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Gynaecology > Contraception > Flashcards

Contraception Flashcards

1
Q

What are the key aspects in a contraception advice hx?

A

Key Aspects of History

o Risk factors:

  • Smoking
  • previous personal history of VTE
  • migraine
  • breast cancer
  • stroke
  • hypertension
  • liver disease
  • family history of DVT/VTE in 1st degree relative
  • breast cancer

Menstrual problems (e.g.heavy periods)

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2
Q

What are the different methods of contraception?

A

The key contraceptive methods available are:

  • Natural family planning (“rhythm method”)
  • Barrier methods (i.e. condoms)
  • Combined contraceptive pills
  • Progestogen-only pills
  • Coils (i.e. copper coil or Mirena)
  • Progestogen injection
  • Progestogen implant
  • Surgery (i.e. sterilisation or vasectomy)
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3
Q

What is the UK medical eligibility criteria for contraception?

A

There are four levels, from least risk of most risk:

  • 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)
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4
Q

How should we explain efficacy of contraception?

A
  • The different methods of contraception are not equally effective. The effectiveness is expressed as a percentage. For example, the combined oral contraceptive is 99% effective. The only method that is 100% effective is complete abstinence.
  • What 99% effective means is that if an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
  • It is essential to distinguish between the effectiveness of perfect use and typical use. This is especially important with methods such as natural family planning, barrier contraception and the pill, where the effectiveness is very user-dependent.
    • Long-acting methods such as the implant, coil and surgery are the most effective with typical use, as they are not dependent on the user to take regular action.
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5
Q

How do we divide types of contraception?

A

o Long-acting (things you insert and leave for a long time)

  • IUS/IUD
  • Injection
  • Implant

o Short-acting (things you have to take everyday)

  • Pills (POP vs COCP)
  • Patches
  • Rings
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6
Q

What are the key contraindications for

  • breast cancer
  • cervical or endometrial cancer
  • Wilson’s disease?
A
  • 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
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7
Q

What additional considerations should be made in older and perimenopausal women?

A
  • 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
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8
Q

Until when should women that are amenorrhoeic (no periods) take progestogen-only contraception?

A
  • FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
  • 55 years of age
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9
Q

What should we consider when prescribing contraceptions to under 20s?

A

When prescribing contraception to women under 20 years:

  • Combined and progestogen-only pills are unaffected by younger age
  • The progestogen-only implant is a good choice of long-acting reversible contraception (UK MEC 1)
  • The progestogen-only injection is UK MEC 2 due to concerns about reduced bone mineral density
  • Coils are UKMEC 2, as they may have a higher rate of expulsion
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10
Q

What should be think about when prescribing contraceptions after childbirth?

A
  • Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point. The risk of pregnancy is very low before 21 days. After 21 days women are considered fertile, and will need contraception (including condoms for 7 days when starting the combined pill or 2 days for the progestogen-only pill).
  • Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
  • The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
  • The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
  • A copper coil or intrauterine system (e.g. Mirena) 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).

TOM TIP: Remember that the combined pill should not be started before 6 weeks after childbirth in women that are breastfeeding. The progestogen-only pill or implant can be started any time after birth.

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11
Q

What are some of the barrier methods of contraception?

A
  • Condoms
  • Diaphragms and Cervical Caps
  • Dental dams
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12
Q

What is the advantage of using barrier methods? Whats the issue with them?

A

They are the only method that helps protect against sexually transmitted infections (STIs). They are not 100% effective for contraception or preventing STIs.

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13
Q

How effective are condoms? What are the made of? What are alternative condom materials?

A
  • Condoms are about 98% effective with perfect use, but can be significantly less effective with typical use (82%).
  • Standard condoms are made of latex.
  • Using oil-based lubricants can damage latex condoms and make it more likely they will tear.
  • Polyurethane condoms can be used in latex allergy.
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14
Q
  • What are diaphragms and cervical caps?
  • How are they to be used?
  • What is the efficacy?
A
  • Diaphragms and cervical caps are silicone cups that fit over the cervix and prevent semen from entering the uterus.
  • The woman fits them before having sex, and leaves them in place for at least 6 hours after sex. They should be used with spermicide gel the further reduce the risk of pregnancy.
  • When used perfectly with spermicide, diaphragms and cervical caps are around 95% effective at preventing pregnancy.
  • They offer little protection against STIs, and condoms need to be used for STI protection.
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15
Q

What are dental dams? When are they used? What infections does it prevent?

