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Contraception Flashcards

1
Q

2 classes of hormonal contraception

A

Combined hormonal contraception

Progestogen only contraception

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2
Q

How do CHCs work?

A

oestrogen and progesterone act on the hypothalmo-pituitary ovarian axis to suppress LH and FSH prodution

this inhibits ovulation (no surge in LH and FSH)

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3
Q

What does a surge in LH and FSH cause?

A

Ovulation

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4
Q

What changes do CHCs do to the cervical mucus?

A

Increase cervical mucus which acts as a mechanical barrier to sperm

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5
Q

What do CHCs do to the endometrium?

A

Cause thinning of the endometrium which reduces the chances of implantation

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6
Q

How does the endometrium become thin?

A

Oestrogen causes the endometrium to proliferate and grow which is opposed by progestogen which prevents hyperplasia (excessive growth) of the endometrium

The endometrium becomes thin, fragile and prone to bleeding

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7
Q

What does the 7 day pill free interval do?

A

Causes oestrogen and progestogen concentrations to fall

Causes the endometrium to shed, mimicking menstruation

Known as a withdrawal bleed

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8
Q

What do combined oral contraceptives contain?

A

Oestrogen and progesterone

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9
Q

What is in the oestrogen component?

A

Synthetic oestrogen - ethinlyestradiol

Some contain mestranol

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10
Q

What does the progestogen component contain?

A

levonorgestrel

norethisterone

desogestrel

gestodene

drospirenone

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11
Q

First generation of progestogen?

A

norethisterone

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12
Q

2nd generation of progestogen

A

levonorgestrel (LNG)

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13
Q

3rd generation of progestogen

A

desogestrel

gestodene

norgestimate

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14
Q

How do COC preparations differ?

A

In how the doses vary over the menstrual cycle

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15
Q

2 types of COC preparations

A

Monophasic COCs

Phasic COCs

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16
Q

Monophasic COCs

A

First line

Amount of oestrogen/progestogen in each tablet is constant throughout the cycle

Most commonly prescribed

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17
Q

Phasic COCs and 3 types

A

Amount of oestrogen/progestogen varies over the 21 days

Biphasic: contain 2 different sets of active tablet

Triphasic: contain 3 different sets of active tablet

Quadraphasic: contain 4 different sets of active tablet

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18
Q

Example of biphasic and triphasic COCs

A

Biphasic- Binovum

Triphasic - Trinordiol

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19
Q

When are phasic COCs used?

A

In women who don’t have withdrawal bleeding or who have breakthrough bleeding with monophasic preparations

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20
Q

Example of a low strength COC

A

20mcg ethinylestradiol

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21
Q

Adv/disadv of low strength ethinylestradiol

A
  • useful if risk factors for circulatory disease

- can cause disrupted bleeding patterns

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22
Q

Standard strength COC

A
  • 30-35 mcg ethinylestradiol in monophasic COCs

* 30–40 mcg ethinylestradiol in phased preparations

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23
Q

Equivalent dose of Mestranol to 35mcg ethinylestradiol

A

50 mcg

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24
Q

2 COC preparations (standard and ED)

A
  • standard preparation - calendar strip of 21 active tabs, 1 taken daily for 21 days and then no tablet taken for 7 days (HFI)
  • ED preparations - useful when compliance is a concern, taken continuously, no HFI, 21 active tablets and 7 inert/placebo tabs taken days 22-28 to allow withdrawal bleed
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25
Q

What is Qlaira?

A
  • Quadriphasic pill used in treatment of heavy menstrual bleeding
  • Start on day 1 of the cycle
  • 28 tabs taken continuously
  • Missed pill rules differ
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26
Q

What is Dianette?

A
  • Co-cyprindiol- Cyproterone acetate and ethinylestradiol 2000/35
  • not indicated for just a contraceptive
  • Used in women who require oral contraception and suffer from acne or hirsutism (hair growth)
  • Carries an Increased risk of venous thromboembolism (VTE)
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27
Q

Initiation of monophasic COC days 1-5

A
  • day 1-5: no additional contraception is needed.

