Contraception Flashcards
What are the 3 main options for emergency contraception and when can they be taken (inc dose)? Outline their mechanisms?
Emergency:
–> Note: £25 each for pills or can get free from GP walk in/GUM clinic
-> 1.5mg Levonorgestrel [Levonelle] - within 72h or 3d of UPSI
Progestogen –> works by stopping ovulation and inhibiting implantation
-> 30mg Ulipristal acetate [EllaOne] - within 120h or 5d of UPSI (‘the morning after pill’)
Works by its action of a selective progesterone receptor modulator, thereby inhibiting ovulation
-> Copper IUD - within 120h
Works by preventing implantation by inducing sterile inflammation and is also a spermicide
What are some of the pros and cons, CIs and efficacies of each emergency contraception options? - Copper IUD
Copper IUD:
- 99% effective in <120h = the MOST effective form of contraception
- Either used within 5d of UPSI OR up to 5d after the likely ovulation date (14d before next period/cycle length-14)
- Offer, especially if likely to present again, as long-term and acts immediately
PROs:
- Not affected by BMI, enzyme-inducing drugs or malabsorption
- Uncomfortable procedure but long-term
- IF risk of PID/STI then offer antibiotics
- Advise taking a pregnancy test if next period is late
See more in LARC section*
What is the efficacy of levonorgestrel? What are some of the pros and cons, and CIs? What happens if you vomit after taking it?
Levonorgestrel:
- Mechanism = stops ovulation and inhibits implantation
- 95% effective before 24h, 84% when <72h
- Double dose (3mg) if BMI >26 or >70kg (2nd line) and woman should take ongoing contraception immediately
- Safe, well tolerated
- If vomited within 2h of dose, repeat dose
- Potential of slight menstrual cycle disturbance
- Can be used >1 in each menstrual cycle
- COCP/POP can be taken immediately after use but requirement of barrier for at least 7d for COCP or 2d for POP
- Advise taking a pregnancy test if next period is late
How effective is EllaOne? When is it CI? When is it indicated?
EllaOne:
- 95% effective <120h
- DO NOT use alongside levonorgestrel or in severe asthma, and if breast feeding then must express+discard milk/avoid feeding for 1w after use
- If normally on hormonal contraception, pt should restart it after 5d of ulipristal and use barrier for 5d
- Can be used >1 in a menstrual cycle
- If BMI >26 or 70kg+ then 1st line is Ullipristal 30mg, 2nd line is double-dose Levonelle
- Advise taking a pregnancy test if next period is late
How would you advise a woman who is requesting emergency contraception? What is the pearl index?
Counselling:
- Options of contraception including long term/acting (injection, IUD, implant) or short acting/daily (pills, patches, rings) –> with IUD first line as 99% effective
- Efficacy within time-frame
- Advise STI screen and pregnancy test if period is late
- Safeguarding, rape and abuse, inquire if partner etc
- SE’s of pill: N+V, spotting/abnormal menstrual bleeding, headache, breast tenderness
- Price
Pearl index = chance of becoming pregnant on contraception by stating the number of pregnancies occurring per 100 woman-years i.e. PI = 2 translates to 2 pregnancies per year in 100 women
State the 4 long-acting reversible methods of contraception? How do they each work and length of time taken to work and duration required for?
IUD - Copper coil
- -> Spermicide and inhibits implantation (causes sterile inflammation)
- -> Works immediately
- -> 5 or 10y options
IUS - Mirena coil
- -> Levonorgestrel which inhibits implantation by promoting thinning of the womb, thickens cervical mucus
- -> Jaydess is a smaller form of the IUS, NOT for heavy periods though, often in nulliparous, easier insertion, lasts 3y
- -> Additional contraception needed for 7 days after insertion unless inserted in first 5-7d of a cycle
- -> stays for 3-5y
Implant (Nexplanon)
- -> Etonogestrel - prevents ovulation, also thickens cervical mucus
- -> small rod is inserted sub-dermally in the non-dominant arm
- -> Additional contraception needed for 7d unless inserted in 1-5d of cycle
- -> Lasts 3y, fertility immediately restored after removal
Injection/DepoProvera
- -> medroxyprogesterone acetate - inhibits ovulation and also thickens cervical mucus
- -> every 12-14w
IE all LARCs take 1w to work, except IUD, so require extra contraception till then
What are some SE’s and risks associated with each long-acting methods of contraception? What are certain indications/CIs of each?