A

Dental dams are used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus. They are used to prevent infections that can be spread through oral sex, including:

  • Chlamydia
  • Gonorrhoea
  • Herpes simplex 1 and 2
  • HPV (human papillomavirus)
  • E. coli
  • Pubic lice
  • Syphilis
  • HIV
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16
Q

What does the COCP contain? How effective is it? Until what age is it licensed?

A
  • The combined oral contraceptive pill (COCP) contains a combination of oestrogen and progesterone.
  • The combined pill is more than 99% effective with perfect use, but less effective with typical use (91%).
  • The pill is licensed for use up to the age of 50 years.
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17
Q

What is the MOA of the COCP?

A

The COCP prevents pregnancy in three ways:

  • Preventing ovulation (this is the primary mechanism of action)
  • Progesterone thickens the cervical mucus
  • Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
  • Oestrogen and progesterone have a negative feedback effect on the hypothalamus and anterior pituitary, suppressing the release of GnRH, LH and FSH.
  • Without the effects of LH and FSH, ovulation does not occur. Pregnancy cannot happen without ovulation.
  • The lining of the endometrium is maintained in a stable state while taking the combined pill.
  • When the pill is stopped the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“.
  • This is not classed as a menstrual period as it is not part of the natural menstrual cycle.
  • “Breakthrough bleeding” can occur with extended use without a pill-free period.
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18
Q

What are the 2 types of COCP?

A
  • Monophasic pills contain the same amount of hormone in each pill
  • Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
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19
Q

What compositions do they monophasic COCPs have?

  • Microgynon
  • Loestrin
  • Cilest
  • Yasmin
  • Marvelon
A
  • Microgynon contains ethinylestradiol and levonorgestrel
  • Loestrin contains ethinylestradiol and norethisterone
  • Cilest contains ethinylestradiol and norgestimate
  • Yasmin contains ethinylestradiol and drospirenone
  • Marvelon contains ethinylestradiol and desogestrel
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20
Q

What COCP is the first line according to the NICE guidelines? Why is this?

A

The NICE Clinical Knowledge Summaries (2020) recommend using a pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin).

These choices have a lower risk of venous thromboembolism.

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21
Q

Which COCP is recommended for PMS? Why?

A
  • Yasmin and other COCPs containing drospirenone are considered first-line for premenstrual syndrome.
  • Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
  • Continuous use of the pill, as opposed to cyclical use, may be more effective for premenstrual syndrome.
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22
Q

What COCP is first line for acne and hirsutism? Why? When should it be stopped?

A
  • Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol) can be considered in the treatment of acne and hirsutism.
  • Cyproterone acetate has anti-androgen effects, helping to improve acne and hirsutism.
  • The oestrogenic effects mean that co-cyprindiol has a 1.5 – 2 times greater risk of venous thromboembolism compared to the first-line combined pills (e.g. Microgynon).
  • It is usually stopped three months after acne is controlled, due to the higher risk of VTE.
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23
Q

What are the 3 common COCP regimes?

A
  • 21 days on and 7 days off
  • 63 days on (three packs) and 7 days off (“tricycling“)
  • Continuous use without a pill-free period
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24
Q

What are the SEs and risks of the COCP?

A
  • 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
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25
Q

What are the benefits of the COCP?

A

The benefits of the combined pill include:

  • Effective contraception
  • Rapid return of fertility after stopping
  • Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
  • Reduced risk of endometrial, ovarian and colon cancer
  • Reduced risk of benign ovarian cysts
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26
Q

What are specific risk factors that should make you avoid the combined contraceptive pill (UKMEC 4)?

A
  • 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

It is worth noting that a BMI above 35 is UKMEC 3 for the combined pill (risks generally outweigh the benefits).

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27
Q

What advice should be given when starting the pill?

A

Start on the first day of the cycle (first day of the menstrual period). This offers protection straight away. No additional contraception is required if the pill is started up to day 5 of the menstrual cycle.

