel
- can start immediately
- use additional protection for 7d

ulpristal acetate [ella one]
- wait 5d
- after the 5d use additional protection for 7d

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23
Q

when can you start COC after childbirth?

A

Breastfeeding - 6w after (ukmec 4 prior, drops to a 2 until 6mo)

Not breastfeeding -3w after as long as no additional RFs for VTE. If you do have RFs then 6w.
0-3weeks = ukmec 3 without additional VTE RFs, = 4 with
3-6 weeks = 2 without, 3 with
>6w = 1 all

7d additional contraception needed!

24
Q

when are the only times you don’t have to use additional contraception for 7d when starting cocp?

A
  1. if in days 1-5 of natural cycle
  2. after abortion, miscarriage, ectopic, or gestational trophoblastic disease and it is days 1-5 following treatment. (nb need additonal 7d if after 5d)
25
Q

How effective is CHC?

A

All CHC have similar effectiveness. If used perfectly = v effective. With typical use, CHC is less effective than LARC.

Perfect use = 0.3% of users experience unplanned pregnancy in the first year
Typical use = 9%

26
Q

Can CHC be affected by obesity/ weight?

A

Most evidence suggests no association between weight and effectiveness
Limited evidence suggests a possible reduction in patch effectiveness in women >90kg. So suggest a diff method for them.

27
Q

Can CHC be affected by bariatric surgery?

A

Theoretical concerns that malabsorptive and restrictive bariatric procedures could reduce absorption. Evidence is too limited to make definite recommendations.

  • advise pts of the above and consider non-oral contraception
28
Q

What drug interactions are there with CHC

A
  1. Enzyme inducing drugs can reduce effectiveness of CHC while using and for 28d after stopping. Women on these drugs should be offered a method unaffected by enzyme inducers i.e. depo, LNG-IUS, Cu-IUD only.

E.gs of enzyme inducers include:
- some AEDs such as carbamazepine, phenytoin
- abx eg rifampicin. NB most abx are not enzyme inducing so are ok
- ARVs eg efavirenz
- st johns wort
- modafinil

  1. Reduces serum levels of lamotrigine during CHC use = reduced seizure control, and increased levels in HFI = lamotrigine toxicity. Consider alternatives
29
Q

Why do pts have to wait 5d before starting CHC after UPA-EC?

A

UPA is a selective progesterone receptor modulator - it acts as a progesterone antagonist in progesterone responsive tissues. Starting hormonal contraception soon after UPA 30mg given for EC reduces the ability of UPA-EC to delay ovulation = reduces effectiveness.

NB this applies to all hormonal contraceptives including progestogens - 5 days is the rule

30
Q

MISSED PILLS
In what situation would someone need EC after HFI?
What other advice (4)?

A

> =9 completed days since last active pill was taken, consider EC if UPSI has taken place during or after HFI. e.g. pill taken on Sunday at 9am - as long as take before Tuesday at 9am you’re ok. i.e. late restarting OR >=8 completed days since ring or patch was removed

  • Take most recent missed pill ASAP
  • Continue remaining pills at usual time
  • Condoms or no sex until 7d of pills consecutively
  • Consider f/u PT
31
Q

MISSED PILLS
1 pill missed in week 1 after HFI - what advice? (4)
[where the first pill after the HFI was taken correctly - if not then follow late restarting advice]

A

EC not required IF consistent and correct use earlier in week 1 and the 7 days prior to hfi
- take missed pill asap
- continue remaining pills at normal time
- no additional contraceptive precaution required

1 missed pill = 48 to <72h since last pill taken

32
Q

UNSCHEDULED RING OR PATCH REMOVAL (OR KEPT OLD PATCH ON) for <48h - in week 1 after HFI

what advice? (4)

A

EC not required IF consistent and correct use earlier in week 1 and the 7 days prior to hfi
- insert ring/patch asap
- keep ring/patch in until scheduled removal day
- no additional contraceptive precaution required (if correct use earlier in week 1 and the 7 days prior to hfi)

33
Q

MISSED PILLS
1 pill missed in week 2 or 3 (or subsequent weeks of continuous pill taking) after HFI - what advice? (4)

A

EC not required if consistent use in past 7d
- take missed pill asap
- continue remaining pills at normal time
- no additional contraceptive precaution required

1 missed pill = 48 to <72h since last pill taken

34
Q

MISSED PILLS
2-7 missed pills in week 1 after HFI - what advice? (5)
[where the first pill after the HFI was taken correctly - if not then follow late restarting advice]

A

Consider EC if UPSI has taken place during the HFI or week 1
- take missed pill asap
- continue remaining pills at normal time
- 7d rule: use condoms / abstain until pills taken for 7 consecutive days
- consider f/u PT

35
Q

MISSED PILLS
2-7 pill missed in week 2 or 3 (or subsequent weeks of continuous pill taking) after HFI - what advice? (5)

A

EC not required IF consistent, correct use in previous 7d
- take missed pill asap
- continue remaining pills at normal time
- omit HFI if this has happened in the 7d before scheduled HFI
- 7d rule: use condoms / abstain until pills taken for 7 consecutive days

36
Q

MISSED PILLS
>7 missed pills in any week of pill taking

A

Consider EC
- Manage as new start contraception
- Consider immediate PT
- Quick start new COC (or consider other)
- 7d rule: use condoms / abstain until pills taken for 7 consecutive days
- Consider f/u PT

