Contraception Flashcards
What is UKMEC?
UK Medical Eligibility Criteria which categorises the risks of starting different methods of contraception.
UKMEC 1: No restriction in use
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk
Avoid COCP (UKMEC4) in these patients:
Uncontrolled HTN
Migraine with aura
History of VTE
Aged >35 and smoking 15+ cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, Cardiomyopathy, or AF
Liver cirrhosis and liver tumours
SLE and Antiphospholipid syndrome
What contraception method should be avoided in women with breast cancer?
Avoid all hormonal contraception and go for copper coil or barrier methods
What contraception method should be avoided in cervical or endometrial cancer?
Avoid IUS
What contraception method should be avoided in patients with Wilson’s disease?
Copper coil
When should the progesterone injection be stopped?
After 50 years due to increased risk of osteoporosis
Choice of contraception for women under 20
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)
Progesterone-only injection is UKMEC2 due to concerns of reduced bone mineral density.
Coils are UKMEC2 as they have higher rate of expulsion
Contraception after childbirth
Fertility is not considered to return until 21 days after giving birth
Lactational amenorrhoea is effective for up to 6 months after birth
POP - safe in breastfeeding and can be started at any time
COCP - should be avoided in breastfeeding (UKMEC4 before 6 weeks postpartum and UKMEC2 after 6 weeks)
Copper coil or IUS - inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC1) - should not be inserted with past 48 hours and between 4 weeks (UKMEC3)
How does the COCP work?
Prevents ovulation
Thickens the cervical mucous
Inhibits proliferation of the endometrium, reducing the chance of successful implantation
What types of COCP pills are there?
Monophonic - same amount of hormone in each pill
Multiphase - varying amounts of hormone to match normal cyclical hormone changes
Side effects of COCP
Unscheduled bleeding
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
VTE
Small increased risk of breast and cervical cancer
Small increased risk of MI and stroke
Starting the COCP
If started:
Day 1 - Day 5 : no additional contraception needed
> Day 5 - requires extra contraception for the first 7 days of use.
How would you switch between COCPs?
Start new pack immediately without pill-free period
How would you switch between a POP to COCP?
Can switch at anytime but 7 days protection required.
What should you do if you missed one pill less than 72 hours since the last pill was taken?
Take the missed pill as soon as possible and no extra protection is required
What should you do if you missed one pill more than 72 hours since the last pill was taken?
Take the most recent missed pill as soon as possible
Additional contraception needed until they have taken the pill regularly for 7 days straight.
If day 1-7 of the packet. -> emergency contraception may be required if UPSI occurred
If day 8-14 - and has taken COCP for the first week, no emergency contraception required
Day 15-21 - and day 1-14 was fully compliant, no emergency contraception required.
How early should you stop COCP prior to surgery?
4 weeks.
Contraindications for POP (UKMEC4)
Active breast cancer
Mechanism of POP
Thickens cervical mucous
Altering endometrium making it less accepting to implantation
Desogestrel also inhibits ovulation
Starting POP
Day 1 - day 5 - woman protected immediately
Can be started any time during the cycle but additional contraception required for 48 hours.
Switching between POPs
No extra contraception required
Side effects and risks of POPs
Unscheduled bleeding in first three months.
Breast tenderness
Headaches
Acne
Increased risk of ovarian cysts, small risk of ectopic pregnancy
Minimal increased risk of breast cancer, which returns to normal after 10 years of stopping
POP missed pill
Take pill as soon as possible and the next pill at the scheduled time and use extra contraception for the next 48 hours of regular use.
How often is the progesterone-only injection administered?
12-13 week intervals
What types of the progesterone-only injection are there?
IM or SC
Contraindications for progesterone-only injection
UKMEC4 - Active breast cancer
UKMEC3 - Ischaemic heart disease and stroke, severe liver cirrhosis, liver cancer
MOA of progesterone only injection
Inhibits ovulation
Thickens cervical mucous
Timing of progesterone only injection
Day 1 - 5 - immediate protection, no extra contraception required
> Day 5 - required 7 days of extra contraception
Side effects of progesterone only injection
Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Reduced bone mineral density
Benefits of progesterone only injections
Improves dysmenorrhoea
Improves endometriosis related symptoms
Reduces risk of ovarian and endometrial cancer
Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
How long does the progesterone implant last for?
3 years
Progesterone implant MOA
Inhibiting ovulation
Thickening cervical mucous
Benefits of progesterone implant
Improves dysmenorrhoea
No need to remember pills
Does not cause weight gain
No effect on bone mineral density
No increased risk of VTE
No restriction on obese patients (like COCP)
Makes periods lighter or stop all together
Side-effects of progesterone implant
Requires minor operation
Can lead to worsening acne
No protection against STIs
Can cause problematic bleeding
Implants can bend or fracture
Rarely can become impalpable or deeply implanted.
What are the two types of IUDs?
Cu-IUD
IUS - Mirena coil
Contraindications for coils
PID or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (fibroids)
Risks related to insertion of coil
Bleeding
Pain on insertion
Vasovagal reactions - dizziness, bradycardia and arrhythmia
Uterine perforation
PID
What should be done if the threads of a coil are not visible?
First line investigation is USS to exclude expulsion, pregnancy or uterine perforation.
How long is the copper coil licensed for?
5-10 years
How long is the mirena coil licensed for for contraception?
5 years
How long is the mirena coil licensed for for HRT?
4 years
How does the copper coil work?
Copper is toxic to the ovum and sperm and alters the endometrium making it less accepting of implantation
How does the Mirena coil work?
Thickens cervical mucous and alters the endometrium
What would you find on a smear in women that have IUDs?
ALO Actinomyces-like organisms - nothing needs to be done unless patient becomes symptomatic
What types of emergency contraception are there?
Levonorgestrel
Ullipristal
Copper coil
How long do you have to take levonorgestrel?
72 hours of UPSI
How long do you have to take ulipristal?
120 hours of UPSI
How long do you have to take cu-IUD?
5 days of UPSI
How long do you have to wait after taking levonorgestrel to start regular contraception?
Can be started immediately
What are common side effects of levonorgestrel?
Nausea and vomiting
How does ulipristal work?
It is a SERM (selective progesterone receptor modulator) and delays ovulation.
How does levonorgestrel work?
It is a progestogens that delays ovulation
How long do you have to wait after taking ullipristal to start regular contraception?
wait 5 days before starting COCP or POP
Common side effects of ulipristal
Nausea and vomiting
Restrictions with use of ulipristal
Severe asthma patients
Avoid breastfeeding after 1 week of taking the pill.
What forms of sterilisation are there?
Tubal occlusion for women and vasectomy for males by cutting the vas deferens