Starting after day 5 of the menstrual cycle requires extra contraception (i.e. condoms) for the first 7 days of consistent pill use before they are protected from pregnancy. Ensure the woman is not already pregnant before starting the pill (i.e. they have been using contraception reliably and consistently).

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28
Q

What advice should be given when switching COCPs?

A

When switching between COCPs, finish one pack, then immediately start the new pill pack without the pill-free period.

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29
Q

What advice should be given when switching from a POP to COCP? What about from desogestrel?

A
  • When switching from a traditional progesterone-only pill (POP), they can switch at any time but 7 days of extra contraception (i.e. condoms) is required. Ensure the woman is not already pregnant before switching (i.e. they have been using contraception reliably and consistently).
  • When switching from desogestrel, they can switch immediately, and no additional contraception is required. This differs from a traditional POP because desogestrel inhibits ovulation.
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30
Q

What do we need to check before putting someone on the COCP?

A

There are several things to check and discuss when prescribing the combined pill:

  • 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)

Screen for contraindications by discussing and documenting:

  • 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)
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31
Q

What should a patient do if she has missed one pill?

A
  • 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
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32
Q

What should a patient do if she has missed more than one pill?

A
  • Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
  • Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
  • 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.

Theoretically, additional contraception is not required if more than one pill is missed between day 8 – 21 (week 2 or 3) of the pill packet and they otherwise take the pills correctly, although it is recommended for extra precaution.

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33
Q

What should be done with the COCP if a major operation is taking place?

A

NICE Clinical Knowledge Summaries (January 2019) recommends stopping the combined pill four weeks before a major operation (lasting more than 30 minutes) or any operation or procedure that requires the lower limb to be immobilised. This is to reduce the risk of thrombosis.

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34
Q

What are the benefits and drawbacks of the COCP?

A

Benefits
o Very effective if taken properly (>99%)
o Reversible upon stopping
o Usually makes periods regular, lighter and less painful

o Reduced risk of ovarian, endometrial and bowel cancer

Disadvantages
o Forgetting to take it

o No protection against STIs

o Increased risk of VTE, breast cancer, cervical cancer, stroke, IHD

35
Q
  • What are the hormones in the combined transdermal patch?
  • How often is it changed?
  • What should be done if a patch is missed?
    • What is the drawback of it?
A
36
Q

What is the POP? How is it taken? How effective is it?

A
  • The progestogen-only pill (POP) is a type of contraceptive pill that only contains progesterone.
  • The POP is taken continuously, unlike the cyclical combined pills.
  • It is more than 99% effective with perfect use, but less effective with typical use (91%).
37
Q

What is the only contraindication of the POP?

A

The only UKMEC 4 criteria for the POP is active breast cancer.

38
Q

What are the types of POP?

A

There are two types of POP to remember:

  • Traditional progestogen-only pill (e.g. Norgeston or Noriday)
  • Desogestrel-only pill (e.g. Cerazette)

The traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”.

The desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”.

39
Q

How does the traditional POP work?

A

Traditional progestogen-only pills work mainly by:

  • Thickening the cervical mucus
  • Altering the endometrium and making it less accepting of implantation
  • Reducing ciliary action in the fallopian tubes
40
Q

How does Desogestrel work?

A

Desogestrel works mainly by:

  • Inhibiting ovulation
  • Thickening the cervical mucus
  • Altering the endometrium
  • Reducing ciliary action in the fallopian tubes
41
Q

What advice should be given when starting the POP?

A
  • Starting the POP on day 1 to 5 of the menstrual cycle means the woman is protected immediately.
  • It can be started at other times of the cycle provided pregnancy can be excluded. Additional contraception is required for 48 hours. It takes 48 hours for the cervical mucus to thicken enough to prevent sperm entering the uterus.
  • The POP can be started even if there is a risk of pregnancy, as it is not known to be harmful in pregnancy. However, the woman should do a pregnancy test 3 weeks after the last unprotected intercourse. Emergency contraception before starting the pill may be considered if required.
42
Q

How can we switch between POPs?

A

POPs can be switched immediately without any need for extra contraception.

43
Q

How can we switch from a COCP to a POP?