* Ideally start on day 1 of the cycle

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28
Q

Initiation of monophasic COC day 6+

A

Day 6 of menstrual cycle onwards:

Additional precautions are required for 7 days after starting

(9 days for Qlaira)

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29
Q

Initiation of monophasic COC postpartum

A

Postpartum:

up to and including day 21 postpartum – no additional contraception required

(if not breast feeding and no VTE risk)

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30
Q

Initiation of monophasic COC and miscarriage/termination

A

If started immediately after or up to day 5, no additional contraception required

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31
Q

What is the standard regimen for COCs?

A

21 days (21 active pills) and 7 days pill free period

or

28 days (21 active pills and 7 inactive pills) and no pill free period

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32
Q

Tailored use - shortened hormone free interval

A

21 days (21 active pills) and 4 pill free days

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33
Q

Tailored use - extended use (tri cycling)

A

Taken for 9 weeks (3 x 21 active pills)

4 or 7 days of pill free interval

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34
Q

Tailored use - flexible or extended use

A

Continuous use (> 21 days) of active pill until breakthrough bleeding occurs for 3-4 days

4 days of hormone free period

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35
Q

Tailored use - continuous use

A

Continuous use of active pills

No hormone free interval

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36
Q

Is there a benefit for hormone free interval?

A

No

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37
Q

Benefits of not taking the hormone free interval

A
  • avoids monthly bleeds
  • reduced withdrawal symptoms such as headache and mood changes
  • reduced the risk of escape ovulation and pregnancy
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38
Q

What can happen when no pill free period is taken?

A

Unscheduled bleeding is common

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39
Q

Are tailored regimes licenced?

A

No

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40
Q

Risk of failure if COC used perfectly

A

Low <1%

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41
Q

Risk of failure if COC used typically

A

9% failure

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42
Q

Questions for missed pill

A
  • when the contraception was missed (time since last pill taken)?
  • how many pills were missed?
  • where are they in the cycle?
  • which pill is the patient taking?
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43
Q

What to do if one pill has been missed or < 48hrs since last pill? (COC)

A
  • take the late/missed pill
  • continue taking the remaining pills at usual times (even if more than one in a day)
  • no additional contraception needed
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44
Q

If 2+ pills missed and > 48hrs since last pill (COC)

A
  • take the most recent pill asap (other missed pills discarded)
  • continue taking the remaining pills at usual time (even is more than 1 in day)
  • use additional contraception (condoms) or avoid sexual intercourse until pills have been taken for 7 consecutive days
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45
Q

What to do if pills were missed in the last week of pills (days 15-21)?

A

Omit the hormone free period and finish the pills in the current pack and start a new pack the next day

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46
Q

What to do if it has been 9+ days since last pill taken?

A
  • consider EC if UPSI
  • missed pill taken asap
  • abstain/barrier method until 7 consecutive pills have been taken
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47
Q

Advantages of COCs

A
  • more effective than barrier methods
  • menstrual bleeding is usually regular, lighter and less painful
  • reduced severity of acne in some women
  • reduced incidence of pre-menstrual tension (PMT)
  • reduces risk of ovarian, endometrial and colorectal cancer
  • normal fertility returns immediately after stopping the COC
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48
Q

Disadvantages of COCs

A
  • temporarily ADR - headache, nausea, breast tenderness, mood changes (don’t stop in few months, change type of COC)
  • BP may increase
  • no protection against STDs (use condom)
  • less effective than long active reversible methods of contraception
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49
Q

COC interaction with enzyme inducing antibiotics

A

Enzyme inducers reduce the effectiveness of COCs which can lead to contraception failure

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50
Q

Examples of enzyme inducing antibiotics

A

Rifampicin

Rifabutin

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51
Q

Short term treatment (< 2 mths) with enzyme inducing antibiotics and COCs

A

• change to an alternative method of contraception
OR
• continue and use barrier while taking and for 28 days after

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52
Q

What does breakthrough bleeding mean during short term enzyme inducing antibiotics and COC?

A

A complication that indicates low serum level oestrogen concentrations

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53
Q

What to do when taking COC and long term (> 2 mths) enzyme inducing antibiotic?

A

Change to an alternative method of contraception

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54
Q

What are non-enzyme inducing antibiotics?