Copper IUD:
- -> Contraindicated in: MENORRHAGIA, PID, Ectopics, malignancy and unknown bleeding
- -> SE’s = heavy painful periods
- -> Risk of expulsion (<1m) and infection (<2m), perforation
- -> Can insert <48h after childbirth or after 4w
Mirena IUS:
- -> Contraindicated in: PID, Ectopics, malignancy and unknown bleeding
- -> Good for women with heavy bleeding; initially may be heavier/irregular but tend to experience lighter, less painful menses or even amenorrhoea
- -> SE’s = mood changes, acne, breast tenderness
- -> Risk of expulsion (<1m) and infection (<2m), perforation
Implant:
- -> Contraindicated in: IHD
- -> Reduced efficacy seen sometimes if on AEDs and rifampicin
- -> SE’s = irregular bleeding is MAIN; mood changes, acne, breast tenderness, nausea
Injection:
- -> Contraindicated in:
- -> SE’s = irregular bleeding is MAIN; fertility takes 6-12m to return from last injection, mood changes, acne, breast tenderness
- -> Associated with weight gain and ectopics
What are the 4 options for short acting reversible contraceptives?
COCP, POP, Transdermal patch, combined hormonal ring
How does the COCP work and how is it taken? Explain the:
- Time taken to work
- Indications/Benefits
- SE’s and Risks
- When should it be stopped?
COCP = ethinyl oestradiol and progestin
- -> Prevents ovulation
- -> 1 tablet/day for 3w followed by 1w pill-free interval for withdrawal bleed (can also take tricyclic to reduce frequency of withdrawal bleed)
- -> 7d of additional contraception required unless inserted in first 5d of cycle, but caution in short-cycle women
Indications + Benefits:
- Less pain, regular lighter periods (good in dysmenorrhea)
- 99% effective if taken properly
- Reduced risk of bowel, endometrial and ovarian cancer
SE’s + Cons:
- Increased risk of cervical and breast cancer
- Increased risk of clots but very small
- Headache, N+V, breast tenderness - if vomit with 2h, take another pill
- STOP 4w before surgery and 2w after surgery
- Easy to forget to take, doesn’t reduce risk of STIs
- Abx require consideration as can interfere
What are all the CI’s for the COCP?
CI's: UKMEC 4 include = - Current breast cancer - <6w postpartum and breast feeding - Smoker aged 35+ >15/day - Past Hx of VTE (thromboembolism) - IHD, CVD, valvular disease, HTN >160/100 - Migraine with aura - Diabetes with complications (NRN) - Severe cirrhosis or liver tumour
‘The pill Cannot Be Sold To Particular Individuals Meeting Certain Criteria’
If you had a missed COCP pill, what is required:
- 1 pill missed in a single week
- 2-7 pill missed in a single week
- 2 missed in week 1
- 2 missed in week 2
- 2 missed in week 3
- 7 pills missed in a single week
1 pill missed in a single week
= take the last pill and current pill (even if 2 in a day), no other contraception needed
2-7 pills missed in a single week
= take last pill and current pill and continue pill use + use condoms until pills taken correctly 7d in a row
- 2 missed in week 1 = consider emergency contraception
- 2 missed in week 2 = no need for emergency contraception
- 2 missed in week 3 = finish pills in current pack and start new pack immediately with no pill-free break
- 7 pills missed in a single week = restart COCP as new user
How does the POP work and how is it taken? Explain the:
- Time taken to work
- Indications/Benefits
- SE’s and Risks
POP
- -> Desogestrel/ levonorgestrel or norethistrone
- -> Thickens cervical mucus - only desogestrel (cerazette) stops ovulation
- -> 1 pill taken everyday at the same time continuously (no pill-free interval)
- -> Takes 2d to work so use additional contraception; but immediate if started on cycle day 1-5
Indications + Benefits:
- -> Usually used in women who can’t take the COCP - no oestrogen risks
- -> If switching from COCP, gives immediate protection
CI’s and risks:
- -> Initial irregular bleeding which may persist - some have no periods (20%), some have regular (40%) and some have irregular (40%)
- -> Risks of ovarian cysts and osteoporosis
- -> Progesterone SEs = breast tenderness, mood changes, acne, headache
- -> Easy to forget
Why is timing important with POP’s and what happens if you miss them i) traditional POPs ii) Cerazette?
