Contraception Flashcards
What are the 3 main types of emergency contraception?
Levonorgesterol
Ulipristal
Copper IUD
When does each type of emergency contraception work?
Levonorgesterol- <72 hrs
Ulipristal- <120 hrs
Copper IUD- <120 hrs
What are the brand names for the emergency contraceptions?
Levonelle (£25)
ellaOne (£25)
Copper IUD (GP)
How effective is levonorgesterol?
95% effective in <24 hours, 84% effective <72 hours
What is the MoA of levonorgesterol?
stops ovulation and inhibits implantation
What is the dose of levonorgesterol?
1.5mg STAT [n.b. double dose if >26 BMI or >70kg]
How well tolerated is levonorgesterol?
o Safe, well-tolerated (potential slight menstrual cycle disturbance)
o If vomiting within 2 hours of dose, repeat the dosage
o Can be used >1 in each menstrual cycle
How effective is Ulipristal acetate?
95% effective in <120 hours (5 days)
What is the MoA of Ulipristal acetate?
selective progesterone receptor modulator -> inhibits ovulation
What is the dose of Ulipristal acetate?
30mg STAT
How well tolerated is Ulipristal acetate?
Not to be used: alongside levonorgesterol, severe asthma
o If normally on hormonal contraception, they should restart 5 days after ulipristal (use barrier for 5 days)
o If vomiting within 3 hours of dose, repeat the dosage
o Unsure if safe if used >1 in each menstrual cycle
How do you deal with emergency contraception in overweight people?
o BMI >26 or >70kg:
§ 1st line: Ulipristal acetate 30mg STAT (ellaOne); continue oral contraception after 5 days
§ 2nd line: Levonorgesterol (Levonelle) double dose (3mg / 3000ug) + barrier contraception
How effective is copper IUD?
99% effective in <120 hours
What are the indications of copper IUD?
§ <5 days of last UPSI; OR
§ Up to 5 days after the likely ovulation dat
What is the MoA of copper IUD?
spermicide and prevents implantation
Prophylactic antibiotics if at high risk of STI
Can copper IUD be used long term?
yes
What other advice do you give for emergency contraception?
· Cost of morning after pill: £25 (can be free from GUM clinic and GP walk in centre)
· ADVICE: offer STI screen and recommend taking a pregnancy test if her next period is late
· Side-Effects of Emergency Contraception (NOT IUD): N&V, headache, breast tenderness, abnormal menstrual bleedin
What is the pearl index?
describes the chance of becoming pregnant on contraception:
o Pearl index = the number of pregnancies occurring per 100 woman-years
o I.E. Pearl of 2 = 2 pregnancies per year in 100 women
§ This is a bad contraception… an index of 0.2 is more likely
What is the time to effect for long term contraception?
- Instant: Copper Coil
- 2 days: POP
- 7 days: COCP, IUS, injection, implant
What is barrier method?
Condom
What are the daily methods of contraception?
Combined oral contraceptive pill (COCP)
Transdermal Patch (weekly)
Progesterone only pill (POP)
Vaginal ring (3-weekly)
What is the hormone in the COCP (microgynon 30)?
OESTROGEN (ethinyl oestradiol) and PROGESTERONE (progestin
How does COCP work?
Prevents ovulation
How do you take COCP?
- OD for 3 weeks -> 1 week off (withdrawal bleed); OR
- Tricycle: OD for 9 weeks -> 1 week off (withdrawal bleed)
If started on the first 5 days of the cycle (28-day cycle) -> confers immediate contraceptive protection If starting at any other time, use additional measures for the first 7 days
What are the benefits of COCP?
+ >99% effectiveness
+ Reversible on stopping
+ Less pain, more regular, lighter periods (used in dysmenorrhoea)
+ Reduced risk of ovarian cancer, endometrial cancer, bowel cancer [BEO]
o N.B. ovarian cancer risk is associated a greater number of OVULATIONS during life
What is the disadvantages of COCP?
- Easy to forget to take May cause breakthrough bleeding and spotting at first
- Does not reduce risk of STIs
- Increased risk of VTE (stroke, heart disease), breast cancer, cervical cancer [BC]
- Side effects: headache, N&V (if vomit <2hr since pill, take another), breast tenderness
- Stop 4w before surgery, restart 2w after surgery [switch to POP]
What are the absolute contraindications to the COCP?
