Combined Contraception & Consent Flashcards
What are the 3 ‘Cs’ of under 16 consultations?
-
confidentiality
- everything remains confidential unless there is a threat to their or another person’s wellbeing
- consent
- competence
How is the competence of a young person determined?
Fraser competence
What are the 5 key points involved in determining Fraser competence?
UPSIS (UnProtected Sex Is Silly)
- the young person Understands the advice given
- Parental involvement is encouraged (but not enforced)
- the young person is likely to continue having Sexual intercourse
- it is in their best Interest to supply contraception
- their mental and physical health is likely to Suffer without contraception
When is sex in a young person deemed illegal and what is done?
sex under the age of 13 years is illegal
- they are deemed incapable of consenting
- this MUST be reported to authorities
- could be police
- could be safeguarding / social services if it is both young people involved
What guidelines are used to ensure contraception provision is safe?
UK MEC guidelines
- give guidance on who can use which methods safely
What are the 3 different categories of contraception?
shorter acting contraceptive methods:
- POP & COCP
- combined contraceptive patch
- combined contraceptive ring
- barrier methods
longer acting contraceptive methods (LARC):
- injectable methods (Depo Provera / Sayana Press)
- subdermal implants (Nexplanon)
- intrauterine devices (copper IUD & levonorgestrel IUS)
irreversible contraception:
- male / female sterilisation
What contraceptive methods are the most effective against pregnancy?
- the implant (Nexplanon) is the most effective method
- this is followed by the IUS and then IUD
- in general, LARCs have a much lower failure rate than other methods
- they are less user dependent
What are the 3 options for combined contraception?
- pills
- patches
- rings
What age is the COCP licensed for use up to?
up to 50 years
In what 3 ways does the COCP act to prevent pregnancy?
- it prevents ovulation (primary mechanism of action)
- progesterone thickens the cervical mucus
- progesterone prevents proliferation of the endometrium, reducing the chance of successful implantation
How does the COCP prevent ovulation?
- progesterone + oestrogen have a negative feedback mechanism on the anterior pituitary + hypothalamus
- this suppresses release of GnRH, LH & FSH
- without LH + FSH, ovulation cannot occur
How is the COCP typically taken?
How does this affect the lining of the uterus?
- typically, pills are taken every day for 3 weeks** followed by a **pill-free week
- the endometrium is maintained in a steady state whilst taking the COCP
- during the pill-free week, the endometrium breaks down and sheds
- this produces a withdrawal bleed
- breakthrough bleeding can occur with extended use without a pill-free period
What is meant by “extended use” of the COCP?
- a pill is taken every day continuously
- at some point, spotting will occur
- this is a breakthrough bleed that signals the endometrium needs to shed
- stop taking the pills** when the **breakthrough bleed occurs
What is meant by “tricycling” of the COCP?
- 3 packets of pills are taken back to back
- this is followed by a withdrawal bleed
- this results in around 4 bleeds a year and is usually done when someone has aggressive, heavy periods
On what day of the cycle should the COCP be started?
- if it is started on day 1 - 5 of the cycle, it provides contraception immediately
- if it is taken after day 5, condoms should be used for the initial 7 days
What advice is given to people about the length of the breakthrough bleed?
- there is contraceptive cover whilst not taking the pill for 7 days
- after 7 days, hormone levels will rise and there is a risk of ovulation
- the breakthrough bleed should not be more than 7 days, and can be shorter than this
When does a COCP count as missed?
- there is a 24 hour window to take the pill
- it only counts as missed if it is more than 24 hours late
What advice is given if one pill is missed?
- if 1 pill is taken > 24 hours late, take the pill and continue as normally
- EC may be required if other pills were missed earlier in the pack or in last week of previous pack
What advice is given if more than one pill is missed?
- take the most recent missed pill and continue the others (even if multiple pills are taken on the same day)
- use condoms for the next 7 days
- EC** is required if there was UPSI in the **hormone-free interval** or **first week of pill
- there is no need for EC in week 2
- if missed in week 3, EC is not required but omit the hormone-free interval
What are the 2 different types of COCP?
monophasic pills:
- contain the same amount of hormone in each pill
multiphasic pills:
- contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
How do different COCPs vary from each other?
