Contraception Flashcards
IBD and contraception
malabsorption reduced efficacy of oral contraception
do not give Dep-Provera in <18y/o due to increased risk of osteoporosis
use combined patched, progesterone-obly injectables and implants, intrauterine and vaginal ethods
Breastfeeding and contraception
No EC = UPSI before day 21 postpartum
COCP = avoid before 6 weeks postpartum, and relatively contraindicated 6wks - 6 months postpartum (affects breast milk volume)
Progesterone-only = no effect on milk production, can be used in first 6 wks postpartum and thereafter
IUD = inserted from 4 wks postpartum
Contraeption and menopause
women <50 = continue contraception for 2 years after last period
IUD and IUS good
COCP also good in non-smoking women with no other RFs
3 types of hormonal contraception
- progestogen tablet = POP
- progestogen as a depot = nexplanon, depo-provera or IUS
- COCP, transermal patch, vaginal ring
COC timetable
every day for 3 weeks and then stopped for 1 week
vaginal bleeding at end of pill packet as a result of withdrawal of hormonal stimulus on endometrium -> cycle then restarted
can be taken back to back to reduce frequency of withdrawal bleed althoguh increased irregular spotting may occur
Common side effects of sex hormones
uses of COC
teenage (in conjunction with condoms)
older woman (no cardiovascular risk factors until age of 50)
useful for: menstrual cycle control, menorrhagia, PMS, dysmenorrhoea, acne/hirsutism and pevention of recurrent simple ovarian cysts
issues with COC: missed pill rules, abx, anti-convulsants, D+V, surgery
reduced pill absorption when D+V = continue taking pills but follow missed pill instructions for each day of illness
- V within 2 hours of taken pill -> take another pill or follow rules of missed pills
- taking BS abx -> continue pills but use condoms during and for 7 days after abx course
- liver enzyme-inducing drugs (e.g. anticonvulsants) -> increase oestrogen dose
Missed pill:
- forgotten pill taken ASAP, packet continued as normal
- if more pills missed = packet continued as normal + condoms used for 7 days
- <7 pills in packet = next packet started straight after last (avoid pill-free break)
Surgery = pill stopped 4 wks before major surgery as prothrombotic risks, but risks of pregnancy should also be considered. Not discontinued prior to minor surgery.
counselling the woman starting on the COC
Major complications and minor side effects of COC
Complications:
- VTE + MI
- smoking, increased age and obesity (increases risk)
- contraindication: BMI >40, or age >35 amd smokes >15 cigarettes per day
- relative: BMI 35-39 and <15 cigarettes per day
- other problems = CVS, focal migraine, hypertension, jaundice, and liver, cervical and breast carcinoma
Minor:
- nausea, headaches, breast tenderness
- breakthrough bleeding common in first few months but ettles after 3 months
- lactation partly suppressed so pill contrainidcated during the first 6 wks of breastfeeding
Advantages of COC
Contraceptive = effective
Non-contraeptive = regular less painful lighter periods. Protects against simple ovarian cysts, benign breast cysts, fibroids, endometriosis. Hirsutism and acne may improve. PID risk reduced. LT reduction in incidence of ovarian, endometrial and bowel cancer.
Contraindications to COC (including oral) contraception
Combined transdermal patch (Evra)
ethinyloestradiol + norelgestromin
weekly for 3 consecutive weeks followed by patch free week
efficacy, contraindications and side effects similar to COC
Combined vaginal ring (nuvaring)
ethinyloestradiol and etonogestrel
worn for 3 week and removed for 7-day ring free break and a withdrawal bleed, new ring inserted
better tolerated than COC due to lower systemic oestrogenic side effects
not recommended to remove during SI but can be for maximum of 3 hrs.
Same metabolic and coagulation effects as other combined hormonal methods
POP
counselling before using the mini-pill:
- advise woman about bleeding patterns
- emphasize the importance of meticulous time-keeping
low dose norethisterone/micronor
every day without a break and at the same time +/- 3 hrs
side effects: vaginal spotting, weight gain, mastalgia and PMS-like symptoms, functional ovarian cysts can occur
less effective than combined pill and need for timing
good for those with contraindication for combined ill
if pill missed by more than 3 hours, another should be taken asap and condom used for 2 days
not affected by BS abx
LARCs
not user dependent and high efficacy rates
more cost-effetive than COC after 12 months of use
current usage rates are low
Depo-Provera, Noristerat and Sayana Press
DP
- IM every 3 months
- irregular bleeding first weeks, followed by amenorrhoea
- prolonged amenorrhoea may follow cessation
- bone density reduction first 2-3 years of use then stabilised and regained after stopping
Noristerate
- IM every 8 weeks
- short-term interim contraception e.g. whilst waiting for vasectomy to become effective
Sayana press
- SC for self-administeartion
- cover for 13 weeks
All 3 may be used in breastfeeding women
Nexplanon
Rod-contianing progestogen (etonogestral) inserted into upper arm subdermally with local anaesthetic
lasts 3 years
irregular bleeding in first year, no drop in bone density, removal easy and rapid resumption of fertility
simple and long acting so may have a particular role in the developing world
EC: morning after pill
Levonelle = best taken within 24 hours and no later than 72 hours after UPSI. Vomiting can occur plus menstrual disturbances in the following cycle
Ullipristal (EllaOne) = SPRM (e.g. mifepristone). Can be used up to 120 hours after UPSI. Will reduce effectiveness of progesterone-contianing contraceptives so women should use condoms or avoid UPSI until the next period
EC: IUD
inserted up to 5 days after either the episode of UPSI or expected day of ovulation (so if intercourse occurened 2 days before expected ovulation, the IUD could be inserted 7 days later).
abx prophylaxis usually given at the time of insertion
diaphragms and caps
fitted before intercourse and must remain in situ for at least 6 hours afterwards
cervical caps fit over cervix whilst spring of latex dome of diaphragm holds it between the pubic bone and sacaral curve covering the cervicx
PID protection but less protection against HIV
some find in inconvenient so best suited for woman with good motivation
Cooper IUD, IUS (mirena coil)
IUS = Jaydess/Levosert replaced every 3 years, Mirena every 5 years
reduced menstrual loss and pain
systemic side effects lower than POP
irregular light bleeding is main probelm
return of fertility after removal is rapid and complete
lack of user dependence
IUD/IUS complications
Pain/cervical shock complicate insertion
device being expelled
perforation of uterine wall at insertion
heavier or more painful menstruation can occur
lapraoscopy to remove IUD if within abdomen
if pregnancy occurs despite presence of IUD -> likely to be ectopic
if ectopic pregnancy excluded -> remove IUD early to reduce risk of miscarriage and particularly mid-trimester loss
contraindications to the IUD
counselling before inserting an IUD
Female sterilisation
Commonly used are clips via laparoscope
high efficacy
indications:
- doctor and woman must be satisfied that there will be no regret
- usually used on older woman whose family is complete, or when disease contraindicates pregnancy
Complications
- visceral damage on laproscopy
Male sterilisation
vasectomy more effective than female sterilisation
sterily not assured until azoospermia is confirmed by two semen analyses and may take up to 6 mmonths to achieve
complications = failure, post-op haematomas and infection, chronic pain
contraception at a glance
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