How do you deal with 1 missed dose of COCP?
take last pill and current pill (even if 2 in 1 day) -> no further action needed
How do you deal with 2 missed doses of COCP?
take last pill and current pill (even if 2 in 1 day) -> further action
o Use condoms until pill has been taken correctly for 7 days in a row
o 2 Missed in Week 1: consider emergency contraception
o 2 Missed in Week 2: no need for emergency contraception
o 2 Missed in Week 3: finish current pack, start new pack immediately (no pill-free break
What is the hormone/ mechanism of POP?
PROGESTERONE (progestin) -> levonorgestrel, norethisterone, desogestrel (cerazette)
Mechanism: Thickens cervical mucus (desogestrel/cerazette primarily stops ovulation)
What are the benefits of POP?
No oestrogen pill risks (n.b. ABx has no effect on POP)
What are the disadvantages of POP?
Very easy to forget to take
Initial irregular bleeding (which may continue) = most common complaint:
20% -> amenorrhoeic
40% -> bleed regularly
40% -> bleed irregularly
Osteoporosis and ovarian cyst risks
SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
What do you do for traditional POPs if you’ve missd a dose?
o <3 hours late: continue as normal
o 3+ hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until pill taking has been re-established for 48 hours
§ If missed 2 pills, take last missed pill and next pill, and use barrier methods until pill-taking has been re-established for 48 hours
§ Emergency contraception needed if UPSI during this interval
What do you do if you miss a dose of cerazette (desogesterel)?
o <12 hours late: continue as normal
o >12 hours late: take missed pill ASAP, continue with rest of pack, extra precautions (condoms) until pill taking has been re-established for 48 hours
What is the combined hormonal transdermal patch?
OESTROGEN (ethinyl oestradiol) and PROGESTERONE (norelgestromin)
Mechanism: Thickens cervical mucus and prevents ovulation
How do you take CHTP?
- Applied (and replaced weekly) for 3 weeks ->1 week off (withdrawal bleed); OR
- Tricycle: Applied (and replaced weekly) for 9 weeks -> 1 week off (withdrawal bleed)
What are the pros and cons of CHTP?
Pros
+ Harder to forget to do (less frequent)
Cons
Skin sensitivity
Contraindications (see COCP contraindications)
What do you do for a missed dose of CHTP?
· Delayed change <48 hours: change immediately with no further precautions
· Delayed change >48 hours (week 1 or 2): change immediately, use barrier protection for 7 days o If UPSI <5 days or during extended patch-free period, consider emergency contraception
· Delayed removal >48 hours (week 3): remove immediately and apply next patch on the usual start date of the next cycle (no additional contraception is needed)
· Delayed at the end of the patch-free week: use barrier contraception for 7 day
What is the combined hormonal ring?
OESTROGEN (ethinyl oestradiol) and PROGESTERONE (norelgestromin)
Mechanism: Thickens cervical mucus and prevents ovulation
How do you take the combined hormonal ring (nuva ring)?
Applied for 3 weeks -> 1 week off (withdrawal bleed)
What are the pros and cons of the combined hormonal ring?
Pros
+ Harder to forget to do (less frequent)
Disadvantages
Skin sensitivity
Patch adherence
Contraindications (see COCP contraindications)
N.B. any progesterone LARC will cause initial irregular bleeding
N.B. any progesterone LARC will cause initial irregular bleeding
What is an intrauterine system (Mirena)?
PROGESTERONE (levonorgestrel)
Mechanism: Prevents endometrial thickening, thickens cervical mucus
How do you insert a mirena?
· Inserted and left for 3-5 years
· Can be the progesterone component of HRT
· Contraindications to IUDs/IUS = pregnancy, PID, malignancy, unknown bleeding
Additional contraception needed for 7 days after insertion (unless <5 days of new cycle)
What are the pros and cons of mirena?
