Contraception Flashcards

Question

What type of information must you give a patient when prescribing hormonal contraceptives?

Answer 1

Need to address: 1. Method of use and what to do in misuse (e.g. missed pill) 2. SE 3. Health benefits 4. Failure rates 5. Fertility on stopping 6. Follow up *Always useful to provide a leaflet.*

Answer 2

1. **Male condom** - thin latex or plastic sheath placed over the man's erect penis to stop sperm during ejaculation, must be put on before any contact ; oil/petroleum jelly will damage the rubber 2. **Female condom** - a thin sheath which is inserted into the vagina. 3. **Diaphragm/cap +/- spermicide cream** - should always be used together; consists of dome of rubber which is fitted by the woman over her cervix before intercourse. All are between 92-95% effective if used correctly.

Answer 3

_Male condoms_ * **Adnvantages**: widely avaialable, free from clinics, protect from STDs like HIV, no health risks with use * **Disadvantages**: none, but must be correctly applied as failure rates can rise to 24% with improper use. _Female condom_ * **Advanatges**: less likely to split than a male condom and not damaged by oil lubricants, protects from UTI, * **Disadvantage**: noisy, penis may be inserted between the condom and vaginal wall _Diaphragm/cap_ * **Advantages**: can be inserted 3hrs before intercourse, reusable * **Disadvantages**: 18% failure rates with improper use, increased rates of UTI and vaginal discharge following use, must be taught how to insert these, must be left in for 6hrs after intercourse, _Spermicides:_ * **Disadvantages**: low efficacy if used alone, may increase risk of HIV transmission according to some data

Answer 4

**LNG-IUS**- progestogen releasing types include: * Jaydess - 13.5mg LNG-IUS - 3 years contraception, narrower and shorter frame so better in nullips, silver band on proximal end helps distinguish it from Mirena. * Mirena - 52mg LNG-IUS - 5 years contraception **Copper IUD** - can also be used for emergency contraception, or normal for 3-10 years depending on device and age at insertion

Answer 5

_LNG-IUS_ * **Advantages**: effective as does not rely on compliance, lighter less painful menses, most effective against HMB and effective for dysmenorrhoea, no effect on fertility once removed. * **Disadvantages**: expulsion may occur, increased risk of infection first few weeks after insertion, may cause long term **acne, breast tenderness, mood disturbance and headaches.** _Cu-IUD_ * **Advantages**: reduced risk of ectopic pregnancy but if pregnancy does occur then it is rlatively more likely to be ectopic than normal, no effect on fertility once removed. * **Disadvantages**: more painful/heavier menses

Answer 6

**IUD**: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions and the inflammation caused) **IUS**: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening (does not prevent ovulation)

Answer 7

IUD - immediately IUS - 7 days later

Answer 8

_Immediate/short term:_ * **Pain** * **Perforation of uterus** - 1 in 500 risk, higher in breastfeeding women * **Infection** - small increase in risk of PID after insertion in first 20 days * **Expulsion** - 1 in 20 risk, most likely in the first 3 months _Long-term_ * **Ectopic pregnancy** proportion increased - relative risk increase but overall risk still low * **Frequent bleeding and spotting** followed by amenorrhoea

Answer 9

IUD: * if inserted \>40 years then can be used as contraception until menopause IUS: * if inserted \>45 years then can be used as contraception until menopause * can be used as the progesterone component to HRT for endometrial protection in women taking oestrogen-only hormone replacement for 4 years

Answer 10

NB: ask whether hysterectomy/sterilisation or orchidectomy has been done as no need for contraception then. _Trasngender men:_ * **Testosterone** does not protect against pregnancy - any **oestrogen** containing pills will anatagonise the effects of testosteroene * **Progesterone only IUS/injection** may be used with testosterone therapy * Non-hormonal contraception may be used but IUD can exacerbate bleeding which may be unacceptable to some trans men * Neither **emergency contraceptiv**e options interact with testosterone so may be used _Transgender women:_ * **Oestrogen, GnRH analogs, finasteride and cyproterone acetate** use cannot be relied on as contraception - despite reducing or cessating sperm production * **Condom use** is advised if engaging in vaginal sex