A

Most broad spectrum antibiotics

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55
Q

Precautions for non-enzyme inducing antibiotics and COCs

A
  • no precautions required

* additional precautions if vomiting or diarrhoea occur

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56
Q

Examples of other enzyme inducing drugs

A

Anti-epileptics:

  • Carbamazepines
  • Phenobarbital
  • Phenytoin
  • Topiramate
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57
Q

COCs and lamotrigine

A

COC can increase clearance of lamotrigine leading to poor seizure control

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58
Q

Is lamotrigine an enzyme inducer?

A

No

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59
Q

Other enzyme inducing drugs COCs can interact with

A

Antiepileptics

Herbal - St. John’s Wort (OTC)

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60
Q

Short term treatment of enzyme inducing drugs and COCs (antiepileptics, lamotrigine, herbal)

A

Change contraception method or use COC with extended regimen and use barrier/abstain

Abstain/barrier while using and for 28 days after

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61
Q

Long term treatment of other enzyme inducing drugs and COCs

A

Additional contraception method required

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62
Q

What to do if vomiting within 3hrs of taking COC?

A

Take another one asap

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63
Q

If vomiting/severe diarrhoea > 24hrs COC

A

Follow instructions for missed pill

Each day of vomiting/diarrhoea is a missed day

Abstain/barrier during and 7 days after

If illness occurs while taking last 7 days omit any HFI and start next cycle

64
Q

Risk of MI/stroke with COCs

A

Vey small increased risk

Increase in those with multiple risk factors for these conditions - smokers, hypertension, migraines with aura, Fx Hx of CVD

65
Q

Hypertension limits to avoid COCs because of risk of MI/stroke?

A

> 160/100 mmHg

66
Q

Risk of VTE on COC

A

Low risk

Risk depends on progestogen type and oestrogen dose

Assess VTE risk

DVT/PE signs stop immediately

67
Q

Breast cancer and cervical cancer risk with COCs

A

Very small increased risk

returns to no risk 10yrs after stopping

Small increased risk weighed against protective effects of cancer of ovaries/endometrium

68
Q

Age risk with COCs

A

Over 35 years and smoker

Avoid over 50 years

Can be used up to 50 if no other risk factors present

69
Q

Criteria to assess cautions/contraindications when prescribing COCs

A

UK Medical Eligibility Criteria

UKMEC

70
Q

4 categories of UKMEC

A
  1. No restrictions to use
  2. Advantages of use outweigh risks
  3. Risks generally outweigh advantages of use
  4. Use would result in unacceptable risk or health (contraindicated)
71
Q

Examples of contraindications in UKMEC 4 for COC

A

Severe/multiple risk factors for arterial disease

VTE

migraine with aura

Smoker > 15 per day and > 35 years

72
Q

Risk factors for UKMEC 3 COC

A

1st degree relative < 45 years history of VTE

BMI > 35

Smoker <15 per day or stoped in last year and > 35

Symptomatic gall bladder disease

Controlled hypertension

Diabetes with nephropathy/retinopathy/neuropathy

Breastfeeding between 6 weeks and 6 months postpartum

73
Q

temporary side effects of COC

A

breast tenderness
headaches
nausea

74
Q

When can breakthrough bleeding (BTB) occur with a COC

A

in the first 3-6 months

75
Q

What causes should be considered for breakthrough bleeding?

A

STIs
pregnancy
malabsorption

76
Q

What to do if the side effects don’t settle over the first 3 months?

A

try an alternative COC or an alternative form of contraception

77
Q

What is migraine a risk factor for and what risks are increased?

A

cardiovascular disease

- venous or arterial thromboembolism

78
Q

Who have the greatest risk of ischaemic stroke with migraine?

A

women who have migraine with aura

79
Q

migraine with aura and COCs UKMEC

A

contraindicated (UKMEC 4)

80
Q

migraines without aura at initiation and COCs

A

UKMEC 2 (not contraindicated)

81
Q

What is new onset of migraine without aura after intitation?

A

UKMEC 3

benefits outweigh the risks

82
Q

What should be considered in women who have migraine while taking COCs?