A
  • When switching from a COCP to a POP, the directions depend on what point they are in the COCP pill packet. The best time to change is on day 1 to 7 of the hormone-free period after finishing the COCP pack, in which case no additional contraception is required.
  • Sometimes it is essential to switch immediately, for example, if they develop migraines with aura. If they have not had sex since finishing the COCP pack, they can switch straight away but need to use extra contraception (i.e. condoms) for the first 48 hours of the POP.
  • If they have had sex since completing the last pack of combined pills, they need to have completed at least seven consecutive days of the combined pill before switching, then use extra contraception for 48 hours. If this is not possible, emergency contraception may need to be considered.
44
Q

What are the SEs and risks of the POP?

A

Changes to the bleeding schedule is one of the primary adverse effects of the progestogen-only pill. Unscheduled bleeding is common in the first three months and often settles after that. Where the irregular bleeding is persistent (for longer than 3 months), other causes need to be excluded (e.g. STIs, pregnancy or cancer).

Approximately:

  • 20% have no bleeding (amenorrhoea)
  • 40% have regular bleeding
  • 40% have irregular, prolonged or troublesome bleeding

Other side effects include:

  • Breast tenderness
  • Headaches
  • Acne

There is also an increased risk of:

  • 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
45
Q

What is classed as a missed pill with the POP? What should be done in response?

A

A pill is classed as “missed” if it is:

  • 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)

The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use.

Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.

Episodes of diarrhoea or vomiting are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle.

46
Q

What are the benefits and disadvantages of the POP?

A

Benefits
o Doesn’t have the risks of oestrogen pills

Disadvantages
o Must be taken at the same time everyday

o Irregular bleeding
o Osteoporosis

47
Q

What are the two types of IUDs? Describe them briefly.

A

There are two types of intrauterine device (IUD):

  • Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy
  • Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus

TOM TIP: Often, the two types of coils are referred to as IUD and IUS. The intrauterine device (IUD) refers to the copper coil, and the intrauterine system (IUS) refers to the levonorgestrel (e.g. Mirena) coil. The copper coil is just a “device”, whereas the hormones in the Mirena make it a “system”.

48
Q

How effective are the IUDs?

A

99% effective, restores fertility when removed.

49
Q

What are the contraindications for the IUDs?

A
  • Pelvic inflammatory disease or infection
  • Immunosuppression
  • Pregnancy
  • Unexplained bleeding
  • Pelvic cancer
  • Uterine cavity distortion (e.g. by fibroids)
50
Q

How is the coil inserted?

A
  1. In women at increased risk of sexually transmitted infections (e.g. under 25 years old), screening for chlamydia and gonorrhoea is performed before insertion of a coil.
  2. Specific qualifications are required to insert the implant.
  3. A bimanual is performed before the procedure to check the position and size of the uterus.
  4. A speculum is inserted, and specialised equipment is used to fit the device.
  5. Forceps can be used to stabilise the cervix while the device is inserted.
  6. Blood pressure and heart rate are recorded before and after insertion.

There may be some temporary crampy period type pain after insertion.

  1. NSAIDs may be used to help with discomfort after the procedure.
  2. Women need to be seen 3 to 6 weeks after insertion to check the threads. They should be taught to feel the strings to ensure the coil remains in place.
51
Q

What are the risks relating to the insertion of the coil?

A
  • Bleeding
  • Pain on insertion
  • Vasovagal reactions (dizziness, bradycardia and arrhythmias)
  • Uterine perforation (1 in 1000, higher in breastfeeding women)
  • Pelvic inflammatory disease (particularly in the first 20 days)
  • The expulsion rate is highest in the first three months
52
Q

How can the coil be removed?

A

Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy. The strings are located and slowly pulled to remove the device.

53
Q

What should we do if the coil threads cannot be seen or palpated?

A

Three things need to be excluded:

  • Expulsion
  • Pregnancy
  • Uterine perforation

Extra contraception (i.e. condoms) is required until the coil is located.

The first investigation is an ultrasound. An abdominal and pelvic xray can be used to look for a coil elsewhere in the abdomen or peritoneal cavity after a uterine perforation.

Hysteroscopy or laparoscopic surgery may be required depending on the location of the coil.

54
Q

What type of contraception is the copper coil? How long does it last for?

A

The copper coil (IUD) is a long-acting reversible contraception licensed for 5 – 10 years after insertion (depending on the device).

55
Q

For what other purpose can the copper coil be used?

