Contraception Flashcards
What are the options for LARC?
Progestogen-only implant
Intrauterine system
Copper intrauterine device
Progestogen injection
What are the options for non-LARC?
Vasectomy Female sterilisation Progestogen-only pills Combined oral hormonal contraception Combined hormonal transdermal patch Combined hormonal vaginal ring Female diaphragm Male condom Fertility awareness methods
What are the most effective methods of contraception?
Progestogen-only implant
Intrauterine system
Male and female sterilisation
Copper IUD
What are the risks of intrauterine methods of contraception?
Painful insertion
Risk of perforation, PID, malposition, expulsion
How do intrauterine contraceptions work?
Prevent fertilisation and implantation
Who are intrauterine contraceptions contraindicated for?
Patients with submucosal fibroids or uterine malformations
Pelvic inflammatory disease
How do intrauterine systems work?
Levonorgestrel (progesterone) releasing
Prevents endometrial proliferation, making the endometrium less favourable for implantation
Causes cervical mucous thickening, making it harder for sperm to reach the egg
How long does the intrauterine system take to work?
7 days after insertion
Immediate effect if in first 5 days of cycle, within 21 days postpartum or within 5 days of abortin or miscarriage
What are the advantages of intrauterine systems?
LARC May become amenorrhoeic (30-50%) Intermittent light menses and less dysmenorrhea Safe while breastfeeding and postpartum Fewer side effects Fertility returns immediately
What are the disadvantages of intrauterine systems?
Spotting for weeks-months after insertion - usually settles by 6 months
Increased relative risk of ectopic pregnancy
No protection against STIs
What is the most common form of intrauterine system?
Mirena IUS
How long does the Mirena IUS provide protection for?
Up to 5 years
What are the specific advantages of the Mirena IUS?
Can be used to treat menorrhagia, dysmenorhoea, endometriosis, hyperplasia
How does the copper IUD work?
Prevents fertilisation by decreasing sperm motility and survival
How long is the copper IUD effective?
5-10 years depending on device
How long does the copper IUD take to work?
Effective immediately after insertion
What are the advantages of the copper IUD?
Can be fitted at any point int he cycle
Can be fitted immediately after abortion or miscarriage
Fertility returns immediately after removal
Can be used as emergency contraception
What are the disadvantages of the copper IUD?
Periods can be heavier, longer and more painful in the first 3-6 months after IUD inserted
Spotting or bleeding can occur between periods
No protection against STIS
What is the subdermal implant also known as?
Nexplanon
What is the subdermal implant?
Thin rod inserted under the skin of the upper arm Releases progesterone (etonogestrel)
How does the subdermal implant work?
Inhibits ovulation and thickens cervical mucus
How long does the subdermal implant take to work?
Immediate if fitted within the first 5 days of cycle
If any other day - 7 days
Immediate if on or before 21 days post-partum - if after, 7 days
At the time of medical or surgical abortion - immediate
What are the advantages of the subdermal implant?
LARC Non-user dependent Can be used if unable to take oestrogen Safe in beastfeeding and postpartum Can help reduce menorrhagia
What are the disadvantages of the subdermal implant?
Can cause irregular bleeding
Hormonal side effects - headache, nausea, breast pain, skin changes
Efficacy can be reduced by enzyme-inducing drugs (anti-epileptics, rifampicin)
No protection against STIs
What are the contraindications for the subdermal implant?
Current breast cancer
Active/severe liver disease
What are the different names of the injective contraception, and what is the difference?
Depo Provera - IM injection, requires administration by healthcare provider
Sayana press - SC injection, can be done by yourself at home, not available everywhere
How does injective contraception work?
Lowers oestradiol and suppresses FSH
This inhibits ovulation and thickens cervical mucus
What are contraindications for injective contraception?
Breast cancer
Significant liver disease
History of thromboembolism
How long does injective contraception take to work?
If given in first 5 days of cycle - immediate protection
If any other time - 7 days
If started before 21 days postpartum - immediate
If over 21 days postpartum - 7 days
Before 5 days after abortion or miscarriage - immediate
After 5 days - 7 days
Can injective contraception be used when breastfeeding?
Yes safe to do so
Can be started any time post-partum if not breastfeeding
If breastfeeding usually given after 6 weeks
What are the advantages of injective contraception?
LARC
Not user-dependent
Useful if you find it difficult to take a pill at same time every day
Not affected by enzyme-inducing drugs so can be used in epileptic women
Can cause amenorrhoea
Can be used to treat heavy menstrual bleeding, dysmenorrhoea, endometriosis
What are the disadvantages of injective contraception?
Can’t be reversed - once it’s in its in for the duration fo the injection
Delayed return to fertility (up to 1 year)
Irregular bleeding
Potential for weight gain - especially adolescents with BMI >30
Increased risk of osteoporosis
No protection against STIs
Hormonal side effects - nausea, spots, headaches
Efficacy reduced by delay in getting injection
How often is injective contraception given?