A

alternative contraception should be considered

progestogen only contraceptive is more appropriate

83
Q

reasons to stop COC immediately (8)

A
  • sudden severe chest pain
  • sudden breathlessness (or cough, blood sputum)
  • severe pain in calf
  • severe stomach pain
  • severe neurological effects including severe headache, vision loss or sudden hearing disturbance
  • hepatitis, jaundice, liver enlargement
  • BP systolic > 160 mmHg, diastolic > 95mmHg
  • detection of a risk factor
84
Q

name of the combined contraceptive patch

85
Q

What does Evra contain?

A

ethinylestradiol and norelgestromin

86
Q

How should Evra patch be applied?

A

applied to clean, dry, lotion-free, healthy, hairless skin

87
Q

Where not to apply Evra patch?

A

breasts, red/broken/inflammed skin

88
Q

detached patch < 48hrs

A

re-apply the patch

no additional precautions needed

89
Q

detached patch > 48hrs or not sure when detached

A
  • start new cycle of patch (new 1 week cycle and new day for starting)
  • abstain/barrer for next 7 days
90
Q

How often is Evra patch applied?

A

1 patch applied weekly for 3 weeks then 7 day patch free interval

91
Q

MOA of traditional POPs

A
  • alter cervical mucus making it more viscous and inpenetrable to sperm
  • suppression of ovulation occurs in some women
92
Q

% of ovultion suppression with traditional and desogestrel POP

A

traditional 60%

desogestrel 97%

93
Q

MA of desogestrel only pill

A
  • inhibits ovulation in 97% of cycles

- can alter cervical mucus

94
Q

2 types of POPs available in UK

A

traditional pills

desogestrel pills

95
Q

How is the traditional POP taken?

A
  • 1 taken continuously without a break

- 3hr window for missed pill

96
Q

2 examples of traditional POP

A

Norethisterone 350mcg - Micronor and Noriday

Levonorgestrel 30mcg - Norgeston

97
Q

How is the desogestrel POP taken?

A

1 taken daily continuously without a break

12 hr window for missed pill

98
Q

examples of desogestrel only pill

A

Desogestrel 75mcg - Cerazette, Aizea, Cerelle, Nacrez

99
Q

When is desogestrel given 1st line?

A
  • patients < 35yrs

- compliance issues likely with tradidional POPs

100
Q

When are POPs contraception of choice?

A 
older women (up to 55yrs)
VTE (or Hx)
smokers
hypertension
valvular heart disease
diabetics
migraine sufferers
breast feeding
101
Q

POP inititation on day 1-5

A

no additonal contraception required

102
Q

POP initiation on day 6

A

additional precautions required - barrier/absitinence for 2 days

103
Q

POP initiation postpartum

A

up to and including 21 days after - no additional contrapceiton required

104
Q

POP initiation after termination/miscarriage

A

start immediatrly or up to 5 days after - no additional contraception required

105
Q

POP missed pill < 3hrs (12hrs for desogestrel)

A

take missed pill asap
continue taking as usual even if 2 in one day
no additional contraception required

106
Q

POP missed pill > 3 hrs (>12hrs for desogestrel)

A

take most recent pill (discard any others)
continue taking at usual time
use additional contraception/abstain for 2 days
EHC if SI within 2 days

107
Q

disadvantages of POPs

A
  • higher failure than COC
  • doesn’t control cycle as effectively as COC
  • menstrual irregularities/bleeding common, settles with time
  • small inc risk of breat cancer
  • inc risk of ovarian cysts (reversible, no op)
108
Q

if bleeding pattern unacceptable with POP

A

alternative contraception considered

- COC if appropriate

109
Q

UKMEC 4 contraindication for POPs

A

breast cancer

110
Q

risk factors for UKMEC 3 for POP

A 
PMH of breast cancer
severe cirrhosis
liver tumours
stroke/CHD
systemic lupus erythematosus with positive antiphospholipid antibodies
specific meds
111
Q

What antibiotics are POPs not affected by?

