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contraception Flashcards

1
Q

contraceptive methods available in UK

A

combined hormonal contraception (CHC), pill or patch - 25%
progesterone only pill (POP) - 5%
progesterone only implants/injection - 5%
intrauterine methods - 6%
sterilised (M/F) - 28%

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2
Q

what makes the ideal contraceptive

A 
100% reversible 
100% effective
unrelated to intercourse
free of adverse side effects
protective against STIs
non-contraceptive benefits
low maintenance, no ongoing medical input
male and female options
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3
Q

how can the effectiveness of contraceptive be descreibed

A

pearl index - number of pregnancies per 100 women within the first year of use
looks at the total mths/cycles of exposure from the initiation of the product to the end of the study

life table analysis provides the pregnancy rate over a specified time frame and can provide a cumulative failure rate for any specific length of exposure

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4
Q

LARC

A

long acting reversible contraception - less user input therefore minimises user failure rates
injection, implant, copper IUD, IUS

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5
Q

what is method failure

A

pregnancy despite correct use of method

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6
Q

what is user failure

A

pregnancy because method not used correctly

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7
Q

when can sex cause pregnancy

A

if 26-32 day cycle and no on hormonal Rx:
likely to ovulate day 12-18
egg survives 24hrs
most sperm survive <4days (5% up to 7days)
highest chance of pregnancy = sex on day 8-19

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8
Q

why can natural methods of contraception fail

A

sperm survival and ovulation timing after last period is variable
even w/ abstinence or barrier options on fertile days as predicted from usual cycle, natural methods can fail
use

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9
Q

what is within combined hormonal contraception

A 
ethinyl estradiol (EE)
synthetic progesterone
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10
Q

what does CHC do

A

stops ovulation

also affect cervical mucus and endometrium

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11
Q

standard regime for CHC

A

21 days w/ hormone free week

sex is safe in pill free week - must remember to start new pack

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12
Q

tailored regimes for CHC

A

tricycling/continuous use
no need for uncomfortable inconvenient withdrawal bleed
avoids forgetting to restart after break

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13
Q

types of CHC

A

pill
patch
vaginal ring

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14
Q

pill CHC

A

taken daily, anytime within 24hrs

not good if frequent GI upset - may not be absorbed properly

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15
Q

patch CHC - EVRA

A

changed weekly
applied to hairless skin, not breast area
<5% have skin reaction

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16
Q

ring CHC - nuvaring

A

changed every 3wks
can take out for 3hrs in 24
may prefer to take out for sex

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17
Q

non-contraceptive benefits of combined hormonal methods

A

regulate/reduce bleeding
stop ovulation - may help premenstrual syndrome
reduction in functional ovarian cysts
50% reduction in ovarian and endometrial cancer
improve acne/hirsutism
reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis

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18
Q

side effects of CHC

A

breast tenderness
nausea
headache
irregular break thorugh bleeding in first 3mths
may effect mood - causal relationship or other life events?
weight gain - not causal

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19
Q

serious risks of CHC

A

increased risk venous thrombosis - DVT, PE
increased risk artherial thrombosis - MI, ischaemic stroke
increased risk cervical cancer - data predates HPV vaccine
increased risk breast cancer

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20
Q

who shouldn’t be using CHC

A

PE/DVT RISK: BMI>34, previous VTE, 1st degree relative VTE <45y/o, reduced mobility, thrombophilia (e.g. SLE)
MI/STROKE RISK: smokers >35 y/o, personal hx arterial thrombosis, focal migraine, >50y/o, HT >140/90

active gall bladder disease/prev liver tumour

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21
Q

breast cancer and CHC

A

back to normal after 10yrs off Rx, avoid if prev breast cancer

non BRCA FHx breast cancer not a CI

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22
Q

risk of VTE w/ CHC

A

risk increases from:
2/10 000 p/a in general pop
5-7/10 000 p/a w/ COC use (LNG and NET progesterone)
6-12/10 000 w/ patch/ring/COC other progesterone use
50/10 000 w/ pregnancy

pill increases risk 3x - overall risk is still small
need VTE prophylaxis if inpatient/surgery/immobile

