Contraception Flashcards
Two types of oral contraception
Progesterone only contraceptive (POP)- ‘mini pill’
Combined oral contraceptive (COC)- ‘pill’
-MONOPHASIC
-PHASIC
Mechanism of Action of oral contraception coc?? (3)
- prevent fertilization via inhibition of ovulation
- thickening of the cervical mucus.
- Decrease motility of the uterus and fallopian tubes thereby inhibiting ova and sperm transport.
Contraception-assessment
Exclude pregnancy
Record BP, BMI, smoking status
History
Plans of pregnancy/reason for contraception
Advantages of Combined oral contraceptive (7)
- reliable and reversible
- reduced dysmenorrhoea (painful periods) and
menorrhagia (abnormal heavy bleeding) - reduced incidence of premenstrual syndrome
- less symptomatic fibroids/functional ovarian cysts
- less benign breast disease
- reduced risk of ovarian and endometrial cancer
- reduced risk of pelvic inflammatory disease.
Consideration for COC?
- Lowest dose to provide effective control
- Well tolerated
- Affordable
- Addition benefits if desired
Low strength preparations (COC)
- Contain ethinylestradiol 20 micrograms
- For women with risk factors for circulatory disease
Standard strength preparation (COC)
- Contain ethinylestradiol 30-35 micrograms, or 30-40 micrograms in phased preparations.
- For women who do not have withdrawal bleeding or have breakthrough bleeding with monophasic products.
Standard strength preparation (COC) example
Microgynon 30
Side effects that may be experienced with COC?
Acne, headache, breast symptoms, and breakthrough bleeding.
What is used for women who have side effects with other progestogens (COC)?
Progestogen desogestrel/drospirenone/gestodene
‘Pill-free interval’ (HFI)
Most COCs contain calendar strips of 21 active tablets
No pill-free interval
To support adherence, woman may prefer 21 active tablets and 7 placebo tablets
Low strength, monophasic.
7-day break in pill taking.
Mercilon (ethinylestradiol and desogestrel)
Standard strength, monophasic.
7-day break in pill taking.
Yasmin (ethinylestradiol and drospirenone)
Standard strength, monophasic.
No break in pill taking.
Femodene ED (ethinylestradiol and gestodene)
Standard strength, phasic.
7-day break in pill taking.
Logynon (ethinylestradiol, levonorgestrel)
Standard strength, phasic.
No break in pill taking.
Qlaria (estradiol valerate and dienogest)
Cautions with use of COCs
Family history of VTE Obesity (measure BMI) Long-term immobilization > 35 years and smoker Smoking FMH of arterial disease Diabetes mellitis HBP (avoid if systolic > 160 mmHg and diastolic > 100 mmHg) Migraine
Which 5 cautions may POP be preferred?
Family history of VTE Smoking Diabetes mellitis HBP (avoid if systolic > 160 mmHg and diastolic > 100 mmHg) Migraine
Starting a COC: Not currently on any contraception
- Start the COC on day 1 of cycle (no other req)
- If started another time but need to use barrier method for first 7 days.
Starting a COC: Switching from another COC/combined contraceptive patch/combined
vaginal ring
-Start COC on the day after the last active (no other req)
pill/patch/vaginal ring
Starting a COC: Switching from a POP or levonorgestrel IUS
-Start any time in cycle but need to use barrier method for first 7 days.
Starting a COC: Switching from a Cu-IUD
-Remove on day 1-5 of cycle and start COCO on the same day. (no other req)
Adverse effects of COCs
Nausea and abdominal pain Headache Breast pain and/or tenderness Menstrual irregularities Hypertension Changes in lipid metabolism-weight gain? Mood changes?
What type of drugs can reduce the effect of enzymes?
Enzyme inducing drugs
Enzyme inducing drugs that can reduce the effects of COC
- Antibiotics (rifamipicin)
- Antiepileptics
- Antiretroviral
- St John’s worts
Enzyme inducing drugs that can reduce the effects of COC advice
Swap to progesterone-only injectable, Cu-UDI or LNG-IU (change contraception if long term med)
What does COC do to lamotrigine?
Serum levels of lamotrigine reduced. When lamotrigine is combined with sodium valproate it does not causes the reduction)
Reasons to stop taking COC
Sudden severe chest pain Sudden breathlessness Unexplained swelling or severe pain in calf of one leg Severe stomach pain Serious neurological effects Jaundice Raised BP Prolonged immobility after surgery
1 pill missed (24-48 hours) COC
Take as soon as remembered, continue as usual. EC no req but might if another in the week missed.
2 or more pills missed (>48 hours) COC
Most recent taken as soon as remembered, continue as usual. Condoms used 7 consecutive active pills.
Pills missed in first week (1-7) COC
EC considered.
Pills missed second week (8-14) COC
No EC but rest of the pills for the week should be continued. Other methods used as caution.
Pills missed in third week (15-21) COC
Omit the pill free interval and continue active pills.
