Contraception Flashcards
what are the types of combined hormonal contraceptives
tablerst (COC) trandsermal patches (CTP) Vaginal rings (CVR)
What age is it not recommmended to use combined hormonal contraceptives
50 yrs
what are the health benefits of combined hormonal contraceptives
reduced risk of overian cancer, endometrial cancer, colorectal
predicatble bleeding patterns
reduced dysmenorrhea and menorrhagia
management of PCOS, endometriosis, premenstrual syndrome
Improvement of acne
reduced menopausal symptoms
maintaining bone mineral density in peri-menopausal females uncer 50 yrs
what does multiphasic and monophasic mean in COC
fixed amountof oestrogen and progestrogen- monophasic
varing amount are multiphasic
What is the oestrogen agent used in coc
ethinylestradiol
what is used for chc
first line- monophasic- 30mcg ethinylestradiol and levonorgestrel or norethisterone
\if concerns over abdosprtion- use non oral combined hormonal contraceptions
females who weigh 90kg or more- consider non-topical options or use additional precautions with transdermal patches
What is the traditional chc regimen
21 days with 7 day withdrawal as hormone free period interval
Tailored chc regimens can only be used for Mononophasic chc containing ethinylesttadiol
What is the shortened hfi regimen
21 days use followed by 4 day hormone free interval
What is the extended use regimen of chc
9 weeks of chc then 4-7 days hormone free interval
What is the flexible extended use regimen for chc
21 days use then 4 day hfi when breakthrough bleeding occurs
What is the continuous use regimen for chc
Continuous chc and no hfi
What happens to pregnant females when using traditional chc use
Withdrawal bleeds
Is there benefit to any regimens
No safety or efficacy difference in regimens
How long should chc be discontinued before surgery and when can it be started
What should u do if it can’t be stopped
Discontinue 4 weeks prior to surgery to legs pelvis, surgery that involves prolonged immobilisation of the lower limb
Start again 2 weeks later
Due to risk of vte
If u can’t discontinue use thromboprophylaxis
Increased risk of vte when using chc
When is risk highest?
Particularly during 1st year and after restarting following break of 4 weeks or more
In all cases increases with age and risk factors such as obesity
Increased risk with higher oestrogen doses
Increased risk of cardio events such as heart attack
Which conditions are contraindicated when using chc due to increased risk of vte and cvd
AF Cardiomyopathy Valvular disease Breast cancer currently Hypertension stage 3 Ischaemic heart disease Major surgery Migraine with aura Peripheral vascular heart disease with intermittent claudicación Positive anti phospholipid antibodies Smoking in aged over 35 using 15 or more cigarettes daily Previous or current venous thrombosis Stroke or tia Systemic lupus erthematosus Less than 3 weeks postpartum in non breastfeeding women with risk factors if less than 6 weeks postpartum in breast feeding women
Increased risk of which type of cancers with chc and when does risk decrease
Small risk of breast cancer
May be due to earlier diagnosis
Age at which contraception stopped is biggest factor in diagnosis of breast cancer
Risk reduces gradually over 10 years after stopping and is gone after 10 years
Using for 5 years or longer increases risk of cervical cancer
Risk reduces after stopping and stops after 10 years
What are the admin requirements for chc
Same time each day
Finish course can be started any day of cycle
If starting on day 6 of cycle- use precaution such as barrier method necessary for first 7 days
For estradiol containing preps barrier method required for 7 days if starting after day 1 of cycle
Pt and carer advice with chc
Travel
Diarrhoea/ vomiting
Increased risk of dvt when travelling over 3 hrs
Risks reduced by using compression socks and exercise
D and v interfere with absorption
If within 3 hrs or 24 hrs of severe diarrhoea then assumed missed pill
Use non oral contraceptive if tus is the case
What counts as a missed pill for chc and what is the protocol
Critical time for loss of protection is beginning and end of cycle
Missed pill is a pill 24 or more hrs late
If within this time take es soon as u remember even if taking two at same time
If only missed one pill then take as soon as remembered and no additional precautions required
If missed two or more then take as soon as remembered ans use barrier for next 7 days
Emergency contraceptive should be used if missed 2 or more pills in first 7 tablets and upsi has taken place
If this 7 days runs into the hfi then continue
Forms available for progenstrogen only contraceptive POC
Oral
Injectable
Subdermal
Intra-uterine
What are options if poc
Levonorgestrel Norethisterone Desogestrel They suppress ovulation to varying extents Levonorgestrel-60% Desogestrel-97%
Example of parenteral only contraceptives
Medroxyprogesterone and norethisterone injections and the etonogestrel implant
MOA of long acting reversible contraceptives poc
Suppresses ovulation along with other progesterogenic effects
Effect on bone when using medoxyprogesterone depot
Small loss of bone mineral density
Precautions taken due to medoxyprogestogene bone loss effects
Females under 18 only use if last resort
Reviewed every 2 yes