Every 8 or 13 weeks
What is the fertility awareness method?
Paying attention to physiological indicators of ovulation to identify when a women is most fertile in her cycle, and avoid unprotected intercourse in this time
Sex should be avoided 7 days before ovulation and at least 2 days after
What are the advantages of fertility awareness?
No side effects
Acceptable in all faiths and cultures
Can be used both to avoid pregnancy or to get pregnant
What are the disadvantages of fertility awareness?
Less effective
Very user-dependent
Restricts timing of intercourse
Can be affected by stress, illness, travel, lifestyle, regularity of cycle, post-partum
What are the advantages of condoms?
Avoids hormones
Protects against STIs
What are the disadvantages of condoms?
Typical use failure rate is high
Can break or irritate skin
How are female condoms used?
Worn inside the vagina before contact to prevent semen from entering the cervical canal
How are diaphragms/caps used?
Reusable circular dome made of thin, soft, silicone which is inserted into the vagina before sex
Always used with spermicide
Left in place for at least 6 hours after sex
What are the disadvantages of diaphragms/caps?
Lack of spontaneity User-dependent No protection against STIs Increased risk of cystitis Latex and spermicide can cause irritation
How does the COCP work?
Oestrogen and progesterone inhibit ovulation and thicken mucus
What are the options for regimens of the COCP?
Taken every day for 21 days and stopped for 7 days where a withdrawal bleed occurs
3 cycles in a row, then a 7 day withdrawal bleed
Taken continually then when a bleed starts stop the pill for 4 days, then start again
How long does the COCP take to work?
If started within the first 5 days of the menstrual cycle - immediate
After day 5 - 7 days
If started by day 21 post-partum - immediate
If started after day 21 post-partum - 7 days
Up to 5 days after miscarriage or abortion - immediate
What is done if 1 COCP pill is missed?
Take the last pill, even if 2 pills taken in 1 day
No additional contraception needed
What is done if 2 COCP pills are missed?
Take the past pill, even if 2 taken in 1 day, omit any earlier missed pills
Use additional contraception until the pill has been taken 7 days in a row
If missed in week 1 - consider emergency contraception if unprotected sex in the pill-free interval or week 1
If missed in week 2 - no emergency contraception needed if the pill was taken for 7 consecutive days before missed pill
If missed in week 3 - finish current pack and start the next pack right after, omitting the pill-free interval
What are the advantages of the COCP?
Treats menorrhagia, dysmenorrhea, endometriosis and pre-menstrual syndrome
Reversible on stopping
What does the COCP reduce the risk of?
Ovarian cancer Endometrial cancer Colorectal cancer Ovarian cysts Benign breast disease Acne vulgaris
What are the disadvantages of the COCP?
Need to take at the same time every day (within 24 hours)
Medications such as enzyme inducing drugs and rifampicin can reduce effectiveness
No protection against STIs
Hormonal side effects - headache, nausea, breast tenderness, mood changes, low libido
Irregular bleeding
What can the COCP increase the risk of?
Cervical cancer
Breast cancer
Venous thromboembolism
Stroke and ischaemic heart disease
What are the relative contraindications of the COCP (disadvantages outweigh benefits)?
> 35 years old and smoking <15 cigarettes a day
BMI >35
Family history of thromboembolic disease in 1st degree relatives <45 years
Controlled hypertension
Immobility
Gene mutations associated with breast cancer e.g. BRACA 1 or 2
Ongoing gallbladder or liver disease
Complicated diabetes
What are the absolute contraindications of the COCP?
> 35 years old and smoking >15 cigarettes a day
Migraine with aura
History of thromboembolic disease or thrombogenic mutation
History of stroke or ischaemic heart disease
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
What is the combined transdermal patch and how is it used?
Daily dose of oestrogen and progesterone through the skin into the blood
Worn for 7 days and changed on day 8
Worn for 3 weeks then patch free on week 4 for a withdrawal bleed
How does the combined transdermal patch work?
Prevents ovulation and thickens cervical mucus
How long does the combined transdermal patch take to work?
If started before day 5 - immediate
If after day 5 - 7 days
What is done if the patch is removed?
If removed for <48 hours - stick it back asap or use new patch, no additional contraception needed if patch used correctly for the past 7 days
If >48 hours - use new patch immediately and use additional contraception for next 7 days
What is the combined vaginal ring also known as?
Nuvaring
What is the combined vaginal ring?
Soft plastic ring placed in the vagina that releases oestrogen and progesterone
How does the combined vaginal ring work?
Release of oestrogen and progesterone inhibits obulation
How is the combined vaginal ring used?
Place ring in vagina for 21 days then remove for 7 days to allow withdrawal bleed
How long does the combined vaginal ring take to work?
If inserted in first 5 days of cycle - immediate
If after that - 7 days
If inserted on or before day 21 postpartum - immediate
If after that - 7 days
What is done if the combined vaginal ring is removed?