A

non-enzyme inducing antibiotics like amoxicillan and doxycycline

112
Q

short term treatment (< 2mths) of enzyme inducing drugs and POPs

A

stop POP and change to alternative contraception
OR
continue POP but abstain/barrier while taking and for 28 days after

113
Q

long term treatment of enzyme inducing drugs and POPs

A

change to alternative contraception (barrier or progestogen-only injectable)

114
Q

vomiting within 2 hrs of taking POP

A

take another asap

115
Q

vomiting/diarrhoea for >24hrs while taking POP

A

follow instructions for missed pill
each day on vom/diarrhoea
abstain/barrier during illness and 2 days afterwards

116
Q

2 brands of POP OTC

A

Hana

Lovima

117
Q

licenced indication for Hana

A

licenced for women of childbearing age

118
Q

Hana price

A

£9.95 for 1 month

£21.95 for 3 months

119
Q

Lovima licencing

A

licenced for women of childbearing age including adolecents

120
Q

Lovima price

A

£14.99 for 1 month

£29.99 for 3 months

121
Q

Supply of Hana/Lovima advice

A

first supply up to 3 months

repeat supply up to 12 months

122
Q

max supply for U18 of Hana/Lovima

A

maximum of 3 months can be supplied

123
Q

switching from COC to POP

A

idealy complete COC pack omiting HFI
start POP next day (day 22)
no additional contraception is required

124
Q

switching from traditional POP to COC

A

start COC the next day after POP

need to abstain/barrier for 1st 7 days (9 days for Qlaira)

125
Q

switching from desogestrel POP to COC

A

start COC next day after desogestrel POP

no additional contraception required

127
Q

examples of long acting reversible contraceptives (LARCs) (4)

A
  1. progestogen-only injectable contraception
  2. progestogen-only implant
  3. progestogen-only intrauterine system (IUS)
  4. copper intrauterine device (Cu-IUD)
127
Q

How does progestogen-only injectable contraception work?

A

preventing ovulation

128
Q

drug in progestogen-only injectable contraception

A

medroxyprogesterone acetate

129
Q

How often is progestogen-only injectable administered?

A

every 12 weeks

130
Q

failure rate of progestogen-only injectable contraception

131
Q

s/e of progestogen-only injectable contraception

A

weight gain

small loss of bone density (recovers after discontinuation)

132
Q

Is efficacy of progestogen-only injectable contraception affected by antibiotics/liver inducing enzymes?

133
Q

When does fertility return after discontinuing progestogen-only injectable contraception?

A

can be delayed up to 1 year

134
Q

Most common reason for discontinuing progestogen-only injectable contraception?

A

altered bleeding pattern and persistent bleeding

135
Q

drug in progestogen-only implant

A

Etonogestrel

136
Q

brand of progestogen-only implant

A

Nexplanon implant

137
Q

How long does progestogen-only implant protection last?

138
Q

failure rate for progestogen-only implant

A

low

< 1 in 1000 over 3 years

139
Q

How is progestogen-only implant inserted?

A

sub dermally by appropriate practitoner

140
Q

s/e of progestogen-only implant

A

irregular bleeding
amenorrhoea
infrequent/prolonged bleeding

141
Q

heavier women and progestogen-only implant

A

effectiveness can be reduced especially in the 3rd year

earlier replacement may be considered

142
Q

dely in return of fertility after progestogen-only implant

143
Q

drug in progestogen-only intrauterine system (IUS)

A

Levonogestrel

144
Q

How does Levonogestrel intrauterine system (LNG-IUS) work?

A

preventing endometroal proliferation
thickening of cervical mucus
suppressing ovulation in some women

145
Q

4 examples of progestogen-only intrauterine system (LNG-IUS)

A

Jaydess
Levosert
Mirena
Kyleena

146
Q

What does LNG-US stand for?

A

Levonogestrel intrauterine system

147
Q

How long does progestogen-only intrauterine system last?

A

up to 5 years

Jaydess 3 years

148
Q

failure rate of progestogen-only intrauterine system

149
Q

s/e of progestogen-only intrauterine system

A

irregular bleeding and spotting in 1st 6 months

150
Q

How does the copper intrauterine device work?

A

inhibits fertilisation by Cu’s toxic effect on sperm and ova

inhibits implantation due to local endometrial inflammatory reaction

151
Q

What is 1st line for EHC?

152
Q

benefits of Cu-IUD

A

no hormonal adverse effects

153
Q

s/e of Cu-IUD

A

heavier bleeding
dysmenorrhoea
pain

154
Q

duration of action of Cu-IUD

A

5-10 years

155
Q

failure rate of Cu-IUD

PHA223 (43 decks)

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