37
Q

UNSCHEDULED RING / PATCH REMOVAL (OR KEPT OLD PATCH ON) <48h
In weeks 2 or 3 after HFI

or subsequent week if correct consecutive ring use in an extended regimen

A
  • EC not required
  • insert/ attach asap
  • keep in until scheduled removal day
  • no additional contraceptive precaution required
38
Q

UNSCHEDULED RING / PATCH REMOVAL (OR KEPT OLD PATCH ON) >=48h
In week 1 after HFI

A
  • Consider EC if upsi has taken place during hfi or week 1
  • insert asap
  • keep in until removal day
  • 7d rule: use condoms / abstain until new ring in for 7 consecutive days
  • Consider f/u PT
39
Q

UNSCHEDULED RING / PATCH REMOVAL (OR KEPT OLD PATCH ON) >=48h
In week 2 or 3 after HFI

A

EC not required IF consistent, correct use in previous 7d
- insert asap
- keep in until removal day
- omit HFI if this has happened in the 7d before scheduled HFI
- 7d rule: use condoms / abstain until new ring in for 7 consecutive days

40
Q

Use of same ring >21 to <=28days

A

EC not required if ring was correctly used from day 21 - day 28
- Start HFI and insert new ring at end of HFI or insert new ring
- No additional contraception needed if ring was in situ from d21-d28

41
Q

ACCIDENTAL CONTINUED USE OF SAME RING BEYOND 3 WEEKS
Use of same ring >21 to <=28days

A

EC not required if ring was correctly used from day 21 - day 28
- Start HFI and insert new ring

42
Q

Use of same ring continued for >4w and <5w

A

EC not required if ring correctly used for last 7d
- Omit HFI
- Insert new ring asap
- 7d rule: use condoms / abstain until new ring in for 7 consecutive days

43
Q

Use of same ring >5w

A

EC if UPSI in week 5 or later
- consider immediate PT
- insert new ring asap
- 7d rule: use condoms / abstain until pills taken for 7 consecutive days
- consider f/u PT

44
Q

Late restarting of ring/ or patch after scheduled HFI
>=8 completed days since ring was removed for scheduled hfi

A

rings and patches are 8d as the contraception stops as soon as take it out/off

  • consider EC if upsi has taken place during or after HFI
  • Insert ring/patch asap
  • keep ring/patch in until scheduled removal day
  • 7d rule: use condoms / abstain until new ring in for 7 consecutive days
  • consider f/u PT
45
Q

age cut off chc

A

50y. can use all the way up to then provided no CI’s. no max length of time but repeated stopping and starting is discouraged (VTE risk highest in months after starting).

After 50y risks outweigh contraceptive benefits and women should switch to another method.

46
Q

Contraindications to CHC and things to specifically ask about a history of:

A
  • inherited thrombophillias [inc VTE risk] - absolute CI
  • strong caution or avoid due to arterial thrombotic risk: HTN, >35 who smoke, women who have multiple RFs for CVD incl SMOKING, high BMI, dyslipidaemia, antiphospholipid ABs, arrhythmia, cardiomyopathy, congenital / valvular heart disease, cardiomyopathy, diabetes, and women with migraine with aura or migraine without aura that is of new onset during use of CHC
  • migraines with aura [ukmec 4] / without aura [ukmec 2] Evidence limited but systematic review: odds ratio of ischaemic stroke rose from 2.7 to 6.1 (women who have migraine with aura –> who start chc). Does not increase for those without aura.
  • personal history of breast cancer / known br ca mutation gene
  • hepatobiliary disease
  • recent childbirth, current breast feeding
47
Q

“I have a fhx of breast cancer - can I have chc?”

A

yes- several studies suggest these women are at no higher risk of breast cancer
UKMEC 1

48
Q

“I have gene mutation assoc. with breast cancer e.g. BRCA, can I have chc?”

A

evidence is inconsistent
ukmec 3

49
Q

“Is weight gain a SE?”

A

No evidence of an association between CHC use and weight gain.

50
Q

“will CHC affect my libido?”

A

Evidence suggests no clear effect of CHC on libido.

51
Q

“will CHC affect my return to fertility?”

A

no- 99% of women in a 187 person study returned to spontaneous menstruation within 90d

52
Q

what to check on initial consult and f/us

A

BMI - <35 ukmec 2 but >=35 ukmec 3
BP (if >160 systolic / 100 diastolic = ukmec 4, 140-159 systolic or 90-99 diastolic - ukmec 3, or adequately controlled HTN - ukmec 3)

53
Q

Key info to ensure covered by end of consult:

A
  1. when/how to start, and when additional contraception is needed before CHC effect can be relied on
  2. what to do if miss pills / when EC might be needed
  3. health risks assoc with CHC, and specific advice for travel, living at altitude and having surgery
  4. signs and symps that should alert them to seek medical advice
  5. significant new health events that should prompt them to r/v contraception
  6. if start on any new medication, check with prescriber or contraception provider re: interactions
  7. arrangements for next prescription of chc
  8. what to do if they wish to discontinue or change their contraception
  9. annual check up
54
Q

f/u for chc

A

annual

  • bmi, bp
  • medical eligibility
  • drug hx
  • method adherence
  • method satisfaction
55
Q

travel advice

A
  • minimise immobility during travel
  • crossing time zones: stick to 24h dosing
  • if trekking to high altitudes (above 4500m) for >1w, consider switching to safer alternative. Exposure to high altitude = increased eythropoiesis = increased thrombotic risk
56
Q

surgery advice

A

switch at least 4 weeks before planned major surgery or expected limited mobility (VTE)

57
Q

use of chc as hrt

A

can be done up to age 50 to prevent BMD loss and provide contraception

Contraception (13 decks)

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