If >3 hours - protection is reduced
- if week 1 or 2 - use additional protection for next 7 days
- if week 3 - insert new ring to start new cycle or allow withdrawal bleed during which time you’re protected and insert new ring no later than 7 days after ring expelled
What is done if the insertion of a new combined vaginal ring is delayed?
Contraceptive protection is lost - insert new ring asap and use additional protection for 7 days
What is done if the removal of the combined vaginal ring is delayed?
If up to 1 weeks - no additional contraception needed
Start 7 days ring free interval and insert new ring after
What is the name of the progesterone only pill (POP)?
Desogestrel
How does the POP work?
Release of progesterone prevents ovulation and thickens cervical mucus
How is the POP taken?
Taken at same time every day without a pill free break
How long does the POP take to be effective?
If started up to day 5 - immediate effect
After day 5 - use additional contraception for the first 2 days
If switching from COCP - immediate protection if continues directly from the end of a pill packet (from day 21)
What is done if a dose of the POP is missed?
If taken <12 hours after usual time - take pill as normal
If taken >12 hours after usual time - take missed pill asap and use additional protection until pill has been taken for 48 hours
For older traditional pills (non-desogestrel) the window is 3 hours not 12
What are the advantages of the POP?
Few contraindications - can be taken if combined contraception contraindicated
Reversible immediately on stopping
What are the disadvantages of the POP?
Irregular bleeding
Diarrhoea and vomiting interfere with absorption - assume missed pill
Liver enzyme inducers may reduce effectiveness
No protection against STIs
What are the contraindications for the POP?
Severe or active liver disease
Current breast cancer
What is a vasectomy?
Procedure to cut or seal the vas deferens, to permanently prevent pregnancy
This blocks the transport of semen from the testes to the urethra during ejaculation
How long does a vasectomy take to work?
Alternative contraception needed until semen samples confirmed negative - take at 12 and 16 weeks
What are the disadvantages of a vasectomy?
Permanent - should be considered irreversible reversal procedures not always successful and unavailable on NHS
Procedural-related risks, e.g. scrotal pain, swelling or bruising, infection, haematoma
Risk of chronic scrotal pain (<15%)
Does not protect against STIs
What is female sterilisation?
Prevention of pregnancy by blocking/sealing the fallopian tubes to prevent egg from reaching the sperm, preventing fertilisation
What are the methods of female sterilisation?
Applying clips or rings over the fallopian tubes
Cutting and removing a small piece of the tubes
Salpingectomy - removal of fallopian tubes
How long does female sterilisation take to work?
Additional contraception necessary until next period after surgery
What are the disadvantages of female sterilisation?
Procedural-related risks - bleeding, infection, injury to other organs
Operation may not be 100% successful - failure rate is 1 in 200
Relative increased risk of ectopic pregnancy
Considered irreversible - reversal procedures less successful than for vasectomy, IVF often required if pregnancy desired
No protection against STIs
What is emergency contraception?
Used in the event of unprotected sex or failure of regular contraception
What are the methods of emergency contraception?
2 types of oral emergency contraception
Copper IUD
Which method of emergency contraception is the most effective?
Copper IUD
When are oral emergency contraceptives effective?
First half of cycle - little to no effect after ovulation (2nd half)
What are the options for oral emergency contraception?
Levonorgestrel (Levonelle) Ulipristal acetate (EllaOne)
What is Levonelle?
Single dose of levonorgestrel (progesterone)
What is the action of Levonelle?
Delays/prevents ovulation, and reduces implantation
When must Levonelle be taken?
Within 72 hours of unprotected sex
Can Levonelle be taken more than once in a menstrual cycle?
Yes
When can hormonal contraception be taken after taking Levonelle?
Immediately
What are the disadvantages of Levonelle?
Disturbance of menstrual cycle - menses may be earlier or later than expected in
the cycle
Nausea and vomiting - dose should be repeated if it occurs within 3h of taking the
pill
Side effects - dizziness, Diarrhoea, Breast tenderness
What is Ellaone?
A progesterone receptor modulator
How does Ellaone work?
Delays/inhibits ovulation by stopping LH surge
Can Ellaone be taken more than once in one cycle?
Yes (but not particularly recommended)
When must Ellaone be taken?
Within 5 days of unprotected sex
When is Ellaone avoided?
Severe asthma
Regular antacid use
What are the disadvantages of Ellaone
May reduce effectiveness of hormonal contraception - restart 5 days after taking Ellaone
Menstrual cycle irregularities
Nausea and vomiting can impair absorption - dose should be repeated if it occurs within 3h of taking the pill
Side effects - headache, dizziness, breast tenderness
When is the copper IUD effective as an emergency contraceptive?
If inserted within 5 days of unprotected sexual intercourse
OR up to 5 days after expected day of ovulation in regular cycle