Progestogen only pill (POP) uses (7)
Very useful when oestrogens are contraindicated
PMH/high risk of venous thrombosis
heavy smokers
those with HTN above systolic 160 mmHg or diastolic 95 mmHg
valvular heart disease
diabetes mellitus with complications
migraine with aura
Advantages of POP (2)
Good for breastfeeding
Fewer adverse drug reactions than COC
Disadvantages of POP
Higher heart failure rate
POP characteristics
No pill free interval
Must take within a 3 hour window
Which POP can be taken in a 12 hour window?
Desogestrel
Starting POP: Not currently on any contraception
- Start POP on days 1-5 of cycle (nothing else req)
- If stated another time use barrier method for 7 days.
Starting POP: Switching from another POP
Start anytime (nothing else req)
Starting POP: Switching from CHC
Start on days 1-7 of hormone free interval (day 1 optimal, nothing else req)
Starting POP: Switching from a Cu-IUD or LNG-IUS
Start at least 2 days before coil removal.
Adverse effects and risks of POPs (4)
Menstrual irregularities
Breast tenderness — this is usually transient.
Ovarian cysts
Ectopic pregnancy — risk smaller with desogestrel.
Increased cancer risk?
More than 3 hours late (> 27 hours since last) POP
Take ASPA, more than 1 take only 1. Continue as normal. Barriers advised for 2 days.
More than 12 hours (>36 hours since last) POP- Desogesterel
Take ASPA, more than 1 take only 1. Continue as normal. Barriers advised for 2 days.
3 types of EC
Copper bearing IUD (First choice)
Oral progesterone- only
Ulipristal Acetate (UPA)
Two oral EC
Lavonelle (levonorgestrel 1.5 mg) LNG
EllaOne (ulipristal acetate 30mg) UPA
Dose (EllaOne)
1 tablet within 120 hours
Patients on CYP34A enzyme inducing medicines in last 4 weeks (EllaOne)
Not recommended
Weight and BMI (EllaOne)
> 70 kg and >26 BMI may be given
Severe asthma on oral glucocorticoids (EllaOne)
Not recommended
Breastfeeding (EllaOne)
Not recommended for 1 week
Dose (Lavonelle)
1 tablet within 72 hours
Patients on CYP34A enzyme inducing medicines in last 4 weeks (Lavonelle)
Give two tablets
Weight and BMI (Lavonelle)
> 70 kg and >26 BMI less effective
Severe malabsorption syndrome (Lavonelle)
Reduced efficacy
Breastfeeding (Lavonelle)
Can breastfeed
Vomiting within 3 hours of EHC?
Repeat dose
Regular contraception Levonelle
Continue
Regular contraception EllaOne
It can reduce efficacy of COC and POPs. Restart after 5 days.
EHC periods effects
Early or late period. See GP if change in flow
EHC abdominal pain
Medical attention
EHC barrier methods
Required
What to do: suitable / request Cu-IUD to be fitted
Refer
What to do: with clinical conditions where use of EHC is not recommended
Refer
What to do: suspected pregnancy
Refer
What to do: with previous allergy to active ingredients in EHC
Refer
What to do: if unprotected sex/contraceptive failure occurred > 120 hours ago
Refer
What to do: if severe lower abdominal pain experienced after taking EHC
Refer
What to do: at risk of an STI
Refer
What to do: repeat requests for EHC
Refer
Transdermal ring containing…
Oestrogen and progesterone
Vaginal ring containing…
Oestrogen and progesterone
Parenteral injections or implants containing…
Progesterone only
Intra-uterine devise or systems (copper IUD or IUS) containing…
Progesterone only
Barrier methods examples
Condoms, caps and diaphragms
LARC
Long-acting contraception is reversible contraception administered less than once a month.
High effective contraception for patient taking medication with teratogenic potential (5)
LARC
Copper intrauterine device (Cu-IUD), Levonorgestrel intrauterine system (LNG-IUS)
Progestogen-only implant (IMP)
Male and female sterilization.
What does the vaginal ring contain?
Ethinylestradiol (2.7mg), Etonogestrel (11.7mg)
What does the transdermal patch contain?
Ethinylestradiol 33.9mg + Norelgestromin 203mg per 24 hours - transdermal
How does the vaginal ring work?
Delivering 0.12mg/0.015mg per day by vagina
How is vaginal ring used?
1 unit inserted on day 1 of cycle; left in place for 3 weeks; remove ring on day 22. Next ones is 7 days after ring free interval.
Important: advise specific directions for vaginal ring
-changing from other methods of
contraception
-post-partum or post abortion use
-expulsion, delayed insertion/ removal or broken ring (<3 hrs)
How does the transdermal patch work?
1 patch applied once weekly for 3 weeks; 1st patch applied on day 1 of cycle; change patch on days 8 and 15; remove 3rd patch on day 22 and apply new patch to start subsequent course after 7-day patch free interval during which withdrawal bleeding occurs
Important: advise specific directions for transdermal patch
- changing from other methods of contraception
- post-partum or post abortion use
- delayed application or detached patch
What is the Evra patch restricted to?
Restrict Evra patches to those likely to comply poorly with COCs