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23
Q

progestogen only pill (POP) - how to take

A

same time every day w/o pill free interval

not good choice if frequent GI upset - poor absorption

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24
Q

types of POP

A

desogestrel pill

traditional LNG NET pills

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25
desogestrel pill
12hr window period nearly all cycles anovulant - also affect mucus most users bleed free after 1st 4-6mths
26
traditional LNG NET pills
3hr window period 1/3 anovulant 2/3 rely on cervical mucus effect 1/3 bleed free, 1/3 irregular, 1/3 regular periods
27
CI for POP
oestrogen free so very few CI | personal Hx breast cancer (current) or liver tumour (past/present)
28
POP side effects
``` appetite increase hair loss/gain mood change bloating/fluid retention headache acne ```
29
risk of VTE/aterial thrombosis on POP
no increased risk with contraceptive doses of progestogen
30
injectable progestogen
medroxyprogesterone acetate | dose every 13wks
31
site of progestogen injection
1ml deep IM injection upper outer quadrant of buttok - depoprovera 0.6ml SC injection abdo/thigh, possible self administration - Sayana press
32
how does the progestogen injection work
prevents ovulation alters cervical mucus - hostile to sperm endometrium unsuitable for implantation
33
benefits of progestogen injection
only need to remember every 12-14wks 70% amenorrhoeic after 3 doses oestrogen free - few CI
34
disadvantages of progestogen injection
delay in return to fertility - ~9mths reversible reduction in bone density - discuss other risks for osteoporosis problematic bleeding - esp after 1st 2 doses weight gain - 2/3 of women 2-3kg
35
what is the only contraceptive method with a causal effect on weight gain , delayed return of fertility and bone density
progestogen injection
36
subdermal implant - nexplanon - contents
small plastic rod, 4cm long core - 68mg etonogestrel (ENG) membrane - ethinyl vinyl acetate (EVA), rate controlling
37
progestogen implant effects
inhibition of ovulation | effect on cervical mucus
38
benefits of progestogen implant
can last 3 yrs, can be removed at any time no user input needed no causal effect on weight change 60% are almost bleed free
39
disadvantages of progestrogen implant
30% have prolonged/frequent bleeding | causes mood change more often than other progestogen only methods
40
how long does intrauterine contraception last
5-10yrs
41
benefits of intrauterine contraception
little user input after fitting, can check own threads can be fitted for any age and any parity effects/side effects immediately reversible when removed
42
risks of intrauterine contraception
very small infection risk in first 3wks (<1:1000) - offer STI testing to all w/ new partner or <25y/o 1:1000 risk perforation 5:100 risk expulsion - check threads after every period higher risk of ectopics, method is so effective that ectopic risk lower than for condoms
43
who cannot have intrauterine contraception
untreated pelvic infection | distorted endometrial cavity e.g. submucous fibrouds/bicornuate/previous ablation
44
mode of action of copper IUD
toxic to sperm stop sperm reaching egg may sometimes work by preventing implantation of fertilised egg
45
advantages of copper IUD
hormone free can last 5-10yrs depending on type device fitted after 40y/o can work until menopause not CI to MRI
46
disadvantages of copper IUD
may make periods heavier/crampier
47
levonorgestrel IUS effects
affects cervical mucus and endometrium most women still ovulate stops fertilisation of egg may prevent implantation of fertilised egg
48
release of progestogen in levonorgestrel IUS
slow release progestogen on stem | low circulating levels compared w/ pill/implant/injection
49
effect of IUS on menstrual bleeding
reduce bleeding after up to 4mths initial irregular bleeding
50
Mirena IUS - how long does it last
5yrs contraception (if fitted >45y/o effective till 55)
51
Mirena IUS - effect on bleeding
85% almost bleed free by 12mths
52
Mirena IUS - dose
equivalent systemic dose to 3 POP/wk
53
other uses for Mirena IUS
licensed to treat heavy menstrual bleeding | can act as the progestogenic part of HRT for 5yrs
54
Kyleena IUS - how long does it last
5yrs
55
Jaydess IUS - how long does it last
3yrs
56
benefits of Kyleena/Jaydess USS
less progestogen so even less chance of side effects BUT less likely to be bleed free smaller frame and insertion tube
57
what are the 3 types of emergency contraception
``` most effective - copper IUD levonorgestrel pill (Levonelle) Ulipristal pill (Ellaone) ```
58
Copper IUD emergency contraception
fit before implantation - within 120hrs of unprotected sex at any point of cycle OR by day 19 of 28 day cycle can keep long term if working well <1 pregnancy for 100 women using it
59
levonorgestrel pill (Levonelle) emergency contraception
take within 72hrs | 2-3 pregnancies for 100 women
60
Ulipristal pill (Ellaone) emergency contraception
take within 120hrs more CI e.g. breastfeeding/enzyme inducing drugs 1-2 pregnancies for 100 women
61
when to start contraception
immediate cover if started in first 5days of cycle can start at other points in cycle if no risk of pregnancy (need condoms/abstain for next 7 days AND do pregnancy test after 4wks)
62
how soon after delivery can you become pregnanct
from 21days after delivery | 5 days after miscarriage or abortion
63
for how long is breastfeeding contraceptive
