Contraception

Question 1

what are the types of combined hormonal contraceptives

Answer 1

tablerst (COC)
trandsermal patches (CTP)
Vaginal rings (CVR)

Question 2

What age is it not recommmended to use combined hormonal contraceptives

Answer 2

50 yrs

Question 3

what are the health benefits of combined hormonal contraceptives

Answer 3

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

Question 4

what does multiphasic and monophasic mean in COC

Answer 4

fixed amountof oestrogen and progestrogen- monophasic

varing amount are multiphasic

Question 5

What is the oestrogen agent used in coc

Answer 5

ethinylestradiol

Question 6

what is used for chc

Answer 6

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

Question 7

What is the traditional chc regimen

Answer 7

21 days with 7 day withdrawal as hormone free period interval
Tailored chc regimens can only be used for Mononophasic chc containing ethinylesttadiol

Question 8

What is the shortened hfi regimen

Answer 8

21 days use followed by 4 day hormone free interval

Question 9

What is the extended use regimen of chc

Answer 9

9 weeks of chc then 4-7 days hormone free interval

Question 10

What is the flexible extended use regimen for chc

Answer 10

21 days use then 4 day hfi when breakthrough bleeding occurs

Question 11

What is the continuous use regimen for chc

Answer 11

Continuous chc and no hfi

Question 12

What happens to pregnant females when using traditional chc use

Answer 12

Withdrawal bleeds

Question 13

Is there benefit to any regimens

Answer 13

No safety or efficacy difference in regimens

Question 14

How long should chc be discontinued before surgery and when can it be started
What should u do if it can’t be stopped

Answer 14

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

Question 15

Increased risk of vte when using chc

When is risk highest?

Answer 15

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

Question 16

Which conditions are contraindicated when using chc due to increased risk of vte and cvd

Answer 16

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

Question 17

Increased risk of which type of cancers with chc and when does risk decrease

Answer 17

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

Question 18

What are the admin requirements for chc

Answer 18

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

Question 19

Pt and carer advice with chc
Travel
Diarrhoea/ vomiting

Answer 19

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

Question 20

What counts as a missed pill for chc and what is the protocol

Answer 20

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

Question 21

Forms available for progenstrogen only contraceptive POC

Answer 21

Oral
Injectable
Subdermal
Intra-uterine

Question 22

What are options if poc

Answer 22

Levonorgestrel 
Norethisterone
Desogestrel
They suppress ovulation to varying extents
Levonorgestrel-60%
Desogestrel-97%

Question 23

Example of parenteral only contraceptives

Answer 23

Medroxyprogesterone and norethisterone injections and the etonogestrel implant

Question 24

MOA of long acting reversible contraceptives poc

Answer 24

Suppresses ovulation along with other progesterogenic effects

Question 25

Effect on bone when using medoxyprogesterone depot

Answer 25

Small loss of bone mineral density

Question 26

Precautions taken due to medoxyprogestogene bone loss effects

Answer 26

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

Question 27

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

Answer 27

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

Question 28

Intra uterine progestrogen only systems

Answer 28

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

Question 29

Risk of cancer with pop | Can it be used in aurgery

Answer 29

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

Question 30

What are the administrative requirements for progesterone only contraception

Answer 30

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

Question 31

Pt cater advice surrounding vomiting or diarrhoea taking poc

Answer 31

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

Question 32

Barrier methods

Answer 32

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

Question 33

Intra uterine devices

Answer 33

All ages Unsuitable I’m pelvic inflammatory disease Unexplainable vaginal bleed Most effective 380 copper and banded copper in transverse arm

Question 34

Symptoms of uterine perforation after intra uterine insertion and who most at risk

Answer 34

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

Question 35

What are cautions associated with Levonorgestrel and copper iud

Answer 35

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

Question 36

which drugs can reduce the effectiveness of contraceptives

Answer 36

``` inducers Carbamazepine nevirapine oxcarbazepine pheytoin Phenobarbital primidone ritonavir st johns wort topiramate rifabutin rifampicin Griseofulvin ```

Question 37

methods are avilable to pts who are taking an ezyme inducing drug and need contraception

Answer 37

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

Question 38

methods of contraception available to pts taking enzyme indicung drug and oral progestrogen only contraception

Answer 38

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

Question 39

methods of contraception available to pts taking enzyme indicung drug and parenteral progestrogen only contraception

Answer 39

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

Question 40

if pts using enzyme inducing drugs and ehc what should be offered

Answer 40

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