- they ALL** contain **ethinylestradiol (oestrogen)
- they contain different amounts of ethinylestradiol
- and they contain different types of progesterone
What type of pills are everyday COCP formulations?
monophasic pills
- the pack contains 7 inactive pills, which makes it easier for women to keep track as they can take 1 pill every day
What are the 2 first line COCPs?
Microgynon:
- contains ethinylestradiol and levonorgestrel
Loestrin:
- contains ethinylestradiol and norethisterone
- these are used first-line as they have a lower VTE risk
What type of COCP is used first-line in premenstrual syndrome and why?
- pills containing drospirenone (e.g. Yasmin)
- drospirenon has anti-androgen + anti-mineralocorticoid activity
- this reduces the symptoms of bloating, water retention + mood changes
- pills should be taken continuously, opposed to cyclical use
What type of COCP is used in the treatment of acne + hirsutism?
- pills containing cyproterone acetate / co-cyprindiol (e.g. Dianette)
- co-cyprindiol has anti-androgen effects
What is the risk associated with use of pills containing cyproterone acetate?
- there is a 1.5-2x greater risk of VTE compared to first-line pills
- it should be stopped after 3 months once the acne is controlled
What should women be told about bleeding when first starting the COCP?
unscheduled bleeding is common in the first 3 months after starting the pill
this should settle with time
What are the side effects associated with the COCP?
- breast pain / tenderness
- mood changes / depression
- headaches
- hypertension
- nausea
- acne
- increased risk of VTE
- small increased risk of MI / stroke
How does taking the COCP effect cancer risk?
- increased risk of breast + cervical cancer
- reduced risk of ovarian, colon + endometrial cancer
- this risk returns to normal within 10 years of stopping the pill
What are the benefits of using the COCP?
- effective contraception
- rapid return to fertility after stopping
- improvement in menorrhagia + dysmenorrhoea
- improvement in premenstrual symptoms
- reduced risk of benign ovarian cysts
What are the contraindications to using the COCP (UKMEC 4)?
- uncontrolled HTN (particularly if >160 / >100)
- migraine with aura (risk of stroke)
- history of VTE
- age > 35 and smoking > 15 cigarettes daily
- major surgery with prolonged immobility
- vascular disease / stroke
- liver cirrhosis / tumours
- ischaemic heart disease / AF / cardiomyopathy
- systemic lupus erythematosus (SLE) + antiphospholipid syndrome
How does BMI affect use of the COCP?
a BMI > 35 is ranked UKMEC 3 for combined contraception
(the risks generally outweigh the benefits)
What advice should be given to women switching to the COCP from a POP?
- use condoms for 7 days after switching
- ensure there is no risk of pregnancy before switching (pill use has been consistent)
- no additional contraception is required if switching from desogestrel as this inhibits ovulation
What advice is given to the patient about vomiting / diarrhoea?
- if vomiting / diarrhoea, this counts as a “missed pill” day
- illness may affect the absorption
- some medications (rifampicin) can also reduce the effectiveness of the pill
What advice is given regarding taking the pill prior to surgery?
- COCP should be stopped 4 weeks prior to a major operation
- this is any surgery lasting for > 30 mins or that requires immobilisation of the lower limb
- this is to reduce the risk of thrombosis
What is the regime for combined transdermal patches?
- a patch is worn for 7 days each
- this is continued for 3 weeks, followed by a patch-free week + withdrawal bleed
- the patch can be placed anywhere on the body except for the breasts
Why might a transdermal patch be chosen over the COCP?
- contains the same hormones so risk profile is identical
- patches may be preferred where there is malabsorption (e.g. colostomy / bowel condition)
What is the regime for the combined vaginal ring?
- a soft, flexible ring is left in for 21 days
- a ring-free interval for 7 days then induces a withdrawal bleed