Females 50 years and over switch to another method
Consider other method for those at risk of osteoporosis
Delayed return to fertility up to 1 year after discontinuation of depot medroxyprogestrogen depot
Where is the etonogestrel implanted and how long does it provide contraception
What is the safety alert surrounding this and what should be told to pta
Subdermally dor 3 years
Reports if neuronas cular injury and migration of me plan on implants from insertion site to vasculature
Pts should be taught how to locate the implant and check and report concerns
If not palpitations insertion site then should be removed asap
Intra uterine progestrogen only systems
Long term use 3-10 years
Seek medical advice if observed- pelvic infection, pain, abnormal bleeding, non-palpable threads or they can feel the stem of the IUS
Risk of cancer with pop
Can it be used in aurgery
Risk of breast cancer same risk as chc
Less evidence
Reduces gradually during 10 years after stopping
Older age has more risk than longer use
Pop are alternative contraception to chc before surgery
What are the administrative requirements for progesterone only contraception
Desogestrel one tablet daily starting day 1 each day same time
If delayed longer than 12 hrs protection lost
Additional precautions not required if started up to and including day 5 of cycle however after this time need additional contraception for 2 days
Levonorgestrel one tablet daily darting day 1 at same time each daof delayed longer than 3 hours contraception lost and additional precautions required for 2 days if after day 5 of cycle
Pt cater advice surrounding vomiting or diarrhoea taking poc
Vomiting within 2 hours of levonorgestrel or Desogestrel take another pill asap
If not taken with 12 hrs for deso or 3 hrs for levo or pt has persistent vomiting or diarrhoea then additional precautions required during illness and 2 days after
Barrier methods
Condoms- female and male
Diaphragm And Cervical caps must be used with spermicide and should be removed until at least 6 hrs after the last episode of Inter course
Intra uterine devices
All ages
Unsuitable I’m pelvic inflammatory disease
Unexplainable vaginal bleed
Most effective 380 copper and banded copper in transverse arm
Symptoms of uterine perforation after intra uterine insertion and who most at risk
Risk of uterine perforation increased in women up to 36 weeks postpartum partum
Perforation in 1 in 1000 pts
Symptoms include
Sever pelvic pain after insertion
Pain or increased bleeding after insertion which continues for a few weeks
Sudden changes in periods
Pain during intercourse
Unable to feel threads
Pts should be informed how to check their threads and arrange check up of threads not felt
Use ultrasound if not found
What are cautions associated with Levonorgestrel and copper iud
Sex avoided or another method use at least 7 days before removal of iud
Risk of sti and pelvic inflammatory disease after insertion
Women considered at risk of Sti if
Under 25 or
Have a new partner
Have had more than one partner in past year
Regular partner has other partners
Pre insertion screening recommended
Attend a and e bc emergency is experienced sustained pain during next 20 days
which drugs can reduce the effectiveness of contraceptives
inducers Carbamazepine nevirapine oxcarbazepine pheytoin Phenobarbital primidone ritonavir st johns wort topiramate rifabutin rifampicin Griseofulvin
methods are avilable to pts who are taking an ezyme inducing drug and need contraception
chnage to reliable contraception e.g parenteral contraception only or uterine
continued for duration of treatment and 4 weeks after stopping.
if this is inappropriate then:
-short course (over 2 months) of enzyme inducing drug: continue chc and condoms for duartoi. of treatment and 4 weeks after
if long term course (over 2 months) of enzyme inducing course: use monophasic coc and extended or tricycling regimen for duration of treatment and four weeks after
use of patches or ring is not recommended
long term of rifampicin or rifabutin: alt method usch as IUD continued for four weeks after
methods of contraception available to pts taking enzyme indicung drug and oral progestrogen only contraception
oral poc reduced by enzyme inducing drug
alt method recommmended during treatment and four weeks after
short course (under 2 months) continue POC with condoms for suration of treatment and four weeks aftrer
methods of contraception available to pts taking enzyme indicung drug and parenteral progestrogen only contraception
IM norethisterone and IM and SC medroxyprogesterone not affected by enzyme inducing drugs
etonogestrel implant effectiveness may be reduced by enzyme inducing drugs
alt method recommended during treatment and at least 4 weeks after
short course of enzyme inducing drug and change of drug not possible use condom for duratoin of treatment and 4 weeks after
if pts using enzyme inducing drugs and ehc what should be offered
copper IUD
If unsuitable double levonelle dose
hormonal contraception
hormonal contraception should not be newly started until 5 days after ella one
women on normal coc can start regular coc immediately after admin of ella one
when progestrogen is given 7 days before or 5 days after admin of ella one, contraceptive effect may be reduced