Answer 11

An IUD/IUS can be fitted at any time during your menstrual cycle, as long as you're not pregnant. You'll be protected in X. Before your IUD/IUS is fitted, a GP or nurse will check inside your vagina to check the position and size of your womb. You may be tested for any existing infections, such as STIs, and be given antibiotics. The appointment takes about 20 to 30 minutes, and fitting the IUD/IUS should take no longer than 5 minutes: * the vagina is held open, like it is during cervical screening (a smear test) * the IUD is inserted through the cervix and into the womb Having an IUD fitted can be uncomfortable, and some people might find it painful, but you can have a local anaesthetic to help. Discuss this with a GP or nurse beforehand. You can ask to stop at any time. You can also take painkillers after having an IUD fitted if you need to. You may get period-type cramps afterwards, but painkillers can ease the cramps. You may also bleed for a few days after having an IUD fitted. Once your IUD has been fitted, you may be advised to get it checked by a GP after 3 to 6 weeks to make sure everything is fine. Tell the GP if you have any problems after this initial check or if you want the IUD removed. An IUS has 2 thin threads that hang down a little way from your womb into the top of your vagina. You should check if the threads are still in place a few times a month and after periods. If you cannot feel the threads you may need additional protection and contact GP/nurse straight away.

Answer 12

Your IUS can be removed at any time by a trained doctor or nurse. If you're not having another IUS/IUD put in and do not want to become pregnant, use additional contraception, such as condoms, for 7 days before you have it removed. It's possible to get pregnant as soon as the IUS/IUD has been taken out.

Answer 13

1. **Levonorgestrel 1.5mg** * **doubled dose if BMI\>26 or \>70kg** * must be taken within 72hours\* of UPSI; * 84% effective within this time. 2. **Ulipristal (EllaOne) 30mg** - * must be taken within 120 hours of UPSI; 3. **Cu-IUD** - * can be inserted within 5 days of UPSI and up to 5 days after the likely ovulation date; * should be kept in until the next period if they want it removed * MOST effective (99%) \*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

Answer 14

Levonorgestrel -MOA not fully understood - acts both to **stop ovulation and inhibit implantation** Ulipristal - a s**elective progesterone receptor modulator**; primary MOA is thought to be inhibition of ovulation Cu-IUD - may **inhibit fertilisation or implantation**

Answer 15

Levonorgestrel: * can be used more than once in a cycle (same as Ulipristal) * double dose in BMI\>26 or \>70kg * safe and well tolerated but SE include vomiting (1%) - if within 3hrs then repeat dose * hormonal contraception can be started ASAP after * no restrictions on breastfeeding (unlike Ulipristal) Ulipristal * cannot be used with levonorgestrel * may reduce the efficacy of normal contraception - barrier needed for 5 days * restart normal pill/patch/ring 5 days after ulipristal * caution with severe asthma * can also be used more than once in menstrual cycle * delay breastfeeding for 1 week Cu-IUD * offer to all women as most effective * prophylactic abx may be given if high risk of STI

Answer 16

In a 28-day cycle, predicted ovulation day 14 + 5 days = insert up to day 19 for EC Failure rate is 1 in 1000

Answer 17

**Spermicide** - Nonoxinol 9 (usually this is applied on the cap/diaphragm but is not recommended for use on condoms) **Use** - cap is filled a third with spermicide; if diaphragm is inserted dome down then put spermicide on upper surface and rim (but not on rim of cap) **Efficacy** - with perfect use of cap is 82% and typical use is 72%; lower efficacy if cap/diaphragm has been in for \>3hrs before intercourse. **Complications** -disrupts cell membranes and increases risk of HIV Source: [FSRH](https://www.fsrh.org/standards-and-guidance/documents/ceuguidancebarriermethodscontraceptionsdi/)

Answer 18

**Fertility awareness method** Encompasses abstinence around normal cycles as well as coitus interrupts/withdrawal and lactational amenorrhoea method.