Benefits
+ 99% effective
+ Lasts for 3-5 years
+ Initially irregular bleeding, followed later by lighter menses or amenorrhoea
+ Indications: heavy bleeding periods, PMS (good for mood symptoms)
Disadvantages
SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
Risk of expulsion (<1m), infection (<2m), perforation
What is Jaydess and Kyleena?
Jaydess
· Smaller IUS, indicated for contraception, not indicated in menorrhagia
· Lasts for 3 years
Kyleena
· Smaller IUS, indicated for contraception, not indicated in menorrhagia
· Lasts for 5 years
What is an IUD (copper coil)?
Hormone Copper
Mechanism Decrease sperm motility and survival (causes sterile inflammation -> implantation not possible)
How do you insert an IUD?
· Inserted and left for 5-10 years
· Contraindications to IUDs/IUS = pregnancy, PID, malignancy, unknown bleeding
· After childbirth, insert: <48 hours OR after 4 weeks
Immediate contraceptive ability, inserted at any point in cycle
What are the pros and cons of an IUD?
Benefits + Lasts for up to 10 years + Works immediately
Disadvantages Side effects: heavy, painful periods, risk of expulsion (<1m), infection (<2m), perforation NOT TO BE USED IN MENORRHAGIA
What is the implant (nexplanon)?
Hormone PROGESTERONE (etonogestrel)
Mechanism Main: prevents ovulation, other: thickens cervical mucus
How do you insert an implant?
· Small rod inserted sub-dermally into non-dominant arm · Lasts for 3 years Additional contraception needed for 7 days after insertion (unless <5 days of new cycle)
What are the pros and cons of the implant?
Benefits + Lasts for up to 3 years + Fertility reversible immediately
Disadvantages SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache Contraindication: IHD
What is the injection (depo-provera)?
Hormone PROGESTERONE (medroxyprogesterone acetate)
Mechanism Main: prevents ovulation, other: thickens cervical mucus
How do you take the injection?
· Lasts for 12-14 weeks Additional contraception needed for 7 days after insertion (unless <5 days of new cycle)
What are the pros and cons of the injection?
Benefits + Nil
Disadvantages SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache Fertility takes 6-12 months to return from last injection Associated with weight gain and ectopic pregnancy
How do you do PACES counselling?
IMPORTANT: all LARCs take 1 week to start being effective (except copper IUD)
o Key Aspects of History
§ Previous personal or family history of VTE, migraine, cancer, stroke and hypertension
§ Menstrual problems (e.g. heavy periods)
o Explain that the contraception can be divided into long-acting and short-acting
How do you prescribe post partum contraception?
· N.B. no contraception required within 21 days postpartum
· COCP NO: <6w post-partum + breastfeeding; WARNING: 6w-6m postpartum + breastfeeding
NOT breastfeeding -> can start from day 21, if starting >21 days, use barrier for 7 days
· POP start ANY TIME but if starting after day 21 post-partum, use barrier for 2 days
· IUD/IUS within 48 hours of childbirth (uncomplicated CS or SVD) OR after 4 weeks
· Lactational 98% effective if: FULLY breastfeeding (no bottle), amenorrhoeic, <6m postpartum
How do you stop non hormonal contraception in under and over 50’s?
<50: Stop contraception ≥2 years amenorrhoea
>50: Stop contraception ≥1-year amenorrhoea
How do you stop COCP contraception in under and over 50’s?
<50: Continue to 50 years (no longer
>50: Switch to non-hormonal or POP
How do you stop implant, POP and IUS contraception?
Continue beyond 50 years
How do you stop Depo-Provera contraception in under and over 50’s?
<50: Continue to 50 years (no longer
>50: Switch to non-hormonal + stop ≥2y amenorrhoea Switch to POP
What are the fraser guidelines?
· The young person understands the professional’s advice
· The young person cannot be persuaded to inform their parents
· The young person is likely to begin or continue having sex with or without contraceptive treatment
· Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
· The young person’s best interests require them to receive contraceptive advice or treatment ± parental consent
· N.B. if the child is <13yo (being 13 is OK), they cannot be competent (even under ‘Gillick’ guidelines) and so you can never prescribe contraception (regardless of the situation) -> contact the local safeguarding lead
· There is NO lower age-limit for Gillick competence (but, in practice, it’s under the age of 13)