POP must be taken at the same time everyday
- -> Traditional POPs
- if <3h late: continue as normal
- If >3h late: take missed pill asap and continue pack, use condoms until re-established for 48h
- If missed 2/+ pills: take last missed pill + next pill asap and continue pack, use condoms until re-established for 48h
- May require emergency contraception if UPSI in this period
- -> Cerazette [same^ but 12h]
- <12h late: continue as normal
- > 12 late: take missed pill asap and continue pack, use condoms until re-established for 48h/emergency if UPSI
How does the transdermal patch work and how is it taken? Explain the:
- Time taken to work
- Indications/Benefits
- SE’s and Risks
Transdermal patch [Evra patch] = oestrogen and progesterone
- -> Thickens mucus and prevents ovulation
- -> Applied for 3w, replacing patch at the end of the week, then 1w off (withdrawal bleed) - can also tricycle
Benefits:
–> NO increased risk of clots
CIs
- -> Same as COCP
- -> Patch adherence and skin sensitivity may be an issue
What happens if you delay changing your transdermal patch by:
- <48h
- > 48h in week 1 or 2
- > 48h in week 3
- delay at the end of the patch free week
<48h = change immediately and no further precautions
> 48h in week 1 or 2
- Change immediately
- Use condoms for 7d
- If had UPSI in previous 5d or in extended-patch free period, consider emergency contraception
> 48h in week 3
- Remove patch immediately and apply next patch at the start of next cycle usual date
- No additional contraception needed
Delay at the end of the patch free week
- Use barrier for 7d
How does the hormonal ring work and how is it taken? Explain the:
- Time taken to work
- Contraindications
Hormonal rings [Nova ring] = oestrogen and progesterone
- -> Thickens mucus and prevents ovulation
- -> Flexible ring inserted into the vagina
- -> Worn for 3w then followed by 1w break
COCP contraindications, adherence and skin sensitivity
When is contraception required postpartum? What contraception options are available to post-partum women? [4] Why is the COCP risky?
Not required until 21d postpartum
Options:
- Lactational = 98% effective only if fully breastfeeding, amenorrhoeic and <6m postpartum
- IUD/IUS either within 48h of birth or 4w PP
- POP can be taken at anytime after 21d - takes 2d to work so use barrier contraception
- COCP - if not breastfeeding then start from day 21 but requires barrier for 7d; if breastfeeding then CI for 6w, and high risk until 6m*
*Can affect milk production, infant growth and increased clot risk
At what age should the implant, POP, IUS, COCP and Injections be stopped?
Implant, POP and IUS = can be continued beyond 50y
COCP and Injection = continue only to 50yo
Remember that women require contraception for 1y of amenorrhoea if 50+ and 2y of amenorrhoea if <50
What is the Frasier Guidelines?
Covers the requirements to prescribe contraception in children
Can only be done if:
- Pt understands professionals advice
- Pt cannot be persuaded to tell parents
- Pt likely to continue having sex, regardless of prescription
- If doesn’t receive prescription, pt’s health is likely to suffer
- In pt’s best interests
NOTE: If child <13yo (13 is okay); then they CANNOT be Gillick competent
–> Contact local safeguarding lead
