Contraception Flashcards
UK medical eligibility criteria for contraception
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
Contraception Specific Risk Factors
Breast cancer: avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil)
Wilson’s disease: avoid the copper coil
combined contraceptive pill (UKMEC 4)
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
Contraceptive considerations in older women
After the last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
Hormone replacement therapy does not prevent pregnancy, and added contraception is required
The combined contraceptive pill can be used up to age 50 years, and can treat perimenopausal symptoms
The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of osteoporosis
Lactational amenorrhea
over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
Safe contraception with breastfeeding
progestogen-only pill and implant - can be started any time after birth
Starting combined contraceptive pill after birth
should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
copper coil or intrauterine system after birth?
can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Max age for COCP
50
Contraception avoided in under 20s
progesterone injection as may reduce bone density
COCP mechanism
Suppress GnRH, LH and FSH. Prevents ovulation
Also progesterone thickens cervical mucus and inhibits endometrium thickening/implantation
Withdrawal bleed
When pill stopped - not a menstrual period
Breakthrough bleeding
With extended use without a pill-free period
COCP side effects
Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism (the risk is much lower for the pill than pregnancy)
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke
COCP regimmes
21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling“)
Continuous use without a pill-free period
COCP screening
Age
Weight and height (BMI)
Blood pressure
Smoker or non-smoker
Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
Family history (particularly VTE and breast cancer)
COCP consultation points
Different contraceptive options, including long-acting reversible contraception (LARC)
Contraindications
Adverse effects
Instructions for taking the pill, including missed pills
Factors that will impact the efficacy (e.g. diarrhoea and vomiting)
Sexually transmitted infections (this pill is not protective)
Safeguarding concerns (particularly in those under 16)
COCP first line
levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin)
Lower VTE risk
first-line for premenstrual syndrome
Yasmin and other COCPs containing drospirenone
anti-mineralocorticoid and anti-androgen, maybe better with continuous use
treatment of acne and hirsutism
Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol)
anti-androgen effects, - but also increased risk of VTE
Usually stopped after 3 months
Starting COCP pill
If in first 5 days of cycle, covered
If after, use barrier for first 7 days of consistent use
if switching COCPs, transition continuously
POP -> switch any time but 7 days of barrier needed - unless desogestrel as this inhibits ovulation
If switching to POP 48 hours if not in pill free zone
Theoretical protection of COCP
7 days on 7 days off would theoretically protect
Definition of missing COCP pill
MORE than 24 hrs late i.e. 48 hrs since last
If missed one COCP pill
<72 hrs since last pill
Take the missed pill as soon as possible (even if this means taking two pills on the same day)
No extra protection is required provided other pills before and after are taken correctly
missed more than one COCP pill
ie >72 hours since last pill
If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
Stopping COCP pill before operation?
combined pill four weeks before a major operation
Emergency contraception options
Levonorgestrel should be taken within 72 hours of UPSI
Ulipristal should be taken within 120 hours of UPSI
Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
Ulipristal contraindications
Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
Ulipristal should be avoided in patients with severe asthma
restarting contraception after Ulipristal
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal. Extra contraception (ie. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.
restarting contraception after Levonorgestrel
combined pill or progestogen-only pill can be started immediately
LARC coils CI
Pelvic inflammatory disease or infection Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion (e.g. by fibroids)
Non-Visible Threads from coil, ivx
Ultrasounds, then xray if needed - may require hysteroscopy or laparoscopic surgery to remove
Progestogen-Only Injection CI
UK MEC 4
Active breast cancer
UK MEC 3
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
Progestogen-Only Injection benefits
Improves dysmenorrhoea (painful periods) Improves endometriosis-related symptoms Reduces the risk of ovarian and endometrial cancer Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
Progestogen-Only Injection SE
Weight gain and osteoporosis
Also carry slight increased risk of Breast and cervical cancer
Progestogen-Only Implant CI
The only UKMEC 4 criteria for the implant is active breast cancer.
POP CI
The only UKMEC 4 criteria for the POP is active breast cancer.
POP Mechanism of Action
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Desogestrel Mechanism of action
Inhibiting ovulation
Thickening the cervical mucus
Altering the endometrium
Reducing ciliary action in the fallopian tubes
Barrier required with starting POP
2 days - by contrast to 7 with COCP
Time taken for POP to be effective
If days 1-5, immediate
If after day 5, takes 48 hours
POP bleeding effects
20% have no bleeding (amenorrhoea)
40% have regular bleeding
40% have irregular, prolonged or troublesome bleeding
POP SE
Breast tenderness
Headaches
Acne
POP risks
Ovarian cysts
Small risk of ectopic pregnancy with traditional POPs (not desogestrel) due to reduce ciliary action in the tubes
Minimal increased risk of breast cancer, returning to normal ten years after stopping
Definition of missed POP
More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
What do do if missed POP
Take extra (even if two in one day), use barrier for 48 hours
Frazer guidelines
They are mature and intelligent enough to understand the treatment
They can’t be persuaded to discuss it with their parents or let the health professional discuss it
They are likely to have intercourse regardless of treatment
Their physical or mental health is likely to suffer without treatment
Treatment is in their best interest
Gillick Competence
decision by decision basis
voluntarily
safeguarding concerns.
under 13 cannot consent to any sexual activity