Answer 19

Advantages: * no side-effects * no change to menstrual cycles - so any abnormalities identified quicker * may be more acceptable to some * awareness helps to concieve in the future Disadvantages: * less effective than LARC due to reliance on user and partner * no non-contraceptive benefits of hormones * no protection from STIs * should not be used where pregnanc yposes a significant health risk

Answer 20

* Menstrual cycle irregularity * Postpartum period (4 weeks if not breastfeeding) * Recent hormonal contraception use * Use of teratogenic drugs * Antibiotics and other medications like NSAIDs * Medical conditions for which pregnancy is high risk * Other medical conditions Trained medical professional should help patients with this method of contraception. Charts may be used to track cycles as [here](https://www.fsrh.org/standards-and-guidance/documents/ceuguidancefertilityawarenessmethods/).

Answer 21

**ovum** = ~24hrs **sperm** = up to 7 days (although mean survival is 1.47 days) *So a woman's fertile window is ~8-9 days of the cycle*

Answer 22

If \<6 months postpartum, amenorrhoeic, fully breastfeeding: 98% effective **NB**: risk of pregnancy is increased if the frequency of breastfeeding decreases (stopping night feeds, supplementary feeding, use of pacifiers/dummies), when menstruation returns or when \>6 months postpartum.

Answer 23

**Efficacy** - ~96% with perfect use, 78% with typical use Men advised to urinate between successive ejaculations to remove sperm from pre-ejaculate (although this is debatable and sperm usually remain) *NB: a few studies have shown no motile sperm in the pre-ejaculate*

Answer 24

Not until regular menstrual cycles have been established , usually recommended until 3 cycles have occurred

Answer 25

**Temperature** - basal body temp monitored when ovulation occurred **Cervical secretions** - wet, slippery and clear if ovulation is approaching **Cervical palpation** - cervix rises 1-2 cm and feels softer and more moist midcycle **Personal fertility monitor** - analyses diposable urine dipsticks that record the presence of metabolites of oestrogen and LH in the urine e.g. preovulatory LH peak **Two-day method** - if secretions seen then avoid sex **Calendar** - tracked over minimum 12 cycles and fertile window calculated using shortes and longest **Standard Days Method** - combination of all above **Lactational amenorrhoea method** - breastfeeing providing contraception

Answer 26

If using one indicator: with typical use ~76% so not recommnded . But perfect symptothermal method then 0.4% failure (NB: COCP is 0.3% failure rate)

Answer 27

Basal body temperature i.e. waking/ temperature at the same time of day/ after at least 3hrs rest

Answer 28

The **combined** hormonal ring is a flexible ring of 54 mm diameter that releases 15 μg ethinyloestradiol and 120 μg etonorgestrel daily, and as such is the lowest dose combined hormonal method.

Answer 29

The ring is self inserted and worn in the vagina for 21 days, followed by a 7-day hormone-free interval, during which a withdrawal bleeding occurs. Women should not feel discomfort from the ring and it can be removed for a short time (\<3 hours) and can be cleaned and replaced.

Answer 30

Evra patch - only **combined** contraceptive patch licensed for use in UK The patch cycle lasts 4 weeks. For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.

Answer 31

Delayed at the end of week 1 or week 2: * \< 48hr delay = changed immediately + no further precautions . * \>48hr delay = changed immediately + barrier contraception for next 7 days. If UPSI during this extended patch-free interval or if UPSI in the last 5 days, then emergency contraception needs to be considered. Removal delayed at the end of week 3: * Removed ASAP + the new patch applied on the usual cycle start day. No additional contraception is needed. Application is delayed at end of week 4 (patch free week): * Additional barrier contraception for 7 days following any delay at the start of a new patch cycle

Answer 32

Etonogestrel- Nexplanon® contains 68 mg of 3-keto-desogestrel (a metabolite of desogestrel). (a type of **progestogen**) MOA: inhibits ovulation, also thickens cervical mucus Lasts 3 years

Answer 33

Can be inserted too deep which may result in difficult removal After removal, serum levels of etonorgestrel levels are undetectable within 1 week, and fertility is restored _immediately_ after removal

Answer 34

Nexplanon® contains a small quantity of **barium**, which permits it to be visualized by X-ray. It can also be localized using low-frequency ultrasound probes, which can help aid removal of implants that are not easily palpable.