only for first 6mths AND feeding every 4hrs AND amenorrhoeic a breastfeeding woman can use any type pof contraception - wait 6wks before CHC
64
contraception and drug interactions
enzyme inducing drugs increase the metabolism of progestogen and oestrogen and reduce the effectiveness of combined pill, patch, ring and POP and the implant progestogen injections and copper IUD/levonorgestrel IUS are not affected
65
examples of enzyme inducing drugs
carbamazepine topiramate rifampicin St John's Wort
66
how is female sterilisation normally carried out
laparoscopic usually Filshie clips applied across tube to block tube lumen metal/silicone not CI for MRI
67
effects of female sterilisation
risks of GA and laparoscopy irreversible - risk regret failure rate 1/200 in lifetime - could be ectopic
68
does female sterilisation effect periods/hormones
no
69
female sterilisation and ovarian cancer risk
reduces risk | even more reduction if salpingectomy but this is a more complex surgery
70
when can a salpingectomy be carried out
at planned C section if baby seems well and discussed in advance
71
what is a salpingectomy
surgical removal of one or both fallopian tubes
72
vasectomy procedure
local anaesthetic, most done in 1y care small incision midline scrotum vas deference divided ends cauterised
73
how long does a vasectomy take to become effective
4-5mths 2 sperm samples sent in by post after 4 and 5 mths failure rates 2/100 do not get clear samples
74
failure rate of vasectomy
after 2x clear samples | 1/2000
75
is a vasectomy reversible
irreversible | anti-sperm antibodies even if vas reconnecte
76
side effects of vasectomy
<1:100 risk long term testicular pain
77
effects of vasectomy on other functions and cancer risk
no effects on testosterone or sexual function | no increased risk of testicular/prostate cancer
78
stats for abortion
``` 1/3 women in UK most common 20-24y/o numbers falling, esp in 20s 90% under 12 wks linked to deprivation ```
79
types of contraception in use by women at TOP clinic
condoms - most common unprotected sex (UPSI) - only 10% of these took emergency contraception pills LARC
80
what is TOP
termination of pregnancy
81
rights and responsibilities of clinicians regarding TOP
right to refuse participation in abortion because they have a conscientious objection to the procedure obligation to ensure that the woman is still able to access abortion care right to refuse participation as long as this doesn't affect any duty to participate in treatment which is necessary to save the life/prevent grave permanent injury to the physical/mental health of a pregnant woman
82
1967 abortion act
2 Drs sign Continuing the pregnancy has grave risk to the life of the pregnant woman- greater than if pregnancy terminated Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman Under 24 weeks and continuation of pregnancy involves risk greater than if the pregnancy were terminated of injury to the physical or mental health of the pregnant woman Under 24 weeks and continuation of pregnancy involves risk greater than if the pregnancy were terminated of injury to the physical or mental health of the existing child (ren) of the pregnant There is a substantial risk that if the child were born it would suffer physical or mental abnormalities as to be seriously handicapped
83
TOP clinic consultation
medical Hx - risk VTE/bleeding/from GA/contraceptive eligibility circumstances - reason for considering abortion, support see alone/language line, check no coercion usually need scan to confirm gestation and viable IUP discuss methods of abortion risks contraception for afterwards
84
risks of abortion
infection <10% | blood transfusion <1:1000
85
investigations before abortion
FBC/rhesus group >10wks or STOP +/- heamoglobinopathy vaginal swab for chlamydia, gonorrhoea, TV STI bloods offered - BBV, syphilis
86
long term effects of abortion
safer than a full term delivery no effect on future fertility unless infection/perforation no effect on cancer risks emotional effects - depend on reasons for abortion, pre-existing mental health issues
87
when is surgical termination of pregnancy carried out
5-12wks
88
procedure - surgical termination of pregnancy
cervical priming - misoprostol 3hrs preop, helps dilation, reduces risk of perforation/haemorrhage GA/LA cervical block transcervical - 6-10mm suction catheter <10 mins
89
complications of surgical termination of pregnancy
1-4:1000 perforation <1:100 cervical injury risks from GA
90
when is medical termination of pregnancy carried out
5-23+5wks
91
medical termination of pregnancy procedure
mifepristone - oral antiprogestogen tablet 36-48hrs later misoprostol initiates uterine contraction which opens cervix and expels pregnancy avg 4-6hrs to pass pregnancy <12wks
92
complications of medical termination of pregnancy
failure 1/100 <8wks, 8:100 >12wks | need surgery for incomplete abortion
93
early medical abortion at home
legal to supply misoprostol for women to take away from clinic for home self administration since COVID now also legal to supply mifepristone for home self administration analgaesia supplied phone advice 24/7
94
who can have an early medical abortion at home
women <10wks gestation and prefer a home procedure and are healthy and have support
95
follow up for early at home abortion
low sensitivity pregnancy test at 2wks or scan sooner if minimal bleeding

Y3 repro (47 decks)

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