Contraception Flashcards
Prescribing COCP for a 14 y/o girl
What are key principles?
- Confidentiality discussed
- Gillick’s competence assessment
- Encourage discussion with parents
- HEADDSSS assessment
- assess for sexual safety - consent, age of partner
- STI prevention
- History - medical/surgical/OGYN
- Contraindications to COCP Qs
- Gardasil vaccination considered
What information do you give about missing the COCP?
- consider ECP if 2 (>72 hrs) or more missed pill in the 1st week after HFI (hormone free interval)
- 1 missed pill is okay in 1st week after HFI as long as taken 7 days prior to HFI + 7 days afterward
- > 2 missed pills okay in weeks 2 and 3 after HFI as long correct use for previous 7 days
- Skip HFI if >2 missed pills in week 3
What general advice do you tell a young woman starting on COCP about how to take?
start first 5 days of cycle = protected
start any other time - use barrier contraception 7 days
does not protect from STI - always use a condom
can run packets together
return if headache or calf pain
return in 3/12 for BP check
What are 3 disadvantages of implanon (jadelle)
- may increase acne
- may cause irregular bleeding in first year
- scar on arm
6 situations you would NOT prescribe COCP?
- Age 35+ and smoker 15+/day
- migraine with aura
- SLE with +ve antiphospholipid syndrome
- h/o DVT/PE
- h/o breast cancer
- h/o liver cancer/disease
- cardiovascular risk factors high
What are 2 possible mechanisms that may link Yasmin (ethinylestradiol + drosperinon) and VTE?
- weak diuretic/dehydration effect
- Less counteraction of the estrogen effect (relative to older progestins)
- personal h/o unprovoked VTE
- family h/o of 1st degree relative with unprovoked VTE
- major surgery
- immobilisation
- age >35
- smoker >15/day
- High BMI
- SMoker
- known thrombophilia
- recently postpartum
List 2 pharmacological effects unique to drosperinone?
Anti-androgen - reduced acne, hirsutism
Diuretic - reduced weight gain, reduced BP, less breast swelling/tenderness
List 4 contraceptive options if concerned about risk of VTE associated with contraception
POP
mirena
jadelle
depo provera
Outline the criteria for the lactation amenorrhoea method
<6 months postpartum
exclusively breast feeding
amenorrhoeic
What does exclusively breast feeding mean?
not providing food or other liquid
no more than 4-6 hours between feeds (4 during day, 6 at night)
What is the success rate of LAM when used correctly?
98%
What is the specific hormone compound and dose within the POP?
Levenorgestrel 30mcg
What is the specific hormone compound and dose of implanon (jadelle)
etonorgestrel
68mg
What is the specific hormone compound and dose in Mirena?
levonorgestrel 52mg (which equates to 0.02mg per day)
What is the hormone compound and dose of the depo provera?
DMPA
150mg
How long do women return to fertility after stopping A) POP B) Implanon C) mirena D) Depo provera
A) within 1 month
B) 7-14 days
C) as early as 1 month, 97% have menses by 3/12
D) Up to 6 months
What is a disadvantage of the Depo provera?
- side effect - bone density issues
List 2 first and second generation progestins
levonorgestrel
norethisterone
list a 3rd generation progestin
desogestrel
Which progestin is in Ginet and why is this good for PCOS?
Cyproterone
Anti-androgen
which progestin is in Yasmin and why is this good for fluid retention/bloating symptoms?
Drosperinone
- derived from spironolactone - therefore weak diuretic effect
What are the two oral ECP methods available in NZ and Australia?
- levonorgestrel 1.5mg
- ulipristal acetate 30mg- selective progesterone receptor modulator
If used in the first 120 hours after intercourse what are the pregnancy rates for levonorgestrel vs ulipristal acetate?
- 2%
- 4% respectively
- LNG only licensed for use within 72 hours of intercourse, UP licensed for up to 120 hours (5 days)
What is the mechanism of action of Ulipristal acetate?
selective progesterone receptor modulator - acts by delaying ovulation for up to 5 days, until sperm from the UPSI are no longer viable
- if taken at time of LH surge it can still delay ovulation a little
- but risk of pregnancy if taken after start of LH surge)
1. 4% pregnancy rate if taken within 5 days
What is the mechanism of action of LNG for ECP?
if taken prior to the start of the LH surge it can delay ovulation by up to 5 days as it inhibits follicle rupture
in the late follicular phase the LNG is no longer effective
What is the MOA of the Copper IUD?
- toxic effect on sperm and ovum and prevents fertilisation
- if fertilisation does occur, Cu IUD also has toxic effect on womb making it inhospitable for a pregnancy and prevents implantation
How does BMI impact on the different ECP methods?
- Does not effect Cu IUD
- Might effect efficacy of UA (although unclear but higher BMI may equal higher risk of pregnancy)
- Does effect efficacy of LNG (Obese women were 4 x higher risk of pregnancy than BMI <25 women), give UA, or 3mg LNG
which medications interact with oral ECP methods?
- inducers of CYP450 enzyme (BS CRAP GPS)
- Ulipristal acetate efficacy can be reduced by use of progesterone or COCP
- UPA has an antiglucocorticoid effect so if women have severe asthma and are taking glucocorticoid therapy this has to be considered
- LNG and UPA not supposed to be taken with severe hepatic impairment however given risk of pregnancy on severe hepatic impairment??
Breast feeding and ECP methods (all 3)
- UPA is excreted in breast milk and not studied therefore advised to express and throwaway breast milk for 1/52 after use
- limited evidence suggests LNG okay with breast feeding
- increased risk of uterine perforation if breast feeding with Cu IUD (during involution)