Answer 35

If the implant/injection is given during the first 5 days of your menstrual cycle, you'll be immediately protected against becoming pregnant If not, use barrier for 7 days.

Answer 36

Similar in size to a match stick (40 mm × 2 mm) and is inserted subdermally 8 cm above the medical epicondyle, usually of the non-dominant arm. Should be palpable but not visible Local anaesthesia is used Only done by a professional who has been specifically trained

Answer 37

Irregular bleeding

Answer 38

Medroxyprogesterone acetate given IM (buttock, upper arm, lower abdomen) (Depoprovera® (150 mg)) or micronized lower-dose formulation of Sayana press® SC. MOA: Inhibits ovulation, also thickens cervical mucus Lasts 12 weeks

Answer 39

**Delay of return to fertility** - may take up to 1 year after the last injection for ovulation to return to normal in some cases **Weight gain** **Loss of bone mineral density** (5% loss at lumbar spine)

Answer 40

With SC the user can be taught to self-administer or can be given by other health professionals e.g. pharmacists, improving access and acceptability

Answer 41

**COCP** - inhibits ovulation. _SE_: increases risk of VTE. Increases risk of breast and cervical cancer **Progestogen-only pill** (excluding desogestrel\*) - thickens cervical mucus. _SE_: irregular bleeding a common side-effect

Answer 42

Potential harms and benefits, including * the COC is \> 99% effective if taken correctly * small risk of blood clots * very small risk of heart attacks and strokes * increased risk of breast cancer and cervical cancer

Answer 43

If started in first 5 days of the cycle then no need for additional contraception. If started at any other time then use additional contraception for 7 days.

Answer 44

If started in first 5 days of the cycle, no contraception is required. If not then additional contraception is required for 2 days. NB: careful in women with short cycles

Answer 45

Advantages of combined oral contraceptive pill * highly effective (failure rate \< 1 per 100 woman years) * doesn't interfere with sex * contraceptive effects **reversible** upon stopping * usually makes periods regular, lighter and less painful * reduced risk of ovarian, endometrial - this effect may last for several decades after cessation * reduced risk of colorectal cancer * may protect against pelvic inflammatory disease * may reduce ovarian cysts, benign breast disease, acne vulgaris

Answer 46

Disadvantages of combined oral contraceptive pill * people may forget to take it * offers no protection against sexually transmitted infections * increased risk of venous thromboembolic disease * increased risk of breast and cervical cancer * increased risk of stroke and ischaemic heart disease (especially in smokers) * temporary side-effects such as headache, nausea, breast tenderness may be seen

Answer 47

Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane review did not support a causal relationship.

Answer 48

If pills are missed in: * Week 1 (Days 1-7): emergency contraception should be considered if she had UPSI in the pill-free interval or in week 1 * Week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception\* * Week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 49

Potential adverse effects * irregular vaginal bleeding is the most common problem

Answer 50

If switching from a COCP the POP gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)

Answer 51

should be taken at the same time every day, without a pill-free break (unlike the COC)

Answer 52

If \< 3 hours\* late: continue as normal If \> 3 hours\*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours NB: for Cerazette (desogestrel) a 12 hour period is allowed

Answer 53

Women should be advised there may be a delay in the return of fertility of up to 1 year for women \> 40 years Use is associated with a small loss in bone mineral density which is usually recovered after discontinuation

Answer 54

Not unless they affect the P450 enzymes e.g. rifampicin

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Contraception Flashcards

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