A

It can also be used as emergency contraception, inserted up to 5 days after an episode of unprotected intercourse.

56
Q

What is the mechanism of the copper coil?

A

Copper is toxic to the ovum and sperm. It also alters the endometrium and makes it less accepting of implantation

57
Q

What are the benefits and drawbacks of the copper coil?

A

Benefits

  • Reliable contraception
  • It can be inserted at any time in the menstrual cycle and is effective immediately
  • It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers
  • It may reduce the risk of endometrial and cervical cancer

Drawbacks

  • A procedure is required to insert and remove the coil, with associated risks
  • It can cause heavy or intermenstrual bleeding (this often settles)
  • Some women experience pelvic pain
  • It does not protect against sexually transmitted infections
  • Increased risk of ectopic pregnancies
  • Intrauterine devices can occasionally fall out (around 5%)
58
Q

What is a contraindication for the copper coil insertion?

A

Wilson’s disease

59
Q

What are the types of Levonogestrel Intrauterine System?

A

There are four types of IUS you may come across, all containing levonorgestrel:

  • Mirena: effective for 5 years for contraception, and also licensed for menorrhagia and HRT
  • Levosert: effective for 5 years, and also licensed for menorrhagia
  • Kyleena: effective for 5 years
  • Jaydess: effective for 3 years
    • smaller form of the LNG-IUS that is effective for contraception but not for heavy periods. Smaller so it is easier to put in (especially if nulliparous).

The IUS to remember is the Mirena coil. It is commonly used for contraception, menorrhagia and endometrial protection for women on HRT. It is licensed for 5 years for contraception, but only 4 years for HRT.

60
Q

How does the LNG-IUS work?

A

The LNG-IUS works by releasing levonorgestrel (progestogen) into the local area:

  • Thickening cervical mucus
  • Altering the endometrium and making it less accepting of implantation
  • Inhibiting ovulation in a small number of women
61
Q

What needs to be taken into account when inserting the LNG-IUS?

A

The LNG-IUS can be inserted up to day 7 of the menstrual cycle without any need for additional contraception. If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.

62
Q

What are the benefits and drawbacks of the LNG-IUS?

A

Benefits

  • It can make periods lighter or stop altogether
  • It may improve dysmenorrhoea or pelvic pain related to endometriosis
  • No effect on bone mineral density (unlike the depo injection)
  • No increase in thrombosis risk (unlike the COCP)
  • No restrictions for use in obese patients (unlike the COCP)
  • The Mirena has additional uses (i.e. HRT and menorrhagia)

Drawbacks

  • A procedure is required to insert and remove the coil, with associated risks
  • It can cause spotting or irregular bleeding
  • Some women experience pelvic pain
  • It does not protect against sexually transmitted infections
  • Increased risk of ectopic pregnancies
  • Increased incidence of ovarian cysts
  • There can be systemic absorption causing side effects of acne, headaches, or breast tenderness
  • Intrauterine devices can occasionally fall out (around 5%)
63
Q

What should you warn the patient about before inserting the LNG-IUS?

A
  • Irregular bleeding can occur, particularly in the first six months. This usually settles with time.
  • Alternative causes need to be excluded where problematic bleeding continues, including a
    • sexual health screen
    • pregnancy test
    • ensuring cervical screening is up to date.

The FSRH guidelines suggest taking the combined oral contraceptive pill (COCP) in addition to the LNG-IUS for three months when problematic bleeding occurs, to help settle the bleeding.

64
Q

What is sometimes found on smear tests in women with the coil? What needs to be done?

A

Actinomyces-like organisms

These do not require treatment unless they are symptomatic. Where the woman is symptomatic (e.g. pelvic pain or abnormal bleeding), removal of the intrauterine device may be considered.

65
Q

What is the progestogen-only injection often referred to as? How often and by what route is it given?

A

The progestogen-only injection is also known as depot medroxyprogesterone acetate (DMPA).

It is given at 12 to 13 week intervals as an intramuscular or subcutaneous injection of medroxyprogesterone acetate (a type of progestin).

66
Q

How effective is the DMPA with perfect and typical use?

A

The DMPA is more than 99% effective with perfect use, but less effective with typical use (94%). It is less effective with typical use because women may forget to book in for an injection every 12 to 13 weeks.

67
Q

How soon after stopping the DMPA is fertility restored?

A

It can take 12 months for fertility to return after stopping the injections, making it less suitable for women who may wish to get pregnant in the near term.

68
Q

What are the common forms of DMPA used in the UK?

A

There are two versions commonly used in the UK, all containing medroxyprogesterone acetate:

  • Depo-Provera: given by intramuscular injection
  • Sayana Press: a subcutaneous injection device that can be self-injected by the patient

Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks. This is usually used as a short term interim contraception (e.g. after the partner has a vasectomy) rather than a long term solution.

69
Q

What are the contraindications for the DMPA?

A

UK MEC 4 - Active breast cancer

UK MEC 3

  • Ischaemic heart disease and stroke
  • Unexplained vaginal bleeding
  • Severe liver cirrhosis
  • Liver cancer

The DMPA can cause osteoporosis. This is something to consider in older women and patients on steroids for asthma or inflammatory conditions. It is UK MEC 2 in women over 45 years, and women should generally switch to an alternative by age 50 years.

70
Q

How does the DMPA work?

A

The main action of the depot injection is to inhibit ovulation. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.

Additionally, the depot injection works by:

  • Thickening cervical mucus
  • Altering the endometrium and making it less accepting of implantation
71
Q

How should injections be timed?

A
  • Starting on day 1 to 5 of the menstrual cycle offers immediate protection, and no extra contraception is required.
  • Starting after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms) before the injection becomes reliably effective.
  • Women need to have injections every 12 – 13 weeks. Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines say it can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary, but this is unlicensed.
72
Q

What are the side effects and risks of the progesterone-only injection?

A

Changes to the bleeding schedule is one of the primary considerations with progestogen-only contraception. Bleeding often becomes more irregular, and in some women, it may be heavier and last longer.

Alternative causes need to be excluded where problematic bleeding continues, including a sexual health screen, pregnancy test and ensuring cervical screening is up to date.

The FSRH guidelines suggest taking the combined oral contraceptive pill (COCP) in addition to the injection for three months when problematic bleeding occurs, to help settle the bleeding. Another option is a short course (5 days) of mefenamic acid to halt the bleeding.

This is usually temporary, and after a year of regular use, most women will stop bleeding altogether (amenorrhoea). It is not possible to predict how individuals will respond.

Other side effects include:

  • Weight gain
  • Acne
  • Reduced libido
  • Mood changes
  • Headaches
  • Flushes
  • Hair loss (alopecia)
  • Skin reactions at injection sites

Reduced bone mineral density (osteoporosis) is an important side effect.

The depot injection may be associated with a very small increased risk of breast and cervical cancer.

The two side effects that are unique to the progestogen injection are weight gain and osteoporosis. These adverse effects are not associated with any other forms of contraception, making them a useful fact for examiners to ask about in exams.

73
Q

What are the potential benefits of the progestogen-only injection?

A

Evidence that it:

  • 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
74
Q

What is the progestogen only implant? Where is it placed? How long does it last for?

A
  • The progestogen-only implant is a small (4cm) flexible plastic rod
  • Placed in the upper arm, beneath the skin and above the subcutaneous fat.
  • It slowly releases progestogen into the systemic circulation.
  • It lasts for three years and then needs replacing.
75
Q

How effective is the progestogen-only implant?

A

99%

76
Q

What is the contraindictaion for the progestogen-only implant?

A

Active breast cancer

77
Q

What progestogen only implant is used in the UK?

A

Nexplanon is the implant used in the UK. It contains 68mg of etonogestrel. It is licensed for use between the ages of 18 and 40 years.

78
Q

What is the MOA of the progestogen-only implant?

A

The progestogen-only implant works by:

  • Inhibiting ovulation
  • Thickening cervical mucus
  • Altering the endometrium and making it less accepting of implantation
79
Q

How is the progestogen-only implant inserted and removed? What needs to be told to the patient?

A
  • Inserting the implant on day 1 to 5 of the menstrual cycle provides immediate protection.
  • Insertion after day 5 of the menstrual cycle requires seven days of extra contraception (e.g. condoms), similar to the injection.
  • Specific qualifications are required to insert the implant.
  • It is inserted one-third the way up the upper arm, on the medial side. Local anaesthetic (lidocaine) is used prior to inserting the implant.
  • A specially designed device is used to insert the implant horizontally, beneath the skin and above the subcutaneous fat.
  • It should be palpable immediately after insertion. Pressing on one end of the implant should make the other end pop upwards against the skin.
  • Specific qualifications are also required to remove the implant. Lidocaine is used as a local anaesthetic.
  • The device is located, and a small incision is made in the skin at one end. The device is removed using pressure on the other end or forceps. Contraception is required immediately after it has been removed (but not immediately before).
80
Q

What are the benefits and drawbacks of the progestogen only implant?

A

Benefits

  • Effective and reliable contraception
  • It can improve dysmenorrhoea (painful menstruation)
  • It can make periods lighter or stop all together
  • No need to remember to take pills (just remember to change the device every three years)
  • It does not cause weight gain (unlike the depo injection)
  • No effect on bone mineral density (unlike the depo injection)
  • No increase in thrombosis risk (unlike the COCP)
  • No restrictions for use in obese patients (unlike the COCP)

Drawbacks

Several factors may limit the appeal of the implant:

  • It requires a minor operation with a local anaesthetic to insert and remove the device
  • It can lead to worsening of acne
  • There is no protection against sexually transmitted infections
  • It can cause problematic bleeding
  • Implants can be bent or fractured
  • Implants can become impalpable or deeply implanted, leading to investigations and additional management

An ultrasound or xray may be required to locate an impalpable implant. They may need referral to a specialist removal centre. The manufacturer of Nexplanon adds barium sulphate to make it radio-opaque so that it can be seen on xrays.

In very rare cases there are reports of devices entering blood vessels and migrating through the body, including to the lungs. If the implant cannot be located even after an ultrasound scan, a chest xray may be considered to identify an implant in a pulmonary artery.

81
Q

What happens to the bleeding pattern in response to the progestogen only implant? How is it managed?

A

The FSRH guideline on the implant (2014) state approximately:

  • 1/3 have infrequent bleeding
  • 1/4 have frequent or prolonged bleeding
  • 1/5 have no bleeding
  • The remainder have normal regular bleeds

Problematic bleeding is managed similarly to the progestogen-only implant. The FSRH guidelines suggest the combined oral contraceptive pill (COCP) in addition to the implant for three months when problematic bleeding occurs, to help settle the bleeding (provided there are no contraindications).

82
Q

What is important about sterilisation?

A

Sterilisation procedures are permanent surgical interventions to prevent conception.

It is essential to thoroughly counsel patients about the permanence of the procedure, and ensure they have made a fully informed decision.

Sterilisation does not protect against sexually transmitted infections.

The NHS does not provide reversal procedures. Private reversal procedures are available, but the success rate is low. Therefore, sterilisation should be considered permanent.

83
Q

What is the female sterilisation process? How is it done? How does it work? How effective is it? What does the patient need to know about contraception?

A

The female sterilisation procedure is called tubal occlusion.

  • This is typically performed by laparoscopy under general anaesthesia, with occlusion of the tubes using “Filshie clips”.
  • Alternatively, the fallopian types can be tied and cut, or removed altogether. This can be done as an elective procedure, or during a caesarean section.

The procedure works by preventing the ovum (egg) travelling from the ovary to the uterus along the fallopian tube. This means the ovum and sperm will not meet, and pregnancy cannot occur.

The procedure is more than 99% effective (1 in 200 failure rate). Alternative contraception is required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.

84
Q

What is the male sterilisation? How is it done? How does it work?

A
  • The male sterilisation procedure is called a vasectomy.
  • This involves cutting the vas deferens, preventing sperm travelling from the testes to join the ejaculated fluid.
  • This prevents sperm from being released into the vagina, preventing pregnancy. It is more than 99% effective (1 in 2000 failure rate).
  • The procedure is performed under local anaesthetic and is relatively quick (15 – 20 minutes). This makes it a less invasive procedure than female sterilisation and often a better option for couples that are considering permanent means of contraception.
  • Alternative contraception is required for two months after the procedure.
  • Testing of the semen to confirm the absence of sperm is necessary before it can be relied upon for contraception.
  • Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.

Gynaecology (15 